Citation Nr: 18144361 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 09-18 075 DATE: October 25, 2018 ORDER Prior to August 28, 2009, entitlement to an initial disability rating for degenerative arthritis of the lumbar spine in excess of 10 percent. On and after August 28, 2009 to April 19, 2018, entitlement to an initial disability rating for degenerative arthritis of the lumbar spine in excess of 20 percent. On and after April 19, 2018, entitlement to an initial disability rating for degenerative arthritis of the lumbar spine in excess of 40 percent. REMANDED Entitlement to service connection for residuals of a whiplash injury to the neck and shoulders, to include as secondary to service-connected lumbar spine degenerative arthritis, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to August 28, 2009, the Veteran’s degenerative arthritis of the lumbar spine did not demonstrate forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. From August 28, 2009, arthritis of the lumbar spine, have been manifested by flexion to greater than 30 degrees, with no findings of ankylosis or the functional equivalent and incapacitating episodes did not total a duration of at least 4 weeks but less than 6 weeks during the past 12 months. 3. From April 19, 2018, the evidence does not show that the Veteran’s arthritis of the lumbar spine manifests any unfavorable ankylosis or incapacitating episodes due to intervertebral disc syndrome having a total duration of at least six weeks during the past 12 months. CONCLUSIONS OF LAW 1. Prior to August 28, 2009, the criteria for a rating in excess of 10 percent for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C. § 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. § 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2018). 2. From August 28, 2009, the criteria for a disability evaluation greater than 20 percent for degenerative arthritis of the lumbar spine were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Code 5242 (2018). 3. From April 19, 2018, the criteria for a disability rating in excess of 40 percent for degenerative arthritis of the lumbar spine are not met. 38 U.S.C. § 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. § 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service in the United States Air Force and the United States Air Force Reserve. She had active duty service from August 1981 to August 1985, October 2001 to September 2002, and February 2003 to February 2004 with various periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). These matters come to the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in December 2015. A copy of the transcript from that proceeding is associated with the record. The Veteran requested to testify at another Board hearing in a September 2018 VA Form 9. As no argument was submitted in support of that request, the Board does not find good cause for another hearing. Accordingly, the Veteran’s right to a hearing before the Board has been satisfied. The issues currently on appeal were remanded by the Board in April 2016 and November 2017 for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). In a 2018 rating decision, the RO granted service connection for bilateral radiculopathy, effective April 19, 2018. The Board will consider the assigment of separate evaluations prior to that time only.   The issues of entitlement to service connection for residuals of a whiplash injury to the neck and shoulders, to include as secondary to the service-connected lumbar spine degenerative arthritis, and entitlement to TDIU is addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). Entitlement to an initial disability rating for degenerative arthritis of the lumbar spine in excess of 10 percent prior to August 28, 2009, and in excess of 20 percent from August 28, 2009, and in excess of 40 percent from April 19, 2018 Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). It is possible for a veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2018) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent evaluation requires evidence of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5237 (2018). The Board must evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphasia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Additionally, intervertebral disc syndrome is to be evaluated either under the general rating formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. Note (1) states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. Burton v. Shinseki, 25 Vet. App. 1 (2011). A May 2008 VA examination was conducted. The Veteran reported experiencing stiffness, visual disturbances, weakness, and bowel complaints. She stated her nausea was due to the spine condition. She did not have numbness, fevers, bladder complaints, malaise, and dizziness. Her pain was constant, traveling through her stomach. The characteristics of pain was squeezing, burning, aching, oppressing, sharp, cramping and throbbing. The Veteran reported her pain level was an 8 out of 10. Pain was elicited by physical activity and stress, relieved by rest and medication. She was able to function with medication but described the symptoms as limited movement and very painful which caused nausea. Over the past twelve months, the Veteran reported an incapacitating episode in July 2007 which lasted 7 days. She denied functional impairment. A physical examination revealed the Veteran’s posture and gait were within normal limits and she did not require any assistive device for ambulation. The examination revealed no evidence of radiating pain on movement. There was no evidence of muscle spasm, tenderness, or ankylosis. The straight leg raising test was negative, bilaterally. The range of motion testing revealed flexion to 90 degrees with pain at 80 degrees. There was extension to 30 degrees, with right and left lateral flexion to 30 degrees, and right and left rotation to 30 degrees, with pain at end range of motion. The joint function of the spine was additionally limited after repetitive use due to pain but there was no evidence of fatigue, weakness, lack of endurance, and incoordination. There was no additional limitation to the joint function. An inspection of the spine revealed normal head position with symmetry in appearance and symmetry of spinal motion with normal curvatures of the spine. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. The Veteran’s diagnosis was degenerative arthritis of the lumbar spine as supported by x-ray findings. The effect of the condition on the Veteran’s occupation was difficulty with bending and heavy lifting. The effect of the condition on the Veteran’s daily activities were avoiding or limiting activities that require bending or lifting. In June and September 2009 private records, a doctor noted severe pain and severe disk disease. In August 2009, the Veteran was afforded a VA examination where there was no history of stiffness, weakness, or spasm. There was a history of decreased motion and pain. The Veteran described her pain as constant stabbing. It was moderate, daily pain. There were no incapacitating episodes of spine disease but she was unable to walk for more than a few yards. A physical examination revealed the Veteran’s gait was normal with no evidence of gibbus, kyphosis, lumbar flattening, lumbar lordosis, scoliosis, or thoracolumbar spine ankylosis. There was no objective evidence of spasm, atrophy, guarding, pain with motion, tenderness, and weakness. The VA examiner noted that there was no evidence of abnormal gait or spinal contour caused by muscle spasm, localized tenderness, or guarding. The range of motion testing revealed flexion to 40 degrees without objective evidence of pain on active range of motion and following repetitive motion. There was extension to 15 degrees, left latera flexion to 20 degrees, left rotation to 40 degrees, right lateral flexion to 20 degrees, and right rotation to 45 degrees. There were no additional limitations after three repetitive range of motion. According to a February 2011 VA treatment record, the Veteran had full range of active and passive motion and the spine and extremities had good alignment. No lumbar deformity was noted. In a March 2011 VA treatment record, the Veteran’s range of motion was limited 25 percent in all lumbar motions, the Veteran had normal gait and balance. An April 2011 VA treatment record indicated there was no evidence of edema, kyphosis, and scoliosis. The Veteran’s curvature was normal. The Veteran also had full range of motion. At the December 2015 Board hearing, the Veteran reported pain in the right lower extremity, that she had difficulty tying her shoes and that she couldn’t play sports anymore. The Veteran reported it affected her sleep. A VA examination was conducted in October 2016. The Veteran reported onset of constant low back pain with intermittent spasm and right lower extremity shooting pain. She stated her symptoms were aggravated by standing for more than five minutes, sitting in a hard chair, and lifting more than 15 to 20 pounds, and lying supine. She denied incapacitating episodes and/or bedrest within the past year. The Veteran denied bladder or bowel dysfunction. The Veteran denied flare-ups of the thoracolumbar spine but report having functional loss or functional impairment of the thoracolumbar spine. A range of motion testing revealed forward flexion of 50 degrees. There was extension to 25 degrees, right and left lateral flexion to 20 degrees. There was right rotation not 30 degrees. There was left rotation to 20 degrees. After repetitive motion, there was 20 degrees of extension, 25 degrees of right lateral flexion, 18 degrees of right rotation, and 25 degrees of left rotation. There was no functional loss due to pain. The VA examination report indicates the range of motion did not contribute to functional loss. In additional, the pain noted did not result in, or cause, functional loss. There was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions but there was additional loss of function or range of motion after three repetitions due to pain. Forward flexion after three repetitions was 40 degrees. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. There was no evidence of no ankylosis or neurologic abnormalities or findings related to a thoracolumbar spine. Furthermore, there was no evidence of IVDS requiring bedrest. There was 5/5 muscle strength, normal reflexes and sensation, and negative straight leg raise. There was no IVDS. The VA examiner stated the Veteran’s low back disability impacted her ability to work as she would experience difficulty with physical labor involving high impact activities, lifting more than 20 lbs, prolonged standing. She would be able to perform sedentary office work with frequent breaks to stretch. Finally, the Veteran was afforded a VA examination in April 2018. The Veteran denied flare-ups, but reported pain on sitting, standing, and walking. The Veteran’s range of motion was forward flexion at 20 percent, 15 degrees of extension, 20 degrees of right lateral flexion, 15 degrees of left lateral flexion, 25 degrees of right rotation, 30 degrees of left rotation, with objective evidence of pain but no additional limitation of motion upon repetition. There was 5/5 strength and normal reflexes and positive straight leg raise test. The Veteran’s abnormal range of motion contributed to a function loss resulting in painful to sit, stand, bend, and lay flat. There was evidence of pain with weightbearing and was described as painful at L1-L5 and right S1 joint and moderate severity. The Veteran had guarding or muscle spasms of the thoracolumbar spine, there were presence of muscle spasms and guarding but did not result in abnormal gait or abnormal spinal contour. There was evidence of radiculopathy in the bilateral extremities. The Veteran did not have other neurologic abnormalities or findings related to the thoracolumbar spine condition, such as bowel or bladder problems/pathologic reflexes. The VA examiner determined the Veteran had but was without any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The veteran also did not use any assistive devices as a normal mode of locomotion. The VA examiner determined the Veteran’s thoracolumbar spine did not impact her ability to work. For the period of time on appeal prior to August 28, 2009, the Board finds that the medical and lay evidence does not demonstrate the criteria for a 20 percent evaluation. The 2008 VA examination noted 80 degrees of flexion after repetitive motion, a combined evaluation in excess of 120 degrees, and normal gait and spinal contour. Thus, an increased evaluation is not warranted. Considering additional functional loss, the examiner found there was no additional limitation to joint function after repetitive motion. Finally, the examiner determined there was no intervertebral disc disease. Thus, an increased evaluation is not warranted. No separate evaluation is warranted for this time period despite the Veteran’s reports of bowel complaints, as the examiner found no evidence of radicular pain and a negative straight leg raise test. From August 28, 2009, to April 19, 2018, the Veteran’s lumbar spine disability manifested in 40 degrees of extension after repetitive motion. Considering additional functional loss, the Veteran had numerous complaints, including severe pain. But the examiners found normal gait, 5/5 strength, and no objective evidence of spasm, atrophy, guarding, pain with motion, tenderness, and weakness. There were no additional functional limitations after three repetitive range of motion other than reduced range of motion. The Veteran was able to perform repetitive use testing with at least three repetitions but there was additional loss of function or range of motion after three repetitions due to pain. Furthermore, the 2016 examiner found there was no evidence of neurologic abnormalities, and that there were normal reflexes and sensation, and negative straight leg raise. The examiner found there was no IVDS, and the Veteran denied bedrest. Thus, no higher evaluation for IVDS or separate evaluations for neurological impairments are warranted. On and after April 19, 2018, the medical and lay evidence reflects that the Veteran’s service-connected lumbar spine disability does not manifests with favorable or unfavorable ankylosis of the lumbar spine or of the entire spine. Even considering additional functional loss, there is no basis for an increased evaluation. The Veteran reported pain on sitting, standing, and walking. Moreover, the Veteran denied flare-ups. There was 5/5 strength. The VA examiner determined the Veteran was without any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran also did not use any assistive devices as a normal mode of locomotion. Thus, no higher evaluation is warranted. In summary, the Board concludes that the preponderance of the evidence is against the claim for increased ratings for the Veteran’s service-connected degenerative arthritis of the lumbar spine for any period of time on appeal. The benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application as there is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and applied appropriately. See Fenderson, supra. In addition, the Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321 (b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the Veteran's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Thun, 22 Vet. App. 111; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, VA must determine whether the Veteran's exceptional disability picture exhibits other related factors, such as those marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Here, the Veteran has asserted that her low back disability pain interferes with her sleep. This symptom is not expressly contemplated in the diagnostic criteria. The Board finds, however, that this is contemplated by the regulations addressing additional functional loss, to include the effects of pain. Thus, referral for an extraschedular evaluation is not warranted. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for residuals of a whiplash injury to the neck and shoulders, to include as secondary to service-connected lumbar spine degenerative arthritis. Remand is required for an additional and adequate VA examination opinion. In June 2016, the Board determined that additional development was warranted as the record suggested that the Veteran has a current diagnosis of degeneration of the cervical intervertebral disc and the March 2010 service treatment record stated that the Veteran likely had cervical spondylosis; and an April 2010 Medical Board Report documented that the Veteran had cervicalgia, probably due to spondylosis, that existed prior to service and was permanently aggravated by service. The Board noted that it was unclear from the record whether the reported whiplash injury occurred when the Veteran was serving on ACDUTRA or INACDUTRA. As the Veteran’s assertions specifically encompassed reserve duty, the Board requested verification of ACDUTRA and/or INACDUTRA. The Board notes the Veteran’s statement in the March 1989 Report of Medical History that she had been treated by a chiropractor for whiplash on December 28, 1988. Based on this information, according to the US Air Force Reserve records, the Veteran performed INACDUTRA from August 20, 1988, to August 21, 1988; October 29, 1988, to October 30, 1988; November 5, 1988; November 6, 1988; November 19, 1988, to November 20, 1988; and December 10, 1988, to December 11, 1988. Following the remand, the Veteran underwent a VA examination in October 2016, where a diagnosis of degenerative arthritis of the cervical spine, cervical spondylosis, was confirmed. The VA examiner provided an opinion whether this condition was at least as likely as not incurred in or caused by an event, illness, or injury during active duty service from August 1981 to August 1985; whether is it at least as likely as not) that the disorder was incurred in or aggravated during a period of ACDUTRA / INADCUTRA; and whether the disorder clearly and unmistakably preexisted the period of service from October 2001 to September 2002, and from February 2003 to February 2004, and if so, whether the disorder clearly and unmistakably not aggravated by this period of service. According to this VA examination report there was no indication of a current shoulder disability. Therefore, the VA examiner provided an opinion regarding the cervical spine disability pursuant to the October 2016 directives. In November 2017, the Board determined additional development was warranted as an opinion regarding whether the Veteran’s disability was secondary to her service-connected arthritis of the lumbar spine. As such the Veteran was afforded new VA examinations in August 2018 where a diagnosis of a left shoulder strain was noted. The VA examiner provided an etiological opinion regarding whether it was secondary to the Veteran’s service-connected lumbar spine disability. Given the new diagnosis of a left shoulder strain, and as etiological opinions as to whether it was related to the Veteran’s periods of service (from August 1981 to August 1985; from October 2001 to September 2002; and from February 2003 to February 2004); ACDUTRA/INACDUTRA; or clearly and unmistakably preexisted any periods of service, and if, so whether it clearly and unmistakably not aggravated by these periods of service were not provided, remand for a VA examination opinion is required. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. As the adjudication of the service connection claim being remanded likely will impact adjudication of the claim for TDIU, it is inextricably intertwined and this issue is also remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the electronic record all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the electronic record. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and her representative. 2. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and her representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the left shoulder strain from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided where any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. A thorough explanation for any opinion must be provided. The examiner must obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully reasoned explanation. For each current shoulder disability, the examiner must provide the following opinions: a) Regarding the period of active duty service from August 1981 to August 1985; from October 2001 to September 2002; and from February 2003 to February 2004, is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability had its onset in or is otherwise related to service? b) For the verified periods of ACDUTRA or INACDUTRA is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability was incurred in or aggravated during one of these periods? c) Regarding the period of active duty service (from August 1981 to August 1985; from October 2001 to September 2002; and from February 2003 to February 2004), did the left shoulder disability clearly and unmistakably preexist this period of service? If so, was such left shoulder disability clearly and unmistakably not aggravated by this period of active service? If not, is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability had its onset in or is otherwise related to this period of active service? In providing an opinion, the examiner must address the following: (1) the Veteran’s testimony from the December 2015 Board hearing that she experienced a whiplash injury that occurred in 1988 or 1989; (2) the Veteran’s statement in the March 1989 Report of Medical History that she had been treated by a chiropractor for whiplash on December 28, 1988; (3) the Veteran’s testimony from the December 2015 Board hearing that the injury occurred after an argument when her hair was grabbed, her head was yanked, and her head was hit against a wall; (4) the Veteran’s testimony from the December 2015 Board hearing that she had to wear a neck brace for a long time after the injury, and she could not work for a while; and (5) the August 2018 VA examination which diagnosed the Veteran with a left shoulder strain. 4. Notify the Veteran that it is her responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yoo, Counsel