Citation Nr: 18144999 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 16-50 236 DATE: October 25, 2018 REMANDED Entitlement to increased rating higher than 10 percent for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1985 to March 2011. The Board finds that a remand is necessary in order to provide the Veteran with an adequate VA examination to determine the current severity of her lumbar spine disability. Notably, in connection with her claim for increase, the Veteran underwent a VA examination for her spine in December 2015. The examiner indicated that the Veteran’s claims file and or other records were not reviewed. The Veteran reported flare-ups and functional loss after repetitive use over time. Nevertheless, the examiner stated that the Veteran was not examined immediately after repetitive use over time and the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner then noted that pain significantly limited functional ability with repeated use over time, but noted that it could not be described in terms of range of motion. Furthermore, regarding flare-ups, the examiner noted that the examination was conducted during a flare-up, but again simply checked “no” for whether pain that significantly limited functional ability could be described in terms of range of motion. No findings for active versus passive motion were provided. Thus, the examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Furthermore, on the September 2016 Substantive Appeal, the Veteran reported the pain shot through her hips and radiated down the back of the legs. Private treatment records reflect a diganosis of sciatica. Significantly, the December 2015 examiantion did not reflect any radicular pain or other signs or symptoms due to radiculoapthy. As the evidence suggests a worsening of symptoms, an updated examination is necessary. The matter is REMANDED for the following action: 1. Ensure that all outstanding VA treatment records since the August 2016 SOC are associated with the claims file. 2. Then, provide the Veteran with a VA examination to identify the severity of her lumbar spine disability. The claims file must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran all signs and symptoms of her lumbar spine disability. In doing so, also obtain information from the Veteran (and the treatment records) as to the frequency, duration, characteristics, severity, or functional loss with any repetitive use or during any flare-ups. (b) Full range of motion testing must be performed where possible. The joints involved should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. If pain is found during the examination, the examiner should note when the pain begins. (c) In assessing functional loss, flare-ups and increased functional loss on repetitive use must be considered. The examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. In other words, the examiner should estimate any additional loss of motion during flare-ups based on the Veteran’s reported history, provided that such history is generally consistent with the overall disability picture. **If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). A complete rationale should be provided. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel