Citation Nr: 1804351 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-02 833 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to a rating in excess of 10 percent disabling for service-connected coronary artery disease (CAD), prior to September 8, 2010 and in excess of 60 percent disabling thereafter. 2. Entitlement to a rating in excess of 50 percent disabling for service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to a rating in excess of 30 percent disabling for service-connected Parkinson's disease. 4. Entitlement to a compensable rating prior to December 31, 2007, for service-connected degenerative arthritis of the lumbosacral spine, and in excess of 20 percent prior to January 8, 2011, and in excess of 10 percent disabling thereafter. REPRESENTATION Veteran represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD J. Unger, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1969 to February 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2008 and February 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, and Phoenix, Arizona, respectively. Jurisdiction presently resides with the RO in Phoenix, Arizona. The February 2008 rating decision increased the evaluation of degenerative arthritis of the low back to 20 percent. The Veteran submitted a Notice of Disagreement in March 2008. No Statement of the Case was issued on the matter until December 2013. FINDINGS OF FACT 1. Prior to September 8, 2010 the Veteran's CAD was not productive of a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs which resulted in dyspnea, fatigue, angina, dizziness, or syncope, or in evidence of cardiac hypertrophy or dilatation in electrocardiogram, echocardiogram or X-ray. 2. At no point during the period on appeal has the Veteran's CAD been shown to be productive of chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction (LVEF) of less than 30 percent 3. The Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas as a result of psychiatric symptomatology to include suicidal ideation, depressed mood, anxiety and panic attacks, difficulty sleeping, irritability, isolation, and exaggerated startle response; however, the frequency, duration, and severity of such symptomatology have not produced more severe manifestations that more nearly approximate total occupational and social impairment. 4. For the entire appeal period, the symptoms related to the Veteran's service-connected Parkinson's disease are most appropriately rated collectively under Diagnostic Code 8004. 5. For the period prior to December 31, 2007 and after January 8, 2011, the Veteran's degenerative arthritis of the lumbosacral spine was not productive of limitation of forward thoracolumbar flexion to less than 60 degrees or combined range of motion of the thoracolumbar spine of 120 degrees or less, even in contemplation of functional loss due to pain, fatigability, incoordination, pain on movement, and weakness, or as a result of repetitive motion or flare-ups; muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour; ankylosis; intervertebral disc syndrome (IVDS) with incapacitating episodes; or neurologic impairment other than service-connected paresthesia of the right lower extremity and neuritis associated with degenerative arthritis of the lumbosacral spine and left lower extremity radiculopathy, sciatic nerve associated with degenerative arthritis of the lumbosacral spine. 6. For the period from December 31, 2007 to January 8, 2011, the Veteran's degenerative arthritis of the lumbosacral spine is not productive of limitation of forward thoracolumbar flexion to 30 degrees or less or ankyloses (favorable or unfavorable) of the entire thoracolumbar spine or entire spine; IVDS with a period of incapacitation of four weeks or great, or neurological impairment other than service-connected paresthesia of the right lower extremity and neuritis associated with degenerative arthritis of the lumbosacral spine and left lower extremity radiculopathy, sciatic nerve associated with degenerative arthritis of the lumbosacral spine. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to September 8, 2010 and in excess of 60 percent thereafter for service-connected CAD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.104, Diagnostic Code 7005 (2017). 2. The criteria for a 70 percent rating, but no higher, for PTSD has been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for a rating in excess of 30 percent for service-connected Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§4.1, 4.124a, Diagnostic Code 8004 (2017). 4. The criteria for a rating in excess of 10 percent prior to December 31, 2007 and after January 8, 2011 and in excess of 20 percent disabling from December 31, 2007 to January 8, 2011, for degenerative arthritis of the lumbosacral spine have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014), 38 C.F.R. §§ 4.1 -4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein decided, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board has reviewed the entire record, with an emphasis on the evidence relevant to this appeal. Although the Board must provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, in the present claims. I. Increased rating claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating 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. 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. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which 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). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. A. CAD The Veteran is seeking a rating in excess of 10 percent prior to September 8, 2010, and in excess of 60 percent thereafter for his service-connected CAD. The Veteran's claim was received in March 2011 therefore the period of on appeal begins in March 2010. The Veteran's CAD is rated under Diagnostic Code 7005. See 38 C.F.R. § 4.104. Diagnostic Code 7005 provides that 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs results in in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent maximum rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). VA treatment records reflect that the Veteran reported a history of dyspnea and chest pressure. Treatment records from June 2007 reflect that the Veteran's heart was not enlarged, his rhythm was regular and rate was normal with no murmur. Furthermore, the Veteran was found not to have heart failure or a history of angina. An electrocardiogram conducted in June 2007 was unremarkable. Subsequent treatment records in February and March 2010 reflect that the Veteran denied chest pressure and dyspnea. Treatment records in 2014 reflect that the Veteran had conversational dyspnea, chest pain, pressure and dyspnea and was diagnosed with congestive heart failure. Private treatment records documented that the Veteran was hospitalized in January 2014 with congestive heart failure. During the September 2010 VA heart examination, the Veteran reported rhythm disturbance with his heart jumping out of his chest and almost passing out. He reported that while he went to the hospital as a result of his rhythm disturbances, he was not admitted. He reported that in 2004 he was admitted to the hospital as a result of an acute myocardial infarction and he underwent cardiac catheterization which revealed multi-vessel disease with severe stenosis of the left anterior descending artery, the right coronary artery, and the diagonal branch. The Veteran reported that he was active since his surgery and doing well. He reported occasional episodes of sharp chest pain, but which were not considered to be cardiac in origin. The Veteran reported a recent stress echo which did not demonstrate any evidence of ischemia, and the ejection fraction was 55 to 65. Upon examination the examiner noted that the Veteran's cardiac rhythm was regular. He diagnosed arteriosclerotic vascular disease with a history of myocardial infarction in 2004 treated with thrombolytic therapy followed by a 2-vessel bypass to the right coronary artery and the left anterior descending artery. In a January 2011 VA Heart examination addendum opinion, the examiner estimated the Veteran's METs to be greater than 3 but less than 5. During the July 2011 General Medical VA examination, the Veteran reported nonanginal, ill-defined, sharp chest pain, but denied syncopal episodes. The Veteran's chest was clear to auscultation and percussion. There was no jugular venous distention, and the Veteran's heart rate was regular and his rhythm was without murmur, gallop, rub, splitting of the base sounds or other adventitious findings. There was no evidence of congestive heart failure. The examiner estimated that the Veteran's cardiac function alone was estimated to be 5 METs, but that such was confused by his Parkinson's disease and lumbosacral problem with peripheral sensory neuropathy which made it difficult to walk. However, the examiner stated that the Veteran's estimated METs on the basis of cardiac function alone was 5, or greater than 3 METs but not greater than 5 METs. In April 2017, the Veteran underwent another VA examination. The examiner diagnosed the Veteran with a history of myocardial infarction from 2000, valvular heart disease from October 2016, and coronary artery bypass graft from 2000. The examiner noted no further cardiac events since the myocardial infarction and bypass surgery in 2000. Furthermore, the examiner noted that the Veteran was physically active and reported no shortness of breath. The examiner found no congestive heart failure and no arrhythmia. The examiner stated that the Veteran had valvular heart disease affecting the mitral valve and some trivial regurgitation of the tricuspid valve. The examiner noted that an October 2016 echocardiogram showed left ventricular ejection fraction to be greater than 50 percent. METs were estimated to be greater than 7 but less than 10. The examiner found no worsening of the Veteran's coronary artery disease and that there had been no new ischemic events. In May 2017, an additional VA examiner examined the Veteran's records, in order to resolve conflicting evidence. The examiner opined that the Veteran did have congestive heart failure in January 2014 and that it was at least as likely as not related to the Veteran's CAD, either partially or wholly. The examiner stated that the precipitating cause was not definitely known but that it may have been aspiration pneumonia. Furthermore, the examiner found that it represented an isolated episode of congestive heart failure with no evidence of prior episodes, persistence, or recurrence. The examiner also found that the Veteran did not have significant valvular heart disease noting that although there was moderate mitral regurgitation and tricuspid regurgitation in 2014, such was related to the acute congestive heart failure. The examiner noted the October 2016 echocardiogram and stated that it showed only trivial mitral valve regurgitation and tricuspid regurgitation which were not limiting or significant and they were not at least as likely as not secondary to or due to a progression of the Veteran's CAD. Period prior to September 8, 2010 The Board finds that, for the period prior to September 8, 2010, a rating in excess of 10 percent for the Veteran's CAD is not warranted. The Board notes that a workload of 5 METs but not greater than 7 METs which results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray is required for a higher 30 percent rating under Diagnostic Code 7005. Prior to September 8, 2010, there is no evidence that the Veteran's CAD meets the criteria for a higher rating. The evidence of record reflects that the Veteran reported a history of dyspnea and chest pressure, however treatment records reflect that his heart was not enlarged, his rhythm was regular and rate was normal with no murmur. Furthermore, the Veteran was found not to have heart failure or a history of angina. An electrocardiogram conducted in June 2007 was unremarkable. Finally, in treatment notes in February and March 2010 reflect that the Veteran denied chest pressure and dyspnea. As such, the Board finds that an increased rating is not warranted for the service-connected CAD for the period prior to September 8, 2010. The Board has considered whether a higher or separate rating is warranted under any other potentially applicable Diagnostic Codes, however, the Board finds that the evidence of record does not establish any additional cardiac diagnoses beyond the already compensated CAD. Period beginning September 8, 2010 The Board finds that, for the period beginning September 8, 2010, a rating in excess of 60 percent for the Veteran's CAD is not warranted. The Board notes that there is no evidence that the Veteran has ever had chronic congestive heart failure. Thus, the only way to substantiate the instant claim is to either show that he is restricted to a workload of three METs or less (that results in dyspnea, fatigue, angina, dizziness, or syncope) or that LVEF is less than 30 percent. The preponderance of the evidence is against a finding of a METs level of 3 or less at any stage during the appeal due to his CAD. The Veteran's METs were consistently greater than 3 and less than 5 during the appeal. It is also critical to note that the most recent VA examination shows his METs level improved significantly, rising to greater than 7 and less than 10 METs. As there is no basis for awarding a higher 100 percent rating based on METs levels, what must be shown to substantiate the present claim is that his LVEF is less than 30 percent. Unfortunately, there is simply no evidence suggesting such severe left ventricular dysfunction. All relevant clinical data indicates LVEFs around 50-65 percent; the lowest recorded LVEF (on the April 2017 VA examination) is 50 percent. Accordingly, there is no basis upon which a higher 100 percent rating may be granted for the Veteran's CAD; the preponderance of the evidence is against this claim, the benefit of the doubt rule does not apply, and the appeal in this matter must be denied. B. PTSD The Veteran contends that a higher rating is warranted for his PTSD. The Veteran's claim was received in March 2011 therefore the period on appeal begins in March 2010. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 10 percent rating is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). In addition to evidence regarding the Veteran's symptomatology and its impact on his social and occupational functioning, a Global Assessment of Functioning (GAF) score is another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126 (a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). VA treatment records reflect intermittent psychiatric treatment. A March 2011 treatment note reflects that the Veteran was assigned a GAF score of 55 and an April 2011 treatment note reflects he was assigned a GAF score of 70. December 2011 treatment notes reflect that the Veteran reported he was not depressed, slept mostly well, and the overall impression was of mild symptoms. January 2013, the Veteran reported that he was "doing alright with his medications" and the examiner noted an impression of mild-moderate symptoms. In November 2014, the Veteran noted that he had discontinued taking his medications. He denied suicidal ideation and the examiner prescribed sertraline. In May 2015, the Veteran reported that he was doing fine on his medication and that he was "a lot calmer." Treatment notes from July 2016, reflect that the Veteran suffered some anxiety and sleep problems but denied suicidal ideation. An April 2010 VA PTSD examination report reflects the Veteran's reports of feeling "rough lately." He stated that he was depressed, irritable and quite "mean." He stated that he became much more irritable and anxious in the evenings and that he primarily stayed to himself. He noted that he did speak to a friend occasionally. He reported suicidal ideation without intent or plan on an almost daily basis. He further noted that he had difficulty sleeping . He also noted that he gets up to check the perimeter of his home regularly in order to feel safe. He stated that he experienced daily nightmares and intrusive thoughts. He also noted an exaggerated startle response. Upon examination, the examiner noted that the Veteran was alert and fully oriented. He was well groomed and his overall mood was depressed or irritable and his affect was appropriate to content. He made good eye contact and his rate, tone and volume of speech were within normal limits. The examiner noted no psychomotor agitation or retardation. The Veteran's memory and concentration were intact and his thought process was spontaneous and goal oriented. He endorsed suicidal ideation without plan or intent and denied any homicidal ideation. The Veteran's judgment and insight were good and his intelligence was estimated in the average range. The examiner assigned a GAF score of 50. A June 2011 VA PTSD examination report reflects the Veteran's reports of sleep disturbances and nightmares. He reported that he checks his doors and locks and avoids crowded places. The Veteran stated that he was "kind of withdrawn" and preferred to stay to himself. He noted an exaggerated startle response and described himself as quick tempered. The Veteran reported that he was married and had been for 10 years. He noted that the relationship was "very good" and he had two biological children and two step children with whom he had "very good" relationships. He also stated that he had two grandchildren with whom he enjoyed spending time. He also reported keeping in contact with some friends. The Veteran reported a history of suicidal thoughts, but that his attitude had changed and he denied any attempts, plans, or intentions. Upon examination, the examiner found the Veteran to be alert and fully oriented. He was adequately groomed and his overall mood appeared slightly dysphoric. His eye contact was adequate and his speech was moderate in rate and tone. His thought process was logical and goal oriented. He denied any suicidal or homicidal ideation. There was no evidence of a psychotic disorder. His judgment and insight were fair and his impulse control was appropriate. His memory appeared intact. The examiner assigned a GAF score of 58. An April 2017 VA PTSD disability benefits questionnaire (DBQ) reflects the examiner's notation that the Veteran suffers from PTSD but no other mental health disorders. The Veteran reported that he had been married and divorced four times and had 3 sons, with whom he remained in contact. He reported that he lived on a ranch and swapped work for rent. He also stated that he kept in contact with some friends and engaged in some leisure activities. The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Upon examination, the examiner noted that the Veteran was oriented to time, place, person, and purpose of the exam. He was pleasant, cooperative and forthright. His speech, hygiene, and grooming were unremarkable. His thought process was clear and goal oriented. He reported some rare and vague suicidal thoughts in the past, but no history of plans, intent, gestures/attempts, and no history of acute psychiatric admissions. As indicated previously, a 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Based on the evidence of record, the Board finds that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas. With respect to the symptomatology considered in the assignment of a 70 percent rating, the probative evidence of record reveals that the Veteran endorsed a history of suicidal ideation on all three of his VA examinations and during the April 2010 VA examination, the Veteran endorsed active suicidal ideation. The Veteran also noted that he was generally depressed and suffered anxiety attacks whenever he had to interact with crowds of people. Additionally, the Veteran had extremely limited social relationships as indicated by his reports of isolation and noting that he interacted occasionally with his direct family and a few friends. Notably, the evidence suggests that while he maintained relationships with his children and a few friends, he had been married and divorced four times and ultimately lived alone on a ranch. Furthermore, the Veteran's psychiatric disability resulted in obsessional rituals where the Veteran had to check the perimeter of his home and his doors and locks multiple times a night in order to feel safe Further, while acknowledging that VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected psychiatric disability, the Court recently indicated that suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (the language of the regulation indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). Here, the Veteran not only reported suicidal ideation, he also exhibited limited social relationships, obsessional rituals, and serious depression. Moreover, he has repeatedly been assigned GAF scores in the 50s, which is indicative of moderate to moderately severe symptoms. Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a 70 percent rating for MDD has been met. However, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has total social and occupational impairment due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Indeed, the record does not reflect that the Veteran's PTSD symptoms have resulted in total social and occupational impairment. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including exaggerated startle response and irritability. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such a duration, severity, or frequency to result in total occupational and social impairment. Ultimately, the Board finds that the Veteran's PTSD does not warrant a rating in excess of 70 percent. Ultimately, the Board finds that a 70 percent rating, but no higher, for PTSD is warranted; however, the preponderance of the evidence is against a rating in excess of 70 percent. Therefore, the benefit of the doubt doctrine is not applicable except as has been applied to the rating assigned herein, and the Veteran's claim for an increased rating is otherwise denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. C. Parkinson's disease The Veteran is seeking a rating in excess of 30 percent for his service-connected Parkinson's disease. The Veteran's claim was received in March 2011 therefore the period of on appeal begins in March 2010. As will be discussed in detail below, the Veteran's Parkinson's disease manifested over the years with mild balance impairment, partial loss of smell, moderate difficulty chewing/swallowing, mild constipation and erectile dysfunction. Upon review of all evidence, the Board finds that the evidence supports the collective 30 percent minimum rating granted under Diagnostic Code 8004. Diagnostic Code 8004 provides for a minimum rating of 30 percent for paralysis agitans. 38 C.F.R. § 4.124a. Paralysis agitans is also known as Parkinson's disease. Dorland's Illustrated Medical Dictionary 972 (26th ed. 1990). The minimum rating is the only rating provided for under Diagnostic Code 8004. If, however, there are identifiable residuals that can be rated under a separate diagnostic code and the combined disability rating resulting from these residuals exceeds 30 percent, the separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. See VA Adjudication Procedures Manual M21-1MR, Part III.iv.4.G.25. VA should also analyze individual symptoms under the appropriate diagnostic code for that bodily system. See 38 C.F.R. § 4.124a. The Board notes that the following are additional potentially applicable diagnostic codes: Diagnostic Code 6204 for peripheral vestibular disorders provides a 10 percent rating for occasional dizziness and a 30 percent rating for dizziness and occasional staggering. However it is noted that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code. Diagnostic Code 6275 for loss of smell provides a 10 percent rating for complete loss of smell. Under Diagnostic Code 5325 for muscle injury, facial muscles. Functional impairment is evaluated as seventh (facial) cranial nerve neuropathy (Diagnostic Code 8207), disfiguring scar (Diagnostic Code 7800), etc. Minimum if interfering to any extent with mastication warrants a 10 percent rating. Diagnostic Code 8207 for paralysis of the cranial nerve provides for a 10 percent rating for moderate incomplete paralysis, 20 percent for severe incomplete paralysis, and 30 percent for complete paralysis. In the alternative under Diagnostic Code 8209 for Ninth (glossopharyngeal) cranial nerve again provide a 10 percent rating for moderate incomplete paralysis, a 20 percent rating for severe incomplete paralysis, and a 30 percent rating for complete paralysis. Under Diagnostic Code 7319 for irritable colon syndrome (spastic colitis, mucous colitis, etc.) a noncompensable rating is provided for mild symptoms resulting in disturbances of bowl function with occasional episodes of abdominal duress. A 10 percent rating is warranted for moderate symptoms which result in frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is warranted for severe symptoms which result in diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Under Diagnostic Code 7522 for Penis deformity, with loss of erectile power a 20 percent rating is warranted. Under Diagnostic Code 8513 for paralysis of all radicular groups. Incomplete mild paralysis of either side warrants a 20 percent rating. Incomplete moderate paralysis of the minor side warrants a 30 percent rating and a 40 percent is warranted for the major side. Incomplete severe paralysis of the minor side warrants a 60 percent rating and a 70 percent rating is warranted for the major side. Complete paralysis warrants an 80 percent rating for the minor side and a 90 percent rating for the major side. Under diagnostic code 8520 for paralysis of the sciatic nerve. Mild incomplete paralysis warrants a 10 percent rating. Moderate incomplete paralysis warrants a 20 percent rating. Moderately severe incomplete paralysis warrants a 40 percent rating. A severe with marked muscular atrophy paralysis warrants a 60 percent rating. Complete paralysis warrants an 80 percent rating. During a September 2010 VA Brain and Spinal Cord examination, the Veteran reported episodic and brief jerks in all of his extremities at random intervals. He noted that his symptoms worsened later in the day, but that his symptoms were well controlled by his medications. The Veteran reported a history of dizziness, and tingling, numbness and rigidity in his right lower extremity. He also noted a decrease in sense of taste or smell, and balance issues while walking. He reported some short-term memory issues and fatigability. He also noted some slight light sensitivity and erectile dysfunction. Upon examination, the Veteran's reflexes were normal and his motor exams exhibited active movement against full resistance. However, the examiner did note mild bradykinesia in both upper extremities. The examiner diagnosed the Veteran with Parkinson's disease, stage 1 which resulted in decreased manual dexterity, lack of stamina, weakness and fatigue. During a July 2011 VA General Medical examination, the examiner noted no pathologic reflexes elicited other than cogwheel rigidity and a parkinsonian pill-rolling tremor. The Veteran's deep tendon reflexes were 1/3 and symmetric. His sensory modalities including vibratory, light touch, two-point discrimination, proprioception, and sharp/dull were all within normal limits. His muscle strength was 5/5 and symmetric. On an October 2012 VA Parkinson's disease disabilities benefits questionnaire (DBQ) the examiner noted that the Veteran was diagnosed with Parkinson's disease in October 2012. The Veteran reported that he shook all over and felt fatigued. He also reported soreness and stiffness of his neck and shoulders. He also reported balance problems and felt as if his face would "turn to stone" if he stared into space. He denied any loss of taste or smell and noted some incontinence and a history of bad constipation. The Veteran was noted to be left hand dominant. Upon examination, the examiner noted no stooped posture, bradykinesia, loss of automatic movements, speech changes, or tremors. However, he did note mild balance impairment, mild muscle rigidity and stiffness of the right upper and lower extremities, and sexual dysfunction. The examiner also noted that the Veteran suffered from Hepatitis C for which he was taking interferon which could cause fatigue. In April 2013, the Veteran submitted a statement from one of his physicians who noted that the Veteran suffered from classical features of Parkinson's disease to include problems with stamina, bradykinesia, tone/stiffness, tremors, writing problems, and dyskinesia. He noted that the Veteran required a cane to help with balance for walking. However, the physician did not provide more detailed information to specify to what degree such symptoms impacted the Veteran, what extremities were impacted, and if such were controlled by his medications. On a private August 2013 Parkinson's disease DBQ, the examiner noted mild stooped posture, balance impairment, and loss of automatic movements. The examiner noted mild to moderate bradykinesia, but no tremors. The examiner noted mild muscle rigidity and stiffness of the right and left upper extremities and moderate muscle rigidity and stiffness of the right and left lower extremities. The examiner noted mild depression and moderate cognitive impairment. The examiner noted partial loss of smell, no sleep disturbance, mild difficulty chewing/swallowing, no urinary problems, moderate constipation and moderate sexual dysfunction. An additional private Parkinson 's disease DBQ was completed in July 2015. The examiner noted moderate stooped posture, balance impairment, bradykinesia, loss of automatic movements, and speech changes. The examiner noted mild tremors and muscle rigidity and stiffness of all the extremities. The examiner further noted moderate depression and mild cognitive impairment or dementia. The examiner also noted partial loss of smell, mild sleep disturbance and difficulty chewing/swallowing. The examiner noted no urinary problems and mild sexual dysfunction but failed to note any problems with constipation. The Board notes that both private examiner's failed to note that the Veteran's depression and cognitive impairment were attributed to his service-connected PTSD and not his Parkinson's disease or discuss how they could possibly be connected. Furthermore, the private examiners attributed the Veteran's sciatic nerve impairment (his lower extremity impairment) to his Parkinson's disease but again failed to mention his service-connected lumbosacral condition and what impact that condition could play. Finally, the July 2015 examiner failed to make any reference as to the Veteran's previously noted constipation. Therefore because of the multiple inconsistencies the Board affords the August 2013 and July 2015 private DBQs little if any probative value. On an April 2017 VA Parkinson's disease DBQ, the examiner again noted that the Veteran was diagnosed with Parkinson's disease in 2010. The examiner noted that the Veteran was left hand dominant. Upon examination the examiner found no stooped posture, bradykinesia, loss of automatic movements, speech changes, tremors or muscle rigidity and stiffness. But the examiner did find mild balance impairment. The examiner noted no depression, cognitive impairment, dementia or urinary problems due to the Veteran's Parkinson's. The examiner did note partial loss of smell, moderate difficulty chewing/swallowing, mild constipation and erectile dysfunction which precluded intercourse. The examiner stated that the Veteran had taken sinemet for years with good control of his symptoms, but that recently his dosage had increased. He walked with a cane which originally was used for his back issues but is also used for his loss of balance. The Veteran reported that he could take care of himself including driving. He reported that in 2014 he was hospitalized for aspiration pneumonia among other diagnoses and at that time he had therapy to learn to chew and swallow better, but that he was not on a restrictive diet. The Veteran reported sleep disturbance and depression but such have been attributed to his PTSD. Based on the evidence of record, the Board finds that the Veteran's symptoms of his service-connected Parkinson's disease are most appropriately rated collectively under Diagnostic Code 8004. The Board notes that the Veteran's Parkinson's disease is manifested by mild balance impairment, partial loss of smell, moderate difficulty chewing/swallowing, mild constipation and erectile dysfunction. The Board notes that if rated separately the Veteran's conditions would not be greater than 30 percent. The Veteran's balance impairment would at most warrant a 10 percent rating under Diagnostic Code 6204 as the Veteran's condition was repeatedly noted to be mild. Specifically the VA examiners in October 2012 and April 2017 noted mild balance impairment. The Veteran's partial loss of smell would warrant a noncompensable rating under Diagnostic Code 6275 as it is not a complete loss. The Board notes that the Veteran's loss of smell has never been noted to be a complete loss. The Veteran's difficulty chewing/swallowing would at most warrant a 10 percent rating under Diagnostic Code 8207 or 8209 as the Veteran's difficulty chewing/swallowing was repeatedly found to be moderate during examination in October 2012 and April 2017. The Veteran's constipation was noted to be mild on examination in October 2012 and April 2017 and therefore a noncompensable rating under Diagnostic Code 7319 would be warranted. The Veteran's erectile dysfunction while noted to preclude intercourse would not warrant a compensable rating under Diagnostic Code 7522. The Veteran's penis has not been found to be deformed therefore a compensable rating is not applicable. Finally, while the private August 2013 and July 2015 noted mild muscle rigidity and stiffness of the right and left upper extremities and moderate muscle rigidity and stiffness of the right and left lower extremities, the Board has found the private DBQs to not be probative. In addition, while the September 2010 VA examiner noted numbness, tingling and muscle rigidity in the Veteran's right lower extremity, the Veteran is already separately service-connected and rated for his paresthesia of the right lower extremity and neuritis and left lower extremity radiculopathy, sciatic nerve, both associated with the Veteran's degenerative arthritis of the lumbosacral spine, therefore any additional compensation for the same symptoms would be pyramiding. Furthermore, while the October 2012 VA DBQ noted mild muscle rigidity and stiffness of the right upper and lower extremities, the examiner did not note any problems with the left extremities, and the April 2017 found no muscle rigidity or stiffness of any of the Veteran's extremities. Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran suffers from compensable muscle rigidity or stiffness of his extremities as a result of his Parkinson's disease. Therefore, the Board finds that the Veteran's symptoms of his service-connected Parkinson's disease are most appropriately rated collectively and assigned the minimum 30 percent rating under Diagnostic Code 8004. D. Lumbar Spine The Veteran generally contends that a higher rating is warranted for his degenerative arthritis of the lumbosacral spine. The Veteran's claim was received in December 2007, and therefore the period on appeal begins in December 2006. The Veteran's degenerative arthritis of the lumbosacral spine is assigned a 10 percent rating prior to December 31, 2007, a 20 percent rating prior to January 8, 2011, and a 10 percent rating thereafter under Diagnostic Code 5242. Diagnostic Code 5242 is rated on the basis of limitation of motion, and the General Rating Formula for Diseases and Injuries of the Spine contemplates limitation of motion. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: a 10 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine was greater than 235 degrees or that muscle spasms or guarding not resulting in an abnormal gait or abnormal spinal contour. A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine was not greater than 120 degrees or that muscle spasms or guarding were severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): 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 dysphagia; 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. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. VA treatment records reflect the Veteran's continued complaints of low back pain and stiffness. A May 2017 MRI reflects that the Veteran suffered from multilevel degenerative osteoarthritis with offset of L4 on L5 with extension suggestive of either ligamentous or osseous instability. During a February 2008 VA examination, the Veteran reported that his back resulted in stiffness worse with activity and standing and pain. He reported no weakness. He stated that his pain was constant and traveled into his right leg. He noted that over the past 12 months, he had an incapacitating episode which resulted in physician recommended bed rest for six days. Upon examination, the examiner noted that the claimant's posture and gait were within normal limits. Furthermore, the examiner found no evidence of radiating pain on movement, but did note muscle spasm and tenderness. The Veteran's straight leg raises were negative bilaterally and there was no ankylosis. Range of motion testing revealed flexion to 60 degrees, extension to 35 degrees, and right lateral flexion, left lateral flexion, right rotation and left rotation to 25 degrees. The examiner found that the joint function of the spine was additionally limited after repetitive use by pain, fatigue, weakness, lack of endurance and incoordination. The examiner noted that pain had the major functional impact with additional limitation of 10 degrees. The examiner found no sign of IVDS. The examiner also noted scars measuring 2 cm by 1 cm with no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hypopigmentation, hyperpigmentation and abnormal texture. During the January 2011 VA spine examination, the Veteran reported constant moderate to severe lower lumbar spine pain. He noted no incapacitating episodes that required bedrest, no flare-ups, but he did note spasms and paresthesia in the legs. Furthermore, the Veteran reported that he used a cane. Range of motion testing revealed flexion to 70 degrees, extension to 10 degrees, and left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation to 30 degrees. The examiner found no change with repeated motion due to pain, fatigue, weakness, lack of endurance, or incoordination. The examiner noted that the Veteran exhibited a guarding of motion indicating pain, but no muscle spasm or tenderness. Sensory examination, motor examination and reflexes were all normal. The examiner noted no ankylosis and no IVDS. During the April 2017 VA DBQ, the Veteran reported low back pain during bending, lifting and carrying. He reported no flare-ups. Range of motion testing reflected forward flexion to 90 degrees, extension to 10 degrees, and right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation to 25 degrees. The examiner noted no evidence of pain with weight bearing, or objective evidence of localized tenderness or pain on palpation. The examiner further noted that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. The examiner noted no muscle spasm or guarding. Muscle strength, reflex and sensory examinations were all primarily normal. Straight leg raises were negative bilaterally. The examiner noted radiculopathy in mild numbness in both lower extremities. The examiner found no ankylosis, and while he did note IVDS, he stated that the Veteran did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician in the past twelve months. The examiner noted that the Veteran used a cane constantly. Furthermore, the examiner noted that the Veteran had a scar on his lower back but such was neither painful or unstable and did not have an area greater than or equal to 39 square cm. The examiner noted that passive range of motion testing could not be performed and that the Veteran's condition had worsened. Periods prior to December 31, 2007 and beginning January 8, 2011 Based on the foregoing, the Board finds that the evidence of record does not support a rating higher than 10 percent for the periods prior to December 31, 2008 and beginning January 8, 2011. Specifically, at no point during the two periods, has the Veteran's degenerative arthritis of the thoracolumbar spine been characterized by ankylosis, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour, forward flexion limited to 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine limited to less than 120 degrees, even in contemplation of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, supra. In this regard, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; see also Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In the instant case, the Veteran has consistently complained of lumbar spine pain as noted in the January 2011 and April 2017 VA examinations. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath, supra. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). However, despite the Veteran's complaints, pain did not result in limitation of flexion to 60 degrees, combined range of motion of the thoracolumbar spine limited to 120 degrees, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or ankylosis of the lumbar spine at any time during the period on appeal. The Veteran was still able to demonstrate flexion in excess of 60 degrees and the combined range of motion of the thoracolumbar spine was greater than 120 degrees during his VA examination. Although pain may cause functional loss, pain itself does not constitute functional loss. Mitchell, supra. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id; see 38 C.F.R. § 4.40. Moreover, the clinical evidence does not reveal any additional functional impairment, including additional limitation of motion, on account of pain, weakness, etc. that is not already contemplated by the now assigned 10 percent rating. Burton, supra; 38 C.F.R. § 4.59. Moreover, the January 2011 and April 2017 VA examinations were negative for muscle spasms or guarding, and there is no other evidence suggesting that either manifestation was present. Thus, a higher rating is not warranted for the Veteran's degenerative arthritis of the lumbosacral spine even in consideration of painful motion and other factors such as weakness, fatigability, lack of endurance, and incoordination, or as a result of repetitive motion or flare-ups. The Board has also considered whether the Veteran's service-connected degenerative arthritis of the lumbosacral spine has resulted in IVDS with incapacitating episodes. While the April 2017 VA examiner did note IVDS, the Veteran has denied incapacitating episodes, and the VA examinations and clinical records fail to show any evidence of incapacitating episodes due to his lumbar spine disorder that meet the requirements set forth in the Formula for Rating IVDS Based on Incapacitating Episodes, i.e., requiring bed rest prescribed by a physician. Therefore, a higher rating is also not assignable under such criteria. In addition to considering the orthopedic manifestations of a back disability, VA regulations also require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. In this regard, the Board notes that the Veteran is already separately service-connected and rated for paresthesia of the right lower extremity and neuritis associated with degenerative arthritis of the lumbosacral spine and left lower extremity radiculopathy, sciatic nerve associated with degenerative arthritis of the lumbosacral spine. Furthermore, the record does not reflect any evidence of other neurologic abnormalities (including bowel or bladder problems), specifically none were noted on examination. The Board finds that for the periods prior to December 31, 2007 and beginning January 8, 2011, a higher rating is not assignable under any other potentially applicable rating criteria. Period December 31, 2007 to January 8, 2011 The Board finds that, when applying the General Rating Formula to the Veteran's degenerative arthritis of the lumbosacral spine, the evidence does not warrant a rating in excess of 20 percent for the period from December 31, 2007 to January 8, 2011. There has been no findings of forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine to warrant a 40 percent rating. The most restrictive range of motion found was 60 degrees of forward flexion documented on the February 2008 VA examination. As previously noted, the Veteran has reported chronic low back pain, and, thus, the Board recognizes the application of 38 C.F.R. §§ 4.40, 4.45, and Deluca. However, a higher compensation is not warranted under these provisions because there is no persuasive evidence of additional functional loss due to pain, weakness, fatigue, or incoordination which would limit motion to such a degree so as to warrant a rating in excess of 20 percent. In the range of motion testing of record, pain was elicited at the limits of forward flexion, and while the examiner noted that such would result in a 10 degree reduction, such would only be a 50 degree limit. In sum, there is no objective evidence that even when pain is taken into consideration that the result is loss of range of motion meeting the criteria for a rating in excess of 20 percent. Again, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss but does not itself constitute functional loss. See Mitchell, supra. In this case, while additional functional loss has been caused by pain, such does not reach the threshold for a higher rating. Therefore, a rating in excess of 20 percent is not warranted based on limitation of motion. Further, consideration has been given as to whether a higher disability evaluation could be assigned under Diagnostic Code 5243 for IVDS. The evidence of record shows that while the Veteran has experienced one incapacitating episode, there is no evidence showing that the Veteran suffered incapacitating episodes lasting a total of at least four weeks during the past 12 months to warrant a 40 percent rating for IVDS. In this regard, the Board finds a higher rating based on IVDS with incapacitating episodes is not warranted. With respect to neurological abnormalities pursuant to Note (1) of the General Rating Formula for Disease and Injuries of the Spine, as previously noted the Veteran is already separately service-connected and rated for paresthesia of the right lower extremity and neuritis associated with degenerative arthritis of the lumbosacral spine and left lower extremity radiculopathy, sciatic nerve associated with degenerative arthritis of the lumbosacral spine. Furthermore, there was no evidence of bowel or bladder dysfunction, and the Veteran has expressly denied such problems during several examinations. Thus, additional separate compensable ratings are not warranted for any neurological symptoms, and the Veteran's current symptoms are adequately contemplated under the assigned disability ratings discussed above. The Board finds that for the period from December 31, 2007 to January 8, 2011, a higher rating is not assignable under any other potentially applicable rating criteria. II. Other considerations In reaching its conclusions, the Board acknowledges the Veteran's belief that his symptoms are more severe than the current disability ratings reflect. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board finds the medical evidence in which professionals with medical expertise examined the Veteran's disabilities, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such conditions. The Board has considered whether additional staged ratings under Fenderson, supra, and Hart, supra, are appropriate for the Veteran's service-connected PTSD, CAD, Parkinson's disease and lumbosacral condition; however, the Board finds that the currently assigned ratings for his conditions represent the earliest dates of increase in his symptomatology and that the remainder of his symptomatology referable to such disabilities has been stable throughout each period of the appeal. Therefore, assigning further staged ratings is not warranted. (CONTINUED ON NEXT PAGE) ORDER A rating in excess of 10 percent prior to September 8, 2010 and in excess of 60 percent thereafter for service-connected CAD is denied. A 70 percent rating, but no higher, for PTSD is granted, subject to the laws and regulations governing the payment of monetary awards. A rating in excess of 30 percent for service-connected Parkinson's disease is denied. A rating in excess of 10 percent prior to December 31, 2007, in excess of 20 percent prior to January 8, 2011, and in excess of 10 percent thereafter is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs