Citation Nr: 18153701 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 12-12 374 DATE: November 28, 2018 ORDER Entitlement to service connection for a low back disability is denied. For the entire period on appeal, entitlement to an initial rating of 50 percent for post-traumatic headaches is granted. For the entire period on appeal, entitlement to a total disability evaluation based on individual unemployability (TDIU) is granted. REMANDED Entitlement to an initial rating in excess of 30 percent for insomnia is remanded. Entitlement to an initial rating in excess of 10 percent for mild traumatic brain injury (TBI) is remanded. Entitlement to a rating in excess of 10 percent for cervical spondylosis/chronic cervical strain is remanded. Entitlement to a rating in excess of 10 percent for residual trauma, right wrist, is remanded. Entitlement to an effective date earlier than April 2, 2012, for the grant of service connection for insomnia is remanded. FINDINGS OF FACT 1. The Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; it is not otherwise etiologically related to an in-service injury, event, or disease; and it is neither proximately due to nor aggravated beyond its natural progression by any service-connected disability. 2. Resolving reasonable doubt in favor of the Veteran, for the entire period on appeal, the Veteran’s post-traumatic headaches have been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. For the entire period on appeal, the Veteran meets the schedular criteria for TDIU, and the evidence demonstrates that his service-connected disabilities likely preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis are not met. 38 U.S.C. §§ 1112, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a), 3.310(a) (2017). 2. For the entire period on appeal, the criteria for a 50 percent rating, and no higher, for the Veteran’s post-traumatic headaches are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.124a, DC 8100 (2017). 3. For the entire period on appeal, the criteria for entitlement to TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1981 to September 1981, and from May 1982 to November 1983. This matter is on appeal from June 2010 (low back), October 2012 (headaches, TBI, neck, right wrist, TDIU), and December 2016 (insomnia) rating decisions. The Board previously remanded the issue of entitlement to service connection for a low back disability in December 2013 and December 2016. The record reflects that after the December 2016 statement of the case was issued, additional VA treatment records pertinent to the service-connected insomnia and mild TBI disabilities were uploaded into the claims file without a waiver of initial review of this evidence by the AOJ. However, as the Board is remanding the increased rating claims, the AOJ will have an opportunity to review this newly submitted evidence before readjudicating the claims. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection for chronic diseases listed in 38 U.S.C. sections 1101(3) and 38 C.F.R. § 3.309(a), such as arthritis, may be established on a presumptive basis if the chronic disease was shown as chronic in service; manifested to a compensable degree within a presumptive period, usually one year, after separation from service; or was noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2017). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for a low back disability. The Veteran contends that he has a low back disability related to a motor vehicle accident during service. In the alternative, he contends that his low back disability is secondary to his service-connected disabilities. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for a low back disability is not warranted. The question for the Board is whether the Veteran’s currently diagnosed degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is etiologically related to service, to include the motor vehicle accident therein, or whether it is proximately due to or the result of, or is aggravated beyond its natural progress by a service-connected disability. With respect to service connection on a direct basis, the preponderance of the evidence is against finding that the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is related to an in-service injury, event, or disease, to include the motor vehicle accident in service. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service personnel records show that the Veteran was involved in a motor vehicle accident in July 1983. A September 1983 report by Dr. H. S. did not show any complaints, findings, or diagnosis pertaining to the low back as a result of the July 1983 motor vehicle accident. Likewise, a May 1985 follow-up report did not show any complaints, findings, or diagnosis pertaining to the low back. The available service treatment records did not show any back problems from November 1983 to April 1987. The Board acknowledges that on a November 1983 reserve report of medical history, the Veteran appeared to check “yes” to “recurrent back pain.” However, as the Veteran checked “yes” for every disability listed in that column, and indicated that he was in “good health” on this report, the Board finds that this was most likely checked in error, and he intended to check “no” instead. Moreover, the Veteran’s spine was described as “normal” on the reserve examination paired with this report of medical history. A post-service private treatment record dated in July 2008 showed complaints of multiple arthralgias, including the lumbar spine, that started two years prior. L5-S1 spondylosis and L5-S1 degenerative disc disease were shown on subsequent x-rays. The August 2015 VA examiner opined that the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is not at least as likely as not related to an in-service injury, event, or disease, including the documented motor vehicle accident in service. The rationale was there was no evidence that the Veteran suffered from a lower back condition for the following 11 years after active duty, as evidenced by the Veteran’s own assessment of his health in the questionnaires he signed in 1983, 1989, and 1994. The examiner explained that it was not until 2009 that documentation supported the Veteran was suffering from a lower back condition, 26 years after he suffered from the motor vehicle accident during active duty. The examiner explained there was a lack of continuity of lower back symptoms to rationally support his claim. While the Veteran believes his degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is related to an in-service injury, event, or disease, including the motor vehicle accident in service, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the August 2015 VA examiner’s opinion. Further, although degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is a chronic disease under 38 C.F.R. § 3.309(a), it did not manifest to a compensable degree in service or within a presumptive period, and continuity of symptomatology is not established. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). As noted above, post-service treatment records show the Veteran did not complain of low back pain until approximately 2008, which he stated began two years prior in 2006, and he was not diagnosed with degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis until July 2008, decades after his separation from service and well outside of the applicable presumptive period. As to service connection on a secondary basis, the Board concludes that, while the Veteran has a current diagnosis of degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis, the preponderance of the evidence is against finding that the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is proximately due to or the result of, or aggravated beyond its natural progression by any service-connected disability. 38 U.S.C. § 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The September 2015 VA examiner opined that the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is less likely than not proximately due to or the result of any service-connected condition. The rationale was that there was no documentation in the medical literature establishing a direct cause and effect relationship between residuals of right wrist trauma, mild TBI, post-traumatic headaches, and/or cervical spondylosis, and the development of degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis. Moreover, the March 2018 VA examiner opined that the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis was less likely than not aggravated by the service-connected residuals of right wrist trauma, mild TBI, post-traumatic headaches, and/or cervical spondylosis. The rationale was that there is no documentation in the medical literature establishing a direct cause and effect relationship between any service-connected disability as an aggravating cause of degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis. The Board finds the VA opinions, taken as a whole, are adequate and reliable, and affords them great probative weight. Moreover, there is no competent medical evidence to refute the conclusions of the VA examiners or to otherwise establish a link between the currently diagnosed degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis and any service-connected disability. Considering the above, the Board finds that the opinions of record adequately explain why the Veteran’s degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis was not caused or aggravated by any service-connected disability. While the Veteran believes his degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis is proximately due to or the result of and/or aggravated beyond its natural progression by a service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the September 2015 and March 2018 VA examiners’ opinions. In this case, the Board ultimately places far more probative weight on the lack of low back complaints following the motor vehicle accident in service, in the Veteran’s reserve records from 1983 to 1987, and for more than 20 years after service, and the negative VA medical opinions of record. Given that the most probative opinions are against a finding of a relationship between the currently diagnosed degenerative arthritis of the lumbar spine with spondylolisthesis and spondylolysis and service or any service-connected disability, the Board finds that service connection is not warranted. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Board should resolve any reasonable doubt regarding the extent of the disability in the Veteran’s favor. 38 C.F.R. § 4.3. 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. Entitlement to an initial compensable rating for post-traumatic headaches prior to July 21, 2015, and a rating in excess of 30 percent thereafter. The Veteran is seeking a higher initial rating for his service-connected post-traumatic headaches. In the November 2017 brief, the Veteran’s representative indicated that the December 2016 VA examiner noted prostrating headaches but failed to indicate the frequency. The representative pointed to the VA TBI examination completed the same day, which noted the Veteran’s reports of having to lay down and elevate his head daily mid-day. The Veteran’s representative also pointed to the buddy statements provided by the Veteran’s children discussing the severity of the Veteran’s headaches. The representative noted that these statements indicated that the Veteran had experienced this same headache pain at its current severity since 2012. Finally, the Veteran’s representative pointed to the November 2017 assessment by Dr. H. S., which noted daily prostrating episodes of headache pain impacting the Veteran’s ability to work. The Veteran’s post-traumatic headaches are rated as noncompensable prior to July 21, 2015, and 30 percent disabling thereafter, under 38 C.F.R. § 4.124a., DC 8100. Under DC 8100, a noncompensable rating is warranted for migraine headaches with less frequent attacks; a 10 percent rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months; a 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months; and the maximum 50 percent rating is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The Court of Appeals for Veterans Claims (Court) has recently held that the criteria of DC 8100 are successive, meaning that each disability level builds on another in terms of duration and frequency, and requiring that a veteran rated at a higher level satisfy all the requirements of the lower levels. See Johnson v. Wilkie, 2018 U.S. App. Vet. Claims LEXIS 1253. While the rating criteria does not define “very frequent,” it is presumed that it would have to be far more frequently than once per month. The rating criteria does not define “prostrating,” nor has the Court. According to WEBSTER’S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which “prostration” is defined as “extreme exhaustion or powerlessness.” “Prolong” is defined as “to lengthen in time: extend duration: draw out: continue, protract.” WEBSTER’S THIRD NEW INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE UNABRIDGED 1815 (1966). Finally, the phrase “productive of severe economic inadaptability” has been interpreted as meaning either “producing” or “capable of producing” severe economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Resolving reasonable doubt in the Veteran’s favor, the Board finds that for the entire period on appeal, the Veteran’s post-traumatic headaches more closely approximate the criteria for a 50 percent rating under DC 8100. During this period, the Veteran described, and the evidence showed, very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In this regard, on VA TBI examination in December 2016, the Veteran reported that he continued with daily constant mild to moderate headaches. He noted that he was taking Propanolol which was helping with his headaches, but was no longer taking this medication. He noted that he currently took ASA and Aleve, and has to lay down and elevate his head daily mid-day. On VA headaches examination in December 2016, the Veteran reported constant sharp head pain on both sides. He reported symptoms of nausea, sensitivity to light, sensitivity to sound, and changes in vision. The examiner found characteristic prostrating attacks of migraine headache pain. However, the examiner indicated that the Veteran did not have very prostrating and prolonged attacks of migraines productive of severe economic inadaptability. Nonetheless, the examiner found that the Veteran’s post-traumatic headaches impacted his ability to work. The examiner explained that the Veteran retired in 2011 from his job as a school teacher, as the principal was on him for not moving more, as he had to sit at times. The examiner noted that the Veteran’s post-traumatic headaches impacted his activities of daily living and resulted in difficulty driving highways and more time needed to complete chores. In September 2017, the Veteran’s son submitted a buddy statement describing the severity of the Veteran’s headaches over the past six or seven years, and their impact on his ability to function. He indicated that the Veteran’s headaches occurred often throughout the week. He noted that they usually lasted for several hours, with some so severe that they last for days. The Veteran’s son indicated that when the Veteran had a headache, he has to lay down and is not able to move around too much because of the pain and dizziness. He also noted sensitivity to light and sound. The Veteran’s son indicated that it was difficult for the Veteran to concentrate, and his headaches affected his vision. The Veteran’s son explained that there was no way his dad could work because he would miss too much time as a result of his headaches, noting that his attendance would be affected at least two or three times a week because of his head pain. He noted further that he had to do things for him, such as chores and running headaches, due to the debilitating nature of his headaches. In September 2017, the Veteran’s daughter, J. B.-C., submitted a buddy statement describing the severity of the Veteran’s headaches. She noted that since 2012, the Veteran has suffered from constant issues with frequent headaches throughout the months. She noted that his headaches bothered his eyes and caused dizziness. She noted that the headaches resulted in light and sound sensitivity, which made it difficult for him to concentrate. She noted that the Veteran had to lay down in a cool, dark, quiet place to try and get relief from his headaches. The Veteran’s daughter indicated that the Veteran would definitely miss work and have attendance problems several times a week because his headaches prevent him from being able to function in a working environment. In September 2017, the Veteran’s daughter, M. B.-M., submitted a buddy statement describing the severity of the Veteran’s headaches. She noted that her dad had been experiencing very severe service-connected headaches for the past several years, at least since 2012. She explained that she could see the pain on his face and he often has to sit and rest or lay down because the pain worsens with physical activity. She indicated that the Veteran’s headaches are frequent and occur more than once a week. She noted times when the headaches lasted for several hours resulting in the Veteran being unable to get out of bed. She indicated that she has had to help the Veteran with errands when he has a headache. She noted that the Veteran became dizzy and even nauseous with his headaches. She described sensitivity to light and sound, difficulty concentrating, and blurry vision. She noted that he had to lay down in a cool, dark, quiet place to get relief from his headaches. She indicated that there was “no way” the Veteran could function in a working environment due to the severity and frequency of his headaches, which would prevent him from being able to meet standard attendance requirements. In a November 2017 headaches disability benefits questionnaire completed by Dr. H. S., the Veteran reported daily prostrating headaches with frequency ranging from 45 minutes to four hours. The Veteran reported that his headaches came on suddenly without warning with constant pulsating/throbbing bilateral head pain associated with blurred vision. The Veteran reported that any activity worsens his head pains, and that he must sit or lie down in a dark environment for up to several hours. Dr. H. S. indicated that the Veteran’s treatment plan included taking medication, which included numerous over-the-counter medications (aspirin, ibuprofen, naproxen, acetaminophen, etc.), which only provided minor temporary relief. Dr. H. S. indicated that the Veteran experienced constant pulsating or throbbing head pain that worsens with physical activity. Dr. H. S. noted that the Veteran’ experienced non-headache symptoms associated with his headaches, to include nausea, blurred vision, diminished concentration, and avoidance of “sudden movements.” Dr. H. S. indicated that the typical duration of head pain was less than one day. Dr. H. S. indicated that the Veteran had characteristic prostrating attacks of migraine and non-migraine headache pain more frequently than once per month. Dr. H. S. found that the Veteran had very frequent prostrating and prolonged attacks of non-migraine headache pain. Dr. H. S. found that the Veteran’s headaches impacted his ability to work. He noted that the Veteran had daily prostrating headaches requiring him to move slowly and deliberately, avoid “sudden movements,” and reduce his ability to remain active for fear of significantly prolonged intensity and duration of his headaches. Dr. H. S. noted that the Veteran must rest at least 45 minutes during headache episodes. Dr. H. S. found that the frequency of the Veteran’s headaches prevented him from sustaining any gainful work. In a residual functional capacity evaluation completed in November 2017, Dr. H. S. indicated that the Veteran would miss three days per week of work due to his headaches. Dr. H. S. indicated that the Veteran would have to leave early from the workplace two or more days per week because of his headaches. Dr. H. S. indicated that the Veteran would have daily trouble concentrating due to his headaches. Dr. H. S. concluded that the Veteran would not be able to maintain substantially gainful employment as a result of his headaches. In light of the foregoing evidence showing very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, the Board finds that for the entire period on appeal, a 50 percent rating is warranted for the Veteran’s post-traumatic headaches. The Board acknowledges that in 2012, the evidence showed that the Veteran was taking medication (Propranolol) to treat his hypertension, which helped with his headaches. For example, in a January 2012 VA treatment record, the Veteran stated that his headaches had significantly improved after starting Propranolol 40 milligrams. Likewise, in a July 2012 VA treatment record, the Veteran reported that his headaches had largely resolved with Propranolol. In his September 2012 VA examination, the Veteran reported that his headaches occurred daily prior to treatment with Propanolol, but now that he was on treatment, he only had occasional mild headaches. He reported a duration of less than one day. He denied characteristic prostrating attacks of migraine headache pain, or very frequent prostrating and prolonged attacks of migraine or non-migraine headache pain. In the September 2012 VA examination, the examiner explained that the Veteran’s headaches had not been debilitating since initiating Propanolol therapy, and did not interfere with the Veteran’s ability to work. However, the rating criteria under Diagnostic Code 8100 does not contemplate the ameliorating effects of medication to treat migraines; consequently, the Board is prohibited from assigning a disability rating based on the severity when such medication is taken. See Jones v. Shinseki, 26 Vet. App. 56 (2012). In evaluating the Veteran’s headaches as if medication was not used, as is required under Jones, it appears that the Veteran’s headaches resulted in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Thus, when considering the frequency of the Veteran’s headaches in light of their severity without the use of medication, to include Propanolol therapy, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the disability picture more nearly approximates the criteria required for the 50 percent rating for the entire time on appeal. 38 C.F.R. § 4.7. Consequently, the Board finds that an increased 50 percent rating is warranted for the entire period on appeal. This is the maximum schedular rating provided by regulation. Entitlement to TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board notes that on his July 2012 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, the Veteran indicated that he was unable to work as a result of his service-connected headaches, along with his nonservice-connected back disability. However, the Veteran has essentially contended that his service-connected post-traumatic headaches, insomnia, and mild TBI symptoms alone render him unemployable. See November 2017 brief. For the reasons discussed below, the Board finds that for the entire period on appeal, the Veteran is entitled to TDIU due to his service-connected disabilities, namely his post-traumatic headaches, insomnia, and mild TBI. The Veteran is in receipt of a 50 percent rating for post-traumatic headaches; a 30 percent rating for insomnia; a 10 percent rating for residual, trauma, right wrist; a 10 percent rating for mild TBI; and a 10 percent rating for cervical spondylosis/chronic cervical strain. As such, he meets the schedular rating threshold for the grant of TDIU. Thus, the main question before the Board is whether the Veteran’s service-connected disabilities alone render him unable to obtain substantially gainful employment. Based on the Veteran’s competent and credible reports, the findings in the September 2012 and December 2016 VA examinations, the findings in the November 2017 headaches disability benefits questionnaire, the symptomatology described in the VA treatment records, and the November 2017 opinion from Dr. H. S., the record essentially shows that the Veteran cannot obtain and maintain employment due to the impairments from his service-connected post-traumatic headaches, insomnia, and mild TBI disabilities. The evidence shows that the Veteran has a college education with a master’s degree in social work. He reported that he worked as a social worker for 15 years, and then changed careers and became a social studies teacher. He last worked full time as a high school teacher from September 1988 to June 2011. He retired and was placed on Social Security Administration (SSA) disability beginning June 10, 2011, due to his non-service-connected back, hypertension, and sleep-related breathing disorder. The Veteran has competently and credibly reported the impact his service-connected disabilities have on his ability to work. In his July 2012 VA Form 21-8940, the Veteran reported that he suffers from nagging headaches and experiences difficulties performing simple tasks. Moreover, a statement provided by the Veteran in September 2017 discussed the specific limitations he experiences on a daily basis from his service-connected conditions. He reported a lot of limitation and impairments due to his service-connected mild TBI. He noted memory lapses, confusion while completing simple basic tasks, and diminished awareness and perception of situations, and indicated that he required help taking care of chores and following through with tasks. The Veteran indicated that his service-connected insomnia exacerbated these problems and made focusing and concentrating even more difficult. He noted that when he is unable to sleep well, he is not as aware or cognizant, and this impairs his ability to complete tasks safely. The Veteran reported that because of these impairments, he does not go out as much anymore and only leaves his home when necessary. The evidence throughout the appeal period has supported the Veteran’s contentions regarding the impact his service-connected disabilities have on his ability to work. For example, the September 2012 VA examiner found that the Veteran’s service-connected cervical spondylosis/chronic cervical strain precluded him from performing heavy physical labor, such as heavy lifting, or work requiring rigorous use of his upper extremities, such as manual labor. The September 2012 VA examiner noted the Veteran’s complaints of memory problems and headaches. The examiner indicated that the Veteran’s memory problems, as the Veteran described them, were severe enough to interfere with work. In the September 2013 private disability benefits questionnaire, Dr. H. H.-G. found that the Veteran could not sustain the stress from a competitive work environment and could not be expected to engage in gainful activity secondary to the level of impairment connected to his service-connected injuries and subsequent mood disorder. In the December 2016 VA headaches examination, the examiner found that the Veteran’s service-connected post-traumatic headaches impacted his ability to work. The examiner noted that the Veteran reported that he retired in 2011 as a school teacher because the principal was on him for not moving more, as he had to sit at times. The examiner indicated that the Veteran’s service-connected headaches would cause difficulty driving highways and completing chores. The Veteran’s children also provided statements in September 2017 detailing his functional limitations in abilities to complete activities of daily living as a result of his service-connected insomnia, headaches, and mild TBI/cognitive symptomatology. They described difficulty concentrating and focusing as a result of the service-connected headaches, insomnia, and mild TBI; memory problems as a result of the service-connected TBI; and probable attendance problems as a result of the service-connected headaches. Moreover, in November 2017, Dr. H. S. provided a medical opinion regarding the Veteran’s employability. Dr. H. S. noted the Veteran’s reports of persistent depression and insomnia that significantly hindered his ability to fall and stay asleep each night, resulting in persistent fatigue every day associated with grossly diminished focus and concentration, increased irritability, social isolation, worsening of headaches, and memory deficits. Dr. H. S. noted the Veteran’s reports of inability to drive long distances due to becoming easily disoriented, as well as headaches impacting his ability to see and focus adequately to operate a vehicle. Dr. H. S. noted the Veteran’s reports of an inability to make any “sudden movements” with his body, especially his neck, upper extremities, or head, due to fear of bringing on or significantly exacerbating his headaches. Dr. H. S. noted the Veteran’s need to lie down each day for approximately 45 minutes – sometimes more than once per day – in order to keep his headaches at bay. Dr. H. S. noted the Veteran’s reports of requiring assistance in performing basic chores around the house and running errands. Based on his review of the Veteran’s claims file, the numerous statements from his children, as well as his interview of the Veteran, Dr. H. S. opined that the Veteran’s service-connected impairments have more likely than not been present to a degree of frequency and severity that has prevented him from maintaining gainful work in any employment base since the Veteran stopped working in 2011. The Board acknowledges that the Veteran has at times attributed his inability to work to the limitations from his non-service-connected low back disability. However, the Board finds that the overall evidence of record, as described above, supports a finding that the Veteran has been unable to work throughout the duration of the appeal period solely as a result of the functional impairments from his service-connected disabilities, namely his headaches, insomnia, and mild TBI. As such, the Board finds that the Veteran is entitled to TDIU due to his service-connected disabilities for the entire period on appeal. The benefit of the doubt rule is therefore for application for this timeframe. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND With respect to the claims for increased ratings for insomnia and mild TBI, the Board observes that the Veteran was last afforded VA examinations in December 2016, and evidence recently added to the claims file indicates that his symptomatology may have worsened. See, e.g., September 2017 buddy statements and Veteran statement (describing the severity and impact of TBI/cognitive/insomnia/mental health problems) and January and February 2018 VA treatment records (containing psychological and neurocognitive consultations). The Veteran should be provided an opportunity to report for VA examinations to ascertain the current severity and manifestations of his service-connected insomnia and mild TBI. The Board notes that although the Veteran submitted a mental health disability benefits questionnaire in September 2013, it does not contain all of the information necessary to adequately rate the claim. For example, it only noted a diagnosis of mood disorder, which is not a service-connected disability. It did not reference the Veteran’s service-connected diagnosis of insomnia. The VA examinations regarding the Veteran’s cervical spondylosis/chronic cervical strain and residual trauma, right wrist, do not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016) or Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Notably, the September 2012 VA cervical spine examination did not include passive range of motion measurements or pain with weight bearing testing. Additionally, the September 2012 cervical spine examiner did not provide estimated range of motion findings regarding repetitive use over time or during flare-ups. The September 2012 VA wrist examination did not include passive range of motion measurements, pain with weight bearing testing, or left wrist range of motion measurements. Additionally, the September 2012 right wrist examiner did not provide estimated range of motion findings regarding repetitive use over time. While on remand, updated VA treatment records should be obtained. Regarding the claim of entitlement to an effective date earlier than April 2, 2012, for the grant of service connection for insomnia, in March 2017, the Veteran submitted a timely notice of disagreement with the December 2016 rating decision, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2018 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected insomnia. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected insomnia alone. 3. Schedule the Veteran for a TBI examination to determine the severity of his mild TBI. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. 4. Schedule the Veteran for an examination of the current severity of his cervical spondylosis/chronic cervical strain. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the cervical spondylosis/chronic cervical strain disability alone and discuss the effect of the Veteran’s cervical spondylosis/chronic cervical strain disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Schedule the Veteran for an examination of the current severity of his residual trauma, right wrist. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must include range of motion measurements for the left wrist, if it is undamaged. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the residual trauma, right wrist, disability alone and discuss the effect of the Veteran’s residual trauma, right wrist, disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 6. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to an effective date earlier than April 2, 2012, for the grant of service connection for insomnia. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. 7. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs