Citation Nr: 1807645 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 14-10 832A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for right upper extremity radicular neuropathy. 2. Entitlement to an initial rating in excess of 20 percent for left upper extremity radicular neuropathy. 3. Entitlement to an initial rating in excess of 10 percent for right lower extremity radicular neuropathy. 4. Entitlement to an initial rating in excess of 20 percent for left lower extremity radicular neuropathy prior to July 16, 2016 and in excess of 10 percent thereafter. 5. Entitlement to a rating in excess of 30 percent for avascular headaches with syncope. 6. Entitlement to a total disability based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD N. Robinson, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1982 to May 1986 and November 1986 to July 2001. These matters are before the Board of Veterans' Appeals (Board) on appeal from March 2009, March 2010, and February 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. Jurisdiction has subsequently been transferred to the RO in Winston-Salem, North Carolina. During the course of the appeal, a March 2010 rating decision granted an increased rating of 30 percent for headaches, effective September 28, 2004. The Veteran has not expressed satisfaction with this determination; therefore, the increased rating claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). This case was previously before the Board in November 2015 and remanded for additional development. In an October 2016 Supplemental Statement of the Case (SSOC), the RO assigned a staged rating of 10 percent for the Veteran's left lower extremity neuropathy, effective July 16, 2016. The Board acknowledges that the Veteran has filed a substantive appeal for the issues of entitlement to increased ratings for sarcoidosis and uveitis, and entitlement to service connection for brain thrombosis, bilateral glaucoma/visual impairment, bilateral hip condition, and whether new and material evidence has been submitted to reopen claims seeking service connection for an ear disorder, depression, facial pain, a right shoulder condition, and a left shoulder condition. The Board's review of the claims file reveals that the Veteran has requested a Board hearing before these issues are adjudicated. As such, they will be the subject of a subsequent Board decision. FINDINGS OF FACT 1. The Veteran's headaches are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. The Veteran's right and left upper extremity peripheral neuropathy is manifested by, at worst, moderate incomplete paralysis of the lower radicular group. 3. The Veteran's right and left lower extremity peripheral neuropathy is manifested by, at worst, moderate incomplete paralysis of the sciatic nerve. 4. The Veteran's service-connected disabilities have rendered him unable to maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an increased rating of 50 percent, but no higher, for headaches been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, Diagnostic Code (DC) 8100 (2017). 2. The criteria for an increased initial disability rating of 20 percent from July 16, 2016, but no higher, for left lower extremity neuropathy, have been met. The criteria for a rating higher than 20 percent prior to July 16, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.120, 4.123, 4.124, 4.124a, DC 8520 (2017). 3. The criteria for an increased rating of 20 percent, but no higher, for right lower extremity neuropathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.120, 4.123, 4.124, 4.124a, DC 8520 (2017). 4. The criteria for an increased rating of 40 percent for right upper extremity neuropathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.120, 4.123, 4.124, 4.124a, DC 8512 (2017). 5. The criteria for an increased rating of 30 percent for left upper extremity neuropathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.120, 4.123, 4.124, 4.124a, DC 8512 (2017). 6. The criteria for a TDIU rating have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised concerns with the duty to notify. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Regarding the duty to assist, the Veteran has been afforded several VA examinations to assess the severity of his service-connected neuropathy, including on remand. Taken together, these examination reports are adequate for rating purposes because they describe the the Veteran's symptoms, discuss his past clinical history, and provide the required examination findings to rate these disabilities under the pertinent diagnostic codes. There also was the required compliance, certainly acceptable substantial compliance, with the Board's previous remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (where the remand orders of the Board are not complied with, the Board itself errs as a matter of law when it fails to ensure compliance); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that "substantial" rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Legal Criteria: Increased Ratings Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. Separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The RO has assigned staged ratings for the Veteran's left lower extremity neuropathy described below. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. I. Headaches Legal Criteria The Veteran is claiming an increased rating for his headaches, which are rated as 30 percent disabling under 38 C.F.R. § 4.124a, DC 8100. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating (the maximum available) is warranted when there are very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Factual Background During his April 2008 VA examination, the Veteran reported daily headaches lasting two to four hours. He stated he retired from the Army sooner than planned due to his headaches, especially because prior episodes were associated with blackouts. The examiner described weekly prostrating migraines lasting hours. The examiner noted that the headaches significantly impacted the Veteran's work by affecting his concentration and causing him to miss full or partial work days. During his October 2009 VA examination, the Veteran reported daily headaches lasting several hours with associated nausea and light and sound sensitivity. He was taking medication to treat his headaches. During his July 2013 VA examination, the Veteran reported taking headache medication for the past seven years. His headache symptoms included light and sound sensitivity, dizziness, and sleepiness. His headaches last for a few hours to a day. The examiner did not indicate the frequency of the Veteran's headaches but stated that he did not have prostrating attacks of headache pain. The Veteran reported he was on social security disability since April 2010 due to all of his medical problems. During an August 2016 VA examination, the physician characterized the Veteran's condition as avascular headaches with syncope. The Veteran reported pulsating and throbbing head pain with light and sound sensitivity, nausea, and fatigue. The physician noted that prostrating headache attacks occur more frequently than once a month, and that the Veteran experiences very frequent and prolonged attacks of headaches and pain. The physician opined that the Veteran is unable to work when the headaches occur. In a September 2017 disabilities benefits questionnaire, the physician reviewed the Veteran's history of severe headaches associated with loss of consciousness and several falls and syncopal episodes. The clinician noted that the Veteran's headaches were probably migraines because they partially responded to migraine medication. The headaches are associated with pain that worsens with physical activity and are not adequately responding to treatment. The physician also noted that the Veteran's daily headaches and neuropathy significantly impact his ability to work. Analysis After a careful review of the evidence, the Board finds that the Veteran is entitled to an increased rating of 50 percent (the maximum available under DC 8100) for his headaches. This rating is supported by April 2008 and August 2016 examination reports of very frequent and prostrating prolonged headaches, as well as the other medical and lay evidence of record including both VA and private neurological treatment records. Moreover, the DC 8100 rating criteria do 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). Thus, to the extent that the July 2013 VA examiner's opinion was affected by the headaches' response to medication, such opinions cannot be considered evidence against the Veteran's claim. Finally, the Veteran has described the impact of his headaches on his ability to work, which is an element of the 50 percent rating under DC 8100. His lay statements are supported by the August 2016 examiner's finding that the Veteran is unable to work when headaches are present. This interference with employment is encompassed by the 50 percent rating under DC 8100 as "productive of severe economic inadaptability," granted here, and also by the award of TDIU discussed below. Resolving reasonable doubt in the Veteran's favor, the Board finds that an increased rating of 50 percent under DC 8100 best approximates his headache disability picture. II. Radicular Neuropathy Legal Criteria The Veteran is claiming an increased rating for his right and left upper and lower extremity neuropathy. His right and left upper extremity neuropathy is rated at 20 percent disabling under 38 C.F.R. § 4.124a, DC 8513-8512. His right lower extremity neuropathy is rated at 10 percent disabling under DC 8520. His left lower extremity neuropathy is rated at 20 percent disabling prior to July 16, 2016 and 10 percent disabling thereafter under DC 8520. Under Diagnostic Code 8512, a 20 percent disability rating is warranted when there is mild incomplete paralysis of the lower radicular group in the minor or major extremity. A 30 percent rating is appropriate when there is moderate incomplete paralysis of the minor extremity and 40 percent rating is appropriate when there is moderate incomplete paralysis of the major extremity. A 40 percent rating is appropriate when there is severe incomplete paralysis of the minor extremity and a 50 percent rating is appropriate when there is severe incomplete paralysis of the major extremity. When there is complete paralysis of the lower radicular group, involving all intrinsic muscles of the hand, and some or all flexors of the wrist and fingers, wherein the paralysis results in the substantial loss of use of the extremity, the maximum 60 percent disability rating is awarded for the minor extremity and a 70 percent rating is warranted for the major extremity. See 38 C.F.R. § 4.124a, DC 8512. Diagnostic Code 8513 provides the rating criteria for paralysis of all radicular nerve groups. Disability ratings of 20 percent, 40 percent and 70 percent are assigned for incomplete paralysis of all radicular groups of the major extremity which is mild, moderate, or severe in degree, respectively. Disability ratings of 20 percent, 30 percent, and 60 percent are assigned for incomplete paralysis of the minor extremity which is mild, moderate, or severe in degree, respectively. Disability ratings of 90 percent and 80 percent are assigned for complete paralysis of the radicular nerve group of the major and minor extremity, respectively. See 38 C.F.R. § 4.124a, DC 8513. Peripheral neuropathies affecting the sciatic nerve are rated under DC 8520. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and a maximum 80 percent rating is warranted for complete paralysis. See 38 C.F.R. § 4.124a, DC 8520. The terms "mild," "moderate," "moderately severe," and "severe" are not defined in the regulations. Rather than applying a mechanical formula, the Board must evaluate all of the evidence. 38 C.F.R. § 4.6. Although the use of the terms "mild," "moderate," "moderately severe," and "severe" by VA examiners and others is evidence to be considered by the Board, it is not dispositive of the issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Neurological conditions are ordinarily rated in proportion to the impairment of motor, sensory or mental function, with consideration especially of psychotic manifestations, complete or partial loss of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Factual Background During his April 2008 VA examination, the Veteran reported constant 8/10 to 10/10 radiating pain to both legs. He also reported 9/10 to 10/10 radiating pain to both shoulders and sometimes to his hands. He denied bladder or bowel dysfunction. Prolonged sitting worsened the pain. His motor/strength examination was normal. There was no muscle atrophy. Upper and lower extremity sensation and reflexes were normal. The examiner opined that the Veteran's cervical spine condition caused decreased mobility, decreased manual dexterity, problems with lifting and carrying, weakness or fatigue, and decreased strength. In an April 2008 VA treatment record, he reported intermittent sharp neck and back pain without definite radiation. In a November 2008 VA treatment record, he reported chronic neck pain with some radiation to his left arm. During his June 2009 VA examination, the Veteran reported left upper and lower extremity weakness and numbness. The examiner diagnosed left lower extremity superficial peroneal nerve palsy. No right-sided neurological disorder was noted. In a June 2009 VA treatment record, the Veteran reported neck pain radiating to both arms. In an August 2009 private treatment record, he reported radiating pain to his arms and legs. The clinician recorded normal motor and sensory examinations and diagnosed lumbar and cervical radiculopathy. In another August 2009 private treatment record, the Veteran reported upper extremity numbness, aching, and pain for several years. Examination revealed 4+/5 handgrip strength, trace reflexes, and mildly decreased right hand sensation. His gait was normal. September 2009 nerve conduction and EMG studies showed bilateral wrist nerve compression and muscle irritability suggestive of C5 radiculopathy. In his October 2009 VA TBI examination, he reported intermittent numbness and tingling and weakness in his arms and legs. On examination, his motor tone and bulk were normal. His motor and sensory examinations were normal. His reflexes were mildly diminished but symmetric. In October 2009 and April 2011 private treatment records, he reported bilateral arm and leg tingling and numbness. In a January 2011 private treatment record, he reported left arm and leg weakness and intermittent decreased sensation in his hands and feet. On examination, there was no muscle atrophy, and his strength was 5/5. His sensation decreased in his right fingers, left leg, and left big toe. His reflexes were normal. The clinician suggested that further investigation could focus on determining the contribution of sarcoidosis, migraines, or cervical spine disc disease to these symptoms. May 2011 EMG and nerve conduction studies showed bilateral lower extremity sensory-motor neuropathy. During May 2011 private treatment, he reported continued bilateral leg numbness and tingling. His muscle strength was 4+/5, and his lower extremity reflexes were decreased. His sensory examination showed distal sensory changes in both legs. In an October 2012 private treatment record, he reported neck pain radiating to his left elbow. Sensory examination was equal bilaterally. The assessment was mild neuropathy. In an April 2013 private treatment record, the Veteran reported hip and hand weakness. The clinician noted decreased sensation in the legs. His muscle strength was normal. His reflexes were abnormal. April 2013 to January 2014 chiropractic treatment records show the Veteran was treated for several neurological concerns including spinal pain and stiffness and hip and hand weakness. The July 2013 VA examiner diagnosed bilateral upper and lower extremity neuropathy. The Veteran reported severe left upper and lower extremity intermittent dull pain, mild right upper extremity dull pain, and denied right lower extremity dull pain. He reported moderate paresthesia in all four extremities, moderate numbness in both upper extremities and his right lower extremity, and severe numbness in his left lower extremity. On examination his muscle strength, reflexes, and sensation were normal, and there was no muscle atrophy. The examiner noted that there was loss of hair and shiny skin from the mid-lower leg to his feet. His gait was normal. The examiner assessed all of the Veteran's nerves including the upper extremity radicular group nerves and lower extremity sciatic nerves as normal. The examiner also reviewed the Veteran's September 2009 EMG and nerve conduction studies. Regarding employability, the Veteran reported that he had received social security disability since April 2010 due to all of his medical problems. November 2013 nerve conduction and EMG studies showed bilateral mild lower extremity sensory-motor neuropathy and mild bilateral medial and ulnar nerve compression at the wrists. In December 2013 private treatment records, the Veteran reported continued numbness and tingling in his arms and legs. The neurologist noted equal muscle bulk in all extremities, muscle power of 4+ to 5/5, and markedly decreased reflexes. The assessment was neuropathy. During his February 2014 VA spine examination, the Veteran reported neck pain radiating to his hands. He denied radiating back pain and weakness. On examination, his upper and lower extremity strength, reflexes, and sensation were normal. There was no muscle atrophy. In December 2014 private treatment records, his sensory examination showed distal changes in a non-dermatomal pattern. The clinician noted mild right arm muscle give-way weakness. In March 2015 private treatment records, the Veteran reported periodic bilateral hand numbness and tingling. On examination, his muscle strength and sensation were normal. In an August 2015 written statement, the Veteran reported that his neuropathy was not controlled with medication, and that he had been referred for neurosurgical treatment and injections. During his October 2015 VA spine examination, the Veteran reported moderate intermittent dull pain, paresthesia, and numbness in both legs. The examiner related these symptoms to sciatic nerve disorder and characterized the overall impairment as moderate. The examination showed normal reflexes, sensation, and muscle strength. The examiner noted that the Veteran's neuropathy impacted his ability to lift heavy objects. In November 2015, the Board remanded the case in order to obtain an updated VA neurological examination. During his August 2016 VA examination, the Veteran reported pain and numbness radiating down both legs and both arms. He denied constant leg or arm pain. He described bilateral leg moderate dull intermittent pain, moderate paresthesia, and mild numbness. For both arms, he reported moderate dull intermittent pain and moderate paresthesia. The examiner recorded normal muscle strength and reflexes. There was no muscle atrophy. His sensory examination was normal, except for reduced sensation in both feet. Overall, the examiner characterized the Veteran's lower extremity neuropathy as mild incomplete paralysis of the sciatic nerve and his upper extremity neuropathy as mild incomplete paralysis of the lower radicular neurological group. The examiner noted that the peroneal nerve arises from the sciatic nerve, and therefore, that its dysfunction (as noted in the June 2009 VA examination) is included in the Veteran's sciatic nerve disability. The examiner noted that the Veteran would be unable to lift heavy objects, stand, sit, or use a keyboard for extended periods due to his neuropathy. Analysis Right lower extremity neuropathy After a careful review of the evidence, the Board finds that an initial increased rating of 20 percent for the Veteran's right lower extremity neuropathy is warranted during the entire appellate period. The Board notes that the August 2016 examiner characterized this disability as mild incomplete paralysis of the sciatic nerve, which is accorded a 10 percent rating under DC 8520. However, because the Veteran has reported moderate and severe pain and tingling and weakness, a 20 percent evaluation better approximates his overall disability picture. In order to receive an increased rating of 40 percent, the evidence must show moderately severe incomplete paralysis of the sciatic nerve. Here, the Board notes the Veteran's April 2008 report of constant 8/10 to 10/10 radiating pain to both legs. However, the remaining evidence of record including copious private and VA treatment records does not reflect these severe symptoms or equivalent examination findings. For example, the July 2013 examiner characterized the Veteran's sciatic nerves as normal. During that examination, the Veteran denied right lower extremity pain. The November 2013 nerve conduction study showed mild neuropathy. In his February 2014 examination, he denied radiating pain from his back. During his October 2015 VA examination, he reported moderate symptoms including pain, paresthesia, and numbness in his right leg. This examiner identified a sciatic nerve disorder, which he characterized as moderate. The physical examination was normal. The August 2016 VA examiner described the Veteran's right lower extremity as mild incomplete paralysis, a finding which was based on the Veteran's report of intermittent moderate pain and paresthesia as well as the largely normal neurological examination. The other evidence including the private treatment records reviewed above is significant for the Veteran's report of impaired sensation, numbness, and tingling. Clinicians documented normal lower extremity muscle strength with some decreased sensation and reflexes. No muscle atrophy was noted. Overall, this evidence supports an increased rating that reflects moderate impairment. This increase takes into account the April 2008 report of more severe symptoms with the Veteran's more consistent reports of moderate intermittent pain and the clinician's findings of none-to- mild-to-moderate impairment. Accordingly, an increased rating of 20 percent, but no higher, is warranted for right lower extremity neuropathy during the appellate period. Left lower extremity neuropathy The Veteran's left lower extremity neuropathy is rated at 20 percent disabling prior to July 16, 2016 and 10 percent disabling thereafter. Resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports a finding that his left lower extremity neuropathy is manifested by symptoms equivalent to moderate incomplete severity during the entire period on appeal. Accordingly, he is entitled to a rating of 20 percent, but no higher, for left lower extremity neuropathy. This rating accommodates the opinions detailed in the VA examination reports that describe generally mild to moderate incomplete paralysis, but recognizes the Veteran's consistent reports of pain, numbness, and tingling. It also reflects the notations in the Veteran's treatment records of decreased sensation and intermittent decreased reflexes. After a careful review of the evidence, the Board finds that an increased rating of 40 percent for moderately severe incomplete paralysis is not warranted. As discussed above, the Veteran reported severe lower extremity pain in the April 2008 examination; however, contemporaneous and subsequent treatment records reflect moderate symptoms. Objective testing by physicians reveals mostly normal muscle function with intermittent decreased sensation and reflexes. No lower extremity muscle atrophy was noted in the clinical records. The most recent VA examinations show the clinicians' overall assessment of the Veteran's left leg neuropathy is mild to moderate. Overall, the Board finds that a 20 percent rating recognizes the Veteran's reports of pain, numbness, and tingling as well as the clinical findings of decreased sensation but largely normal muscle function and tone without atrophy. Because the weight of the evidence supports a finding that the Veteran's overall clinical picture is that of moderate symptoms, the Board finds that an increased rating higher than 20 percent is not warranted. Accordingly, a 20 percent rating is warranted for the entire appellate period. Right and left upper extremity neuropathy The Veteran has stated that he is right handed. Accordingly, the right arm is the major extremity for rating purposes. After a careful review of the evidence, the Board finds that an increased rating of 40 percent for right upper extremity neuropathy and an increased rating of 30 percent for left upper extremity neuropathy is warranted under DC 8512. This increased rating recognizes the Veteran's report of moderate symptoms despite the most recent VA examiner's conclusion that his incomplete paralysis is mild. A higher rating is not available under either DC 8512 or DC 8513 unless the evidence shows severe incomplete paralysis. This finding is not supported by the August 2016 examination or the other VA examinations and medical and lay evidence of record. These examinations list the paralysis as mild or do not find paralysis at all. They also document normal sensory and motor examinations. The Board also carefully considered the other medical and lay evidence of record. This evidence also does not support a finding of severe paralysis. The treatment records reflect the Veteran's reports of intermittent pain, numbness, and weakness. It also reflects nerve conduction studies showing mild neuropathy and 4+/5 grip strength. Overall, the Board finds that this evidence, taken in the light most favorable to the Veteran, reflects moderate impairment and supports a rating of 40 percent for his major upper extremity (right arm) and 30 percent for his minor upper extremity (left arm), but no higher. III. TDIU To establish entitlement to TDIU, there must be impairment so severe that it is impossible for the Veteran to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is eligible for a schedular rating of TDIU if either one service-connected disability is rated at least 60 percent or multiple service-connected disabilities yield a combined rating of 70 percent (with at least one of those disabilities rated 40 percent or more). 38 C.F.R. § 4.16(a). In this case, the Veteran meets the schedular criteria for TDIU. He provided competent and credible reports that symptoms from his service-connected headaches and peripheral neuropathy have prevented him from working from April 2, 2010 forward. Eligibility for TDIU is supported by the evidence showing that he has not worked since April 2010, and that he has significant functional limitations due to his headaches and peripheral neuropathy disabilities as noted on the VA examination reports. For example, the August 2016 headache examiner opined that the Veteran is unable to work when having headaches. The examiner also stated that due to his neuropathy he cannot perform heavy physical activities lifting but also cannot use the keyboard or perform other sedentary activities for extended periods of time. The Veteran stated his attempts to work have been unsuccessful due to continuing headache, neurological, and respiratory symptoms. In addition, the Veteran is service connected for sarcoidosis, and Social Security Administration (SSA) documents of record show that he is considered disabled for SSA purposes in part due to his sarcoidosis. Accordingly, the Board finds that the Veteran has been unable to obtain and maintain substantially gainful employment since April 2, 2010 (his last day of employment), and TDIU is granted. The Board would also like to recognize the Veteran's numerous written statements where he patiently explained and summarized his medical conditions. These statements also reflect the Veteran's concern that his clinical picture and symptoms were not completely understood by his medical providers. As noted by the Veteran, he has repeatedly sought private treatment, including traveling extensive distances, to receive comprehensive evaluation. He also ensured that the Board would have a complete record upon which to evaluate his claims by personally obtaining and submitting many of his records. As noted above, the Board carefully reviewed these private treatment records and the Veteran's statements before deciding these issues. The Board appreciates the Veteran's diligent and thorough efforts to explain his conditions while living with significant disability. ORDER Entitlement to an increased rating of 50 percent, but no higher, for headaches is granted, subject to the laws and regulations governing the award of monetary benefits. An increased disability rating of 20 percent, but no higher, for left lower extremity neuropathy from July 16, 2016 is granted, subject to the regulations governing monetary awards. An increased disability rating in excess of 20 percent prior to July 16, 2016 for left lower extremity neuropathy is denied. An increased disability rating of 20 percent, but no higher, for right lower extremity neuropathy is granted, subject to the laws and regulations governing the award of monetary benefits. An increased disability rating of 40 percent, but no higher, for right upper extremity neuropathy is granted, subject to the laws and regulations governing the award of monetary benefits. An increased disability rating of 30 percent, but no higher, for left upper extremity neuropathy is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to TDIU is granted effective April 2, 2010, subject to the laws and regulations governing the award of monetary benefits. ______________________________________________ M. SORISIO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs