Citation Nr: 1812580 Decision Date: 02/28/18 Archive Date: 03/08/18 DOCKET NO. 04-41 523A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for a cervical spine disability prior to July 29, 2003, and in excess of 20 percent thereafter. 2. Entitlement to an initial rating in excess of 10 percent for migraine headaches prior to September 6, 2006, and in excess of 30 percent thereafter. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1983 to December 1987. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from August 2002 and June 2003 rating decisions issued by the RO. In June 2007, the Board remanded the case in order to obtain updated medical records and provide the Veteran with new VA examinations in connection with his claims on appeal. In August 2010, the Board remanded the case again, for the RO to readjudicate the claims in light of new evidence that was submitted without a waiver. In a May 2012 rating decision, the RO increased the Veteran's disability rating for his cervical spine disability to 20 percent, effective July 29, 2003, and his headaches disability rating from 10 to 30 percent, effective September 6, 2006. In July 2012, the Board remanded the case for an additional time, so the RO readjudicate the Veteran's claim for associated neurological disorders in connection with his claims on appeal. In December 2016, the Board remanded the case for an additional time in order to provide the Veteran with updated VA examinations. In August 2017, the Board remanded the case to afford the Veteran a Travel Board hearing per his request. In November 2017, the Veteran and his spouse testified at a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. The issue of potential entitlement to a total disability rating based on individual unemployability (TDIU) is an element of all increased rating requests. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the record suggests that the Veteran is unemployable due to his service-connected disabilities. As will be discussed in the remand portion below, the issue of TDIU requires further development and adjudication by the RO. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to July 29, 2003, the Veteran's cervical spine disability was manifested by moderate limitation of cervical spine motion, but not worse. 2. For the period on appeal beginning July 29, 2003, the Veteran's cervical spine disability was still manifested by moderate limitation of cervical spine motion; there is no evidence of severe limitation of motion or forward flexion worse than 30 degrees. 3. Resolving any doubt in the Veteran's favor, beginning December 16, 2002, his cervical spine disability has been productive of neurological impairment of the left upper extremity that results in disability analogous to mild incomplete paralysis of the peripheral nerve, at worst. 4. Beginning May 12, 2010, the medical evidence demonstrates that the Veteran's cervical spine disability has been productive of neurological impairment resulting in urinary and bowel leakage. 5. Resolving any doubt in the Veteran's favor, for the entire period on appeal, he had very frequent, completely prostrating, and prolonged migraine headache attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. Prior to July 29, 2003, the criteria for a 20 percent rating for a cervical spine disability, but not higher, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5290 (2002). 2. For the period on appeal beginning July 29, 2003, the criteria for a rating in excess of 20 percent have not been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5290, 5237 (2002, 2017). 3. For the period on appeal beginning December 16, 2002, the criteria for a separate 20 percent rating, but no higher, for radiculopathy of the left upper extremity secondary to service-connected cervical spine disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.123, 4.124, 4.124a; DC 8510 (2017). 4. For the period on appeal beginning May 12, 2010, the criteria for a 10 percent rating for neurogenic bladder impairment associated with service-connected cervical spine disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.115a, 4.115b, Diagnostic Code 7542 (2017). 5. For the period on appeal beginning May 12, 2010, the criteria for a separate 10 percent rating for neurogenic bowel impairment associated with service-connected cervical spine disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.114, Diagnostic Code 7332 (2017). 6. For the entire period on appeal, the criteria for an initial 50 percent disability rating, but not higher, for migraine headaches have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100 (2017). (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Mater The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Claims - Applicable Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has also held that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Cervical Spine - Rating Schedule Historically, by a May 1990 rating decision, the RO granted service connection for a cervical spine disability and assigned a 10 percent disability rating, effective May 21, 1990 under DC 5010-5287. Subsequently, the Veteran filed a claim for increase on February 12, 2002, which was denied by an August 2002 rating decision. Thereafter, by a May 2012 rating decision, the RO increased the Veteran's disability rating to 20 percent, effective July 29, 2003 under DC 5237. During the course of this appeal, the applicable rating criteria for spine disorders were amended under changes to the rating criteria applicable to the diseases and injuries of the spine under 38 C.F.R. § 4.71a, effective September 23, 2002 and September 26, 2003. All applicable diagnostic criteria will be discussed below. Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110 (2012); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Board will consider the Veteran's cervical spine disability prior to September 26, 2003 under the corresponding diagnostic codes in effect in 2002, Diagnostic Codes 5010-5290. Prior to July 29, 2003, the Veteran's cervical spine disability was evaluated as 10 percent disabling under Diagnostic Codes 5010-5290. 38 C.F.R. § 4.71a, Diagnostic Code 5010, 5290 (2002). Diagnostic Code 5010 provides that degenerative arthritis, established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Id. Prior to July 2003, limitation of motion of the cervical spine was evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5290. Diagnostic Code 5920 provided for a 10 percent evaluation where limitation of motion was slight; a 20 percent evaluation when limitation of motion was moderate; and a maximum 30 percent evaluation when limitation of motion was severe. 38 C.F.R. § 4.71a, Diagnostic Code 5290 (2002). The terms "slight," "moderate," and "severe" were not defined in the Schedule. Rather than applying a mechanical formula, the VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2002). For VA compensation purposes, normal cervical spine forward flexion 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. The combined range of motion is 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. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Cervical Spine -Analysis a. Prior to July 29, 2003 Turning to the evidence during this period on appeal, treatment records from Shulze Chiropractic & Alternative Medicine Center dated November 2000 to September 2002 indicate that the Veteran reported moderate cervical pain. Upon physical examination, it was noted that the Veteran had localized restriction of the cervical range of motion with associated cervical muscular spasm. Range of motion in degrees was not documented during these visits. A letter by the medical professional who treated the Veteran throughout the years at this facility dated January 2002 indicates that the Veteran was treated at this Center for reported complaints of neck pain and headaches. He was seen three times in 1990, seven times in 1991, once in 1992, eight times in 1993, five times in 1994, thirteen times in 1995, which included several visits of acupuncture, and eight times in 1996 his last visit was in February 1998, where he had palpable upper cervical subluxation with associated spasm and pain. At the January 2002 visit, the chiropractor noted fixations at the cervical region, and indicated that ranges of motion were stiff and painful at all directions. Positive orthopedic tests were noted at the upper and lower body regions. Neurological examination revealed hyper but even reflexes at the upper body quadrants. Post examination impressions were cervicalgia with associated DJD and loss of cervical curve, and multiple levels of fixation and associated joint dysfunction. The Veteran underwent an additional VA examination in July 2002, in which he reported daily symptoms of pain, weakness, and stiffness of the neck. He further indicated that he received chiropractic treatment frequently and was taking Robaxin 500mg twice a day, which provided some relief. He also indicated that he was experiencing headaches in association with his neck pain. The pain limited him in lifting, bending, and stooping, and he could not pick up large or cumbersome objects, or those that weighed more than 30 pounds. Upon physical examination the examiner noted that the Veteran was walking without antalgic gait and was using no assistive devices. It was further noted that there was no obvious curvature abnormality or discoloration or increased warmth. Range of motion testing of the cervical spine revealed forward flexion to 50 degrees, extension to 70 degrees, lateral flexion to 40 degrees, bilaterally, and rotation to 80 degrees, bilaterally. The examiner indicated that range of motion was noted reduced after repetitive testing, and there was no apparent fatigue or weakness of the neck. Strength of the upper extremities was 5/5, and there was no evidence of focal neurological deficit. It was lastly noted that the Veteran had painful range of motion of the cervical spine. The examiner rendered a diagnosis of arthritis of the cervical spine and myofascitis of the neck. VA treatment records from Pensacola VAMC dated July 2002 indicate that the Veteran came in for a follow-up with reported 7 out of 10 pain in his neck, which radiated to his shoulder blades, and pulled his neck to the left side. The medical professional noted edema abrasions and difficulty in leaning head backward due to pain. Pain to the left scapular region was also noted. X-rays showed straightening of the normal cervical curvature, intervertebral foramina were "widely patent," and the vertebral body heights and disc spaces were normal. There was some minor spurring anteriorly at C5-6 level. The atlantodental relations were normal. The impression was "no significant abnormality determined," but the diagnosis was "minor abnormality." Additional diagnosis dated July 2002 at the Pensacola VAMC was cervical spondylosis without myelopathy. Private neurological treatment notes dated October 2002 indicate that a computed radiograph showed evidence of a right metallic orbital foreign body contraindicating MRI. Based on the above, changes to the CT scan were suggested. Thereafter, a review of the Veteran's cervical CT scan at the West Florida Hospital revealed anterior longitudinal ligament calcification at the C5-6 level. The Veteran had some mild disc degeneration at 4-5, 5-6, and 6-7, but no disc herniation or stenosis. He did have some osteoarthritis of the facet joints on the right at the 5-6 level. There was minimal central posterior longitudinal ligament calcification at C3-4 levels. The impression was multilevel cervical degenerative disc disease. Physical examination revealed "good voluntary range of motion." Additional progress notes dated November 2002 indicate that cervical range of motion was mildly decreased in directions. Spurling's test was negative, but there was minimal warmth to the wrists, bilaterally. Private medical progress notes dated December 2002 show that the Veteran had cervical epidural steroid injection for cervical radiculopathy. He received additional epidural injections in January 2003, during this visit his range of motion was slightly decreased with tenderness over the ZA line at C5-6, bilaterally, and a slightly positive Spurling's or pseudo-Spurling to the left, which produced pain radiating into the parascapular region. Additional treatment notes dated February 2003 show complaints of headaches and cervical radicular pain to the shoulder. The Veteran reported localized neck pain associated with popping and cracking when he "bends his neck about," constant pain with aching and burning across the shoulders, spasm and sharp pain primarily on the left side of the neck. He also had some diffuse aching in the hands and elbows with have been associated with arthritic changes based on the Veteran's lay reports. The Veteran also reported increased pain with weather changes. The examiner noted that associated symptoms included subjective weakness in hands, but the Veteran denied any numbness and tingling. Review of the Veteran CT scan of the cervical spine from October 2002 showed mild degenerative disc disease and spondyloarthropathy, as well as C5-6 and C6-7 facet arthropathy, which was likely generating some pain. The examiner indicated that the Veteran had non-antalgic gait and decreased range of motion primarily with lateral rotation of the cervical spine. Otherwise, the examiner indicated that he appeared grossly normal with flexion, extension, right lateral rotation, and lateral bending. There was some tenderness to palpation over the cervical facets with the left side being greater than the right. Additional private treatment notes dated March 2003 indicate that the Veteran was examined for cervical spondylosis, degenerative disc disease, and possible radiculopathy. The Veteran reported chronic neck pain that was increasing in frequency. He received facet injections. A follow-up evaluation dated April 2003 show that there was no significant improvement after the Veteran underwent cervical facet injections, and he was referred back to his doctor for further evaluations. The cervical spine range of motion was intact without deficits, but there were bilateral exquisite trigger points of trapezius areas reproducing local and regional pain. Progress notes dated June 2003 note that the Veteran received cervical facet injections, which were minimally efficacious. It was further noted that he did get some help from the cervical epidurals, but still had some left cervicogenic headache without any radiation of the neck pain to the shoulder or arm on either side. Progress notes dated July 2003 show range of motion assessment of forward flexion to 30 degrees with moderate pulling and pain, extension to 30 degrees, right lateral flexion to 25 degrees with minimal pain, left lateral flexion to 40 degrees with moderate pain, right rotation to 50 degrees, and left rotation to 60 degrees. During a June 2003 VA neurological disorders examination, the Veteran's range of motion of the cervical spine revealed flexion to 45 degrees, extension to 60 degrees, rotation to 40 degrees, bilaterally, and lateral flexion to 30 degrees, bilaterally, all without pain. The examiner concluded that "surely it is likely that [the] Veteran could have further limitation of function with increased or repetitive use or during a flare-up; however, it is not feasible to express any of this in terms of additional degree change in range of motion." Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that his cervical spine disability more nearly approximate a 20 percent evaluation based on "moderate" limitation of motion under the former Diagnostic Code 5290, which as noted above, was applicable during this period on appeal. The Board notes that the medical record reveals conflicting measurements in terms of loss of motion with flexion to 30 degrees, at worst. Nonetheless, the medical evidence also shows moderate cervical pain with localized restriction of the cervical range of motion with associated cervical muscular spasms, which suggests that the limitation is more than mild. Resolving any reasonable doubt in the Veteran's favor, the Board assigns a 20 percent rating, but no higher, for the Veteran's cervical spine disability prior to July 29, 2003 under Diagnostic Code 5290. 38 C.F.R. § 4.71a. In addition to consideration of the orthopedic manifestations of the cervical spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. The evidence suggests that the Veteran in this case is right-hand dominant. Diagnostic Code 8510 for provides ratings for the upper radicular group for complete and incomplete paralysis of the peripheral nerves. 38 C.F.R. § 4.124a. Disability ratings of 20, 30, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of a peripheral nerve of a minor upper extremity. 38 C.F.R. § 4.124, Diagnostic Code 8510. A disability rating of 60 percent is warranted for complete paralysis of all shoulder and elbow movements lost or severely affected, hands and wrist movements not affected. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Veteran has reported radicular pain in his left upper extremity during the pendency of the appeal, and he is competent to report pain, as it is observable by a layperson. Although VA examiners throughout the appeal period indicated that there is no official diagnosis of radiculopathy, other competent evidence affirmatively stated that the Veteran has radiation of pain down his left arm/hand stemming from his cervical spine disability. In addition to the Veteran's competent and credible lay statements of having radicular pain, his IME, as noted above, supports the presence of neurologic impairment. As such, the Board finds that the evidence is in equipoise as to whether the Veteran has neurological manifestations in his left arm secondary to his service-connected cervical spine disability. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that, based on the lay and medical evidence, he has had neurologic impairment in his left arm associated with his cervical spine disability beginning December 16, 2002, the first date showing complaints and treatment of radicular pain. His left arm symptoms are analogous to mild, at worst, radiculopathy of the peripheral nerve. As such, the Board concludes that the evidence supports his entitlement to a separate 20 percent rating under Diagnostic Code 8510 for radiculopathy of the left upper extremity as associated with the cervical spine disability. However, an even higher rating of 30 percent is not warranted for left upper extremity radiculopathy, as the Veteran's neurologic symptoms are only intermittent and there is clearly no evidence of radicular impairment to a moderate degree. See 38 C.F.R. § 4.124a. Furthermore, the Board notes that while the IME indicates bilateral upper extremity radiculopathy, the Veteran throughout the appeal period specifically indicated that the radiating pain affected his left arm, but has not mentioned radiating pain to the right arm. Lastly, during this period on appeal, the competent evidence does not reflect any other objective neurologic abnormalities associated with the cervical spine disability to warrant any additional separate ratings. b. From July 29, 2003, forward During this period on appeal, the RO rated the Veteran's cervical spine disability as 20 percent disabling. The Veteran asserts that his symptoms are worse than the currently assigned rating. Turning to the evidence during this period on appeal, private progress notes dated August 2003 show complaints of neck pain ranging from 5 out of 10 to 10 out of 10, range of motion testing of forward flexion to 30 degrees, extension to 30 degrees, right lateral flexion to 25 degrees, left lateral flexion to 40 degrees, right rotation to 50 degrees, and left rotation to 60 degrees. Upper extremity strength test was 4+/5 for bilateral shoulders with the exception of internal rotator, which was 5/5, bilaterally. The Veteran also reported that he had difficulties with functional activities including computer usage, reading, looking overhead, and rotating his neck for driving. After physical therapy, range of motion revealed forward flexion to 50 degrees, extension to 45 degrees, right lateral flexion to 35 degrees, left lateral flexion to 25 degrees, right rotation to 60 degrees, and left rotation to 65 degrees. Private treatment notes dated August 2003 indicate that the Veteran was followed up after having some myofascial predominant cervicogenic pain with allied headaches. He had recurrent lateral epicondylitis on the left side. Physical examination revealed that the Veteran was in no severe or acute distress. The neck was "fairly supple," but there was a bit of suboccipital and trapezius tenderness. Neurological examination was normal. The impression was cervical spondylosis with myofascial predominant pain, some muscle tightness or spasm, and left lateral epicondylitis. Additional private medical progress notes dated November 2003 indicate that the Veteran reported pain, decreased cervical range of motion, decreased cervical and upper extremity strength, decreased posture and body mechanics, and decreased functional abilities. It was noted that the Veteran made progress, but did not reach the goals set of reducing his pain or increase his range of motion, especially for rotation, so he would be able to drive. During this visit, the Veteran was noted to demonstrate continued poor posture. Private treatment notes from the Pensacola Physical Medicine and Rehabilitation dated October 2003 note that the Veteran stated the therapy has been helping, and he was having less neck spasms. The Veteran also denied numbness and tingling. Upon examination, the Veteran's range of motion showed flexion to 60 degrees, extension to 45 degrees, and lateral flexion to 30 degrees, bilaterally. There was evidence of tenderness to palpation in the cervical paraspinals and upper trapezius. Spurling and Lhermitte's tests were both negative. The pain was noted to be worse with extension and rotation. Upper extremities sensation was intact, and deep tendon reflexes were 2/4 and symmetric. The impression was cervical facet mediated pain, with secondary myofascial pain, and cervicogenic headaches. In May 2005, the Veteran underwent a VA examination to assess the severity of his service-connected cervical spine disability. The Veteran reported neck pain described as constant pulling and burning in his bilateral posterior neck that radiates to his bilateral trapezius muscles. He denied any weakness, but noted that he experiences stiffness and occasional swelling and heat without redness or "give way." He further noted locking in the neck and fatigability. He reported occasional weakness in his left arm, denied any numbness, but also indicated that he was told it was due to his tendonitis and not related to his neck. The examiner noted that the Veteran was employed as a firefighter, and aggravating factors included his air pack, fire helmet, and working at the computer for over an hour. It was further noted that the Veteran was regularly taking pain medications, to include Methadone, Zanaflex, Bextra, and Nabumetone, as well as receiving injections every month. There was no evidence of dislocation or recurrent subluxation, and no history of inflammatory arthritis. There examiner also indicated that the cervical spine disability had no effect on activities of daily living; however, the Veteran indicated that there was minimal impact on his occupation due to the neck pain. X-rays dated April 2005 were reviewed and noted spurring at the anterior margins of vertebral bodies, C4-6 levels, indicated to show "little" changes in comparison to the February 2002 x-rays. The disc spaces were maintained and posterior elements were aligned. Upon physical examination, range of motion testing revealed flexion to 56 degrees with pain at 46 degrees, extension to 40 degrees with pain at 20 degrees, right lateral flexion to 26 degrees with increased pain, left lateral flexion to 28 degrees with pain at the end of the motion, left rotation to 70 degrees, and right rotation to 76 degrees. Deep tendon reflexes were normal and there was no decrease in sensation to sharp and dull testing in the upper extremities. Motor strength was 5/5, bilaterally, and there was no evidence of muscular atrophy. The examiner concluded that per the Deluca criteria, there was no increase in pain, fatigue, weakness, or lack of endurance with repetitive motion. There were no abnormalities noted on a neurologic examination. Private treatment records dated February 2006 authored by the Veteran's treating physician show x-ray findings of reversal of cervical lordosis and multilevel degenerative disc disease C4 to C7. There was also evidence of soft tissue calcification in the nuchal ligament at C5-6. The impression was multilevel facet capsular insufficiency C3 to C7, bilaterally and symmetrically (greatest at C4-5 and C5-6), kyphotic reversal of cervical lordosis with associated muscle spasm and degenerative disc disease, alar and suspensory ligamentous insufficiency with 2mm excess C1-2 motion, and sigmoid mandibular motion. The doctor indicated that the Veteran may benefit from a repeat examination in the future to demonstrate any masked musculoskeletal insufficiency in the presence of muscular spasm. Additional private treatment notes from the Renfroe Spinal Center dated February 2006 reveal range of cervical spine motion of flexion to 40 degrees, extension to 40 degrees, left lateral flexion to 35 degrees, right lateral flexion to 30 degrees, and rotation to 70 degrees, bilaterally (normal measurements are noted as 60, 75, 45, 45, and 80, respectively). Pain was noted on all ranges. Tenderness was noted on the left side. A March 2006 notation by the medical professional indicates that the Veteran had positive orthopedic testing and restricted range of motion in the cervical spine. X-rays were positive for degenerative changes throughout the cervical spine and ligament damage, which the medical professional stated was related to the same in-service injury. The medical professional further noted that these changes were not age related, because they were not seen in all of the joints, as would have been if it was age related. The Veteran was seen by the same provider very frequently for treatments until March 2007; however, despite occasional reports of slight improvement, he reported increased or similar pain levels. The Veteran underwent an IME in January 2007 by a chiropractic neurologist after he had a car accident in October 2006. The Veteran reported bilateral paracervical discomfort, more localized in the suboccipital region. The Veteran rated the pain as 4 out of 10. Upon physical examination, the Veteran was able to approximate chin to chest during forward flexion without complaint, extension was full with complaints of cervicothoracic discomfort. Lateral flexion was full without complaint, bilaterally, and rotations were full with complaint of contralateral paracervical pull. Muscle strength was 5/5, shoulder depressor was negative, and foraminal compression was positive for bilateral pressure at the skull, more left sided. There was no evidence of spasms, decreased spinal motions, or neurological deficits during this examination. X-ray studies were not done or reviewed during this examination. The examiner concluded that there were no restrictions on the Veteran's activities with regard to employment or recreational endeavors. Though, the examiner further opined that the Veteran had "reached the maximum medical improvement effective to-date." Pain charts dated from August 2007 to October 2008 show extreme stiffness, limitation of motion, pulling of left side of neck, spasms, burning sensation in shoulder blades, tingling and numbness in right hand, and burning sensation and pain in left elbow. The Veteran rated his neck pain between 7 and 9 out of a scale of 10. Private treatment notes from Baptist Walk-In Care dated August 2007 indicate that the Veteran was ambulatory with a steady gait. His neck was supple without JVD or lymphadenopathy noted. Upon physical examination, there was paraspinals tenderness that radiated into the occipital areas. There was no evidence of edema, erythema, or ecchymosis. The medical professional stated that the Veteran had range of motion that was limited by pain, but did not provide results in degrees. During an outpatient orthopedic examination dated September 2007, there was evidence of cervical spondylosis with severe chronic cervical discogenic, and facet mediated pain, secondary cervical myofascial pain, and spasms. Extension of the cervical spine was to 45 degrees, left rotation to 60 degrees, and right rotation to 55 degrees (normal shown to be 75, and 80, respectively). The examiner indicated that the Veteran had a decrease in cervical extension by about 30 degrees, decrease in right rotation with a deficit of approximately 25 degrees, and left rotation decrease of approximately 20 degrees. Spurling's test was negative. There was evidence of tenderness throughout the mid-and-upper cervical paraspinals down to the upper medial trapezius regions. The Veteran had moderate spasms, especially with contralateral rotation. There was tenderness with palpation and percussion over the occipitalis musculature, and over the greater occipital nerves, bilaterally. In a letter dated September 2007 authored by the Veteran's chiropractic physician, the Veteran's chief complaints are noted as chronic neck pain and reduced range of motion. It was noted that when he returned from a medical appointment in October 2006, he was involved in a car accident that further aggravated his cervical spine disability. The Veteran reported that his neck and shoulders were stiff and painful with decreased range of motion. He stated that even simple repetitive tasks such as painting, bookkeeping, and working on the computer, all aggravate his cervical spine, which brings on or perpetuates a debilitating migraine. There was no past surgical history, but the physician indicated that the Veteran had significant multiple greater and lesser occipital nerve blocks and cervical epidural steroid injections. The examiner reiterated the February 2006 range of motion findings noted above. The shoulders had a "fairly good" range of motion with negative impingement tests. There was evidence of tenderness in his left upper extremity over his left lateral epicondyle region, and pain was increased with resisted wrist and third digit extension. Private treatment notes from the Pensacola Open MRI & Imaging dated July 2008 show reports of progressive chronic neck pain, left shoulder pain, concern for radicular symptoms, and decreased range of motion. Findings revealed evidence of a slight curve reversal in the cervical spine. The impression was "straightening of the cervical spine mild; spondylosis more away from the canal degree of encroachment both bony and limited bulge of the annulus and disc is limited." Private treatment notes authored by Dr. M.A.G dated August 2008 indicate that the Veteran reported severe neck pain, despite undergoing full conservative management. He denied any numbness, weakness, bowel, bladder complaints, or any radicular symptoms. Sensory and reflexes examination were normal. A review of a previous CT scan showed degenerative disc changes at C4-5 and C5-6. The examiner stated that after a long discussion with the Veteran, he was noted that he could not take it anymore. He had three years of conservative management including chiropractic manipulation, physical therapy, and pain management with epidurals, which provided only temporary and partial relief. The examiner noted that in order to fully evaluate the disability, a myelogram was needed. The Veteran returned the following month post-myelogram, which showed degenerative disc disease. The examiner restated that there were no radicular symptoms. It was noted that another provider diagnosed "some sort of mass" on the CT myelogram, which should be reevaluated. A surgery was not recommended, because the medical professional could not guarantee that he will get better. The medical professional recommended that the Veteran undergo some facet blocks in the cervical spine as a further adjunct to his pain condition. In June 2009, the Veteran underwent an additional VA examination to assess the severity of his spine disability. The Veteran reported pain, stiffness, weakness, fatigability, lack of endurance, and incapacitation. He denied any bladder or bowel complaints, but reported a burning sensation at the back of his neck on the left, and a pulling sensation down into his shoulder blades, to an area the size of a quarter, which burns. The pain sometimes radiated into his left upper arm, which was described as nagging and persistent. The Veteran further indicated that he had difficulty turning his head, since the pain is constant, and always there across the base of his neck. The pain was rated as 4-5 out of 10. The examiner stated that the radiating pain occasionally went into the right side of his neck. The Veteran reported flare-ups that were rated as 8 out of 10, with a frequency of 3 to 4 times a month, for duration of at least 12 to 72 hours. He stated that during a flare-up his neck becomes very stiff with decreased range of motion. Strenuous firefighting (due to the Veteran's job) sometimes caused a flare-up, but other times the Veteran stated that he woke up with a flare-up. The pain is alleviated by bedrest, medications, hot showers, and if none of these help, the Veteran undergoes chiropractic massages and epidurals. It was noted that the Veteran had a neck brace, which helped when he was wearing it. Upon physical examination, the examiner noted that the Veteran gait was normal. The neck was symmetric without gross deformity or apparent scoliosis. Deep tendon reflexes were +1/4 and equal bilaterally in the biceps, triceps, and brachial radialis tendon. There was no evidence of muscle atrophy, contracture, hypertrophy, or loss of tone. Sensory examination was normal. Range of cervical spine motion was as follows: flexion to 40 degrees, extension to 30 degrees, right lateral flexion to 20 degrees, left lateral flexion to 30 degrees, all limited by pain, right lateral rotation to 55 degrees limited by pulling, and left lateral rotation to 60 degrees limited by pain. The examiner indicated that there was no evidence of painful motion, tenderness, spasms, edema, fatigability, lack of endurance, weakness, or instability, except as noted. The examiner further stated that loss of function due to flare-ups could not be determined without resorting to mere speculation; however, the examiner did not provide any rationale for this statement. The examiner concluded that the Veteran's cervical spine disability resulted in minimal functional impairment. The examiner also questioned the Veteran as to why he chose to be a firefighter despite having such severe neck pain, to which the Veteran replied by indicating that he applied to many jobs, but this was the one he was hired for. In May 2010, the Veteran obtained a private independent medical expert (IME) evaluation of his claim by a neuro-radiologist. The expert indicated that the Veteran should be assigned a separate rating for his cervical nerve function problems/radicular symptoms, since these symptoms were new and worsened along with radicular problems described as burning and tingling in his hands and arms. The expert concluded that the Veteran did in fact have symptoms associated with bilateral upper extremity radiculopathy. Moreover, the expert indicated that the Veteran had a relatively new loss of bowel and bladder function resulting in multiple daily leaks of his bowel and bladder. It was noted that the Veteran was prescribed Flomax, but continued to have urinary leakage. In addition, the Veteran was noted to suffer from loss of erection and ejaculation over the past 5 years. The expert opined that the Veteran's current bowel and bladder incontinence and sexual dysfunction were "very likely due in significant part" to his cervical and/or lumbar spine (for which he is also service-connected) disabilities. It was further noted that the Veteran's gastritis and GERD were due using NSAIDS to treat his spine and arthritis conditions. In correspondence dated November 2010, the Veteran's primary care physician (noted to be treating the Veteran for "20 plus years") indicated that the IME opinion above was reviewed, and agreed that the Veteran's "sexual/bladder/bowel problems with respect to loss of erection/sexual dysfunction and loss of bowel and bladder function are all very likely due in significant part to his cervical and or lumbar diseases." Private treatment notes dated December 2010 show complaints of urinary hesitancy. The Veteran reported that he had this issue for a few years and was prescribed Flomax but later had increased problems with his urinary tract symptoms. The Veteran reported symptoms of urinary hesitancy, obstructive lower urinary tract symptoms, difficulty starting urinary stream, decreased force of stream, and post void dribbling. During the appointment, the Veteran had post-void residual measurement by ultrasound, which was 15ml, but he was not able to produce a urine specimen, since he voided just prior to his appointment. Private treatment notes from the North Florida Surgery Center dated April 2011 indicate that the Veteran continued to receive cervical epidural steroid injection, fluoroscopically guided epidurogram to treat his cervical degenerative disc disease. Private medical progress notes dated June 2012 to January 2013 indicate that the Veteran continued to report neck pain. Physical examination revealed no active synovitis, good range of motion, with left lateral epicondylitis, and exquisite tenderness reproducing local and regional pain, worse by forced extension of the wrists. Strength was noted as 5/5 with no breakaway weakness. Sensory examination was intact throughout the upper extremities. Additional private treatment notes dated February 2013 show reports of severe pain rated as 8 out of 10, and radiating down to the left arm. He further stated that without his medications he would not be able to attend to his activities of daily living. The physician noted that the Veteran's muscles were tender with areas of rigidity and spasm, bilaterally. It was further noted that due to the severity of the Veteran's pain and the noted trigger point tenderness, the physician found it "medically necessary" to proceed with bilateral occipital nerve blocks. Upon completion, the Veteran reported immediate pain relief. In correspondence dated February 2013, the Veteran stated that he had pain radiating down into his left arm with burning under his arm between the shoulder and elbow, and constant burning just past the elbow, between the elbow and wrist. He further noted that he had a "bruised like feeling" in the tissue of the palm, below the thumb on the left hand. The Veteran underwent an additional VA examination in February 2017. The Veteran reported stiffness, pain ranging between 3 and 6 out of 10, but overall unchanged. He described his cervical spine as "tight pulling" in the back of the neck. He did not report any radiculopathy symptoms during this examination. The Veteran additionally reported flare-ups that occurred approximately two to three times a month usually after prolonged yard work. He stated that during a flare-up the pain increases in severity and he has to take a warm shower, use a heat wrap, and take Lortab until the pain reduces 1 or 2 hours later. Upon physical examination, range of motion testing revealed flexion to 40 degrees, extension to 35 degrees, right lateral flexion to 40 degrees, left lateral flexion to 35 degrees, right lateral rotation to 60 degrees, and left lateral rotation to 55 degrees. It was noted that the range of motion itself contributed to functional loss, but pain on extension that was noted on the examination did not result or cause functional loss. There was no evidence of pain with weight bearing, localized tenderness, or pain to palpation. The Veteran was able to perform repetitive use testing, which did not result in additional loss of function or range of motion. Nevertheless, the examiner noted that the Veteran was not examined immediately after repetitive use over time, and the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner further noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner further noted that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups. There was no evidence of guarding or muscle spasm. Muscle strength testing was normal with no evidence of muscle atrophy. Reflex and sensory examinations were normal, and the examiner indicated that there was no radiculopathy. There was no ankylosis. The examiner additionally noted that the Veteran had IVDS, but without episodes that required a physician prescribed bed rest in the previous 12 months. The Veteran was not using any assistive devices. The examiner concluded that the Veteran's cervical spine disability caused a mild functional limitation. In a statement in support of claim dated July 2017 as well as during his November 2017 hearing testimony, the Veteran challenged the adequacy of the February 2017 VA examination. Specifically, the Veteran noted that the examiner's description of his condition as "stable" since his last VA examination was incorrect. He stated that his condition caused him severe pain and severe limitation to his ability to function, contrary to the last VA examination findings. Furthermore, the Veteran challenged the examiner's notation that there were no reports of radicular pain or symptoms, and continued to indicate that he did in fact continued to experience pain that radiates down his left arm. Based on the foregoing, for this period on appeal, the Board finds that a disability rating in excess of 20 percent is not warranted under the former DC 5290 or the current DC 5237. The Board notes that during this period on appeal, the Veteran's range of motion does not appear to have worsened in comparison to the period on appeal prior to July 29, 2003, for which the Board awards a 20 percent disability rating. The Board considered whether a higher disability rating for the cervical spine is warranted on the basis of functional loss due to pain or due to pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca. Here, as noted above, there is no evidence of additional loss of cervical spine motion after repetitive use testing. The Board however acknowledges that the Veteran's cervical spine disability has caused pain and stiffness, which has restricted overall motion. The Veteran has consistently reported difficulty in turning his head, using the computer, and driving; however, the VA examination reports and treatment records indicate ranges of motion that do not more nearly approximate the 30 percent criteria, even taking into account the additional functional limitations that the Veteran may experience with repetitive use over time or during a flare-up. Again, the evidence of record notes that cervical spine flexion was limited to, at worst, 30 degrees, and otherwise was normal or nearly normal. Based on the above, the degree of functional impairment does not warrant a higher rating based on limitation of motion for the cervical spine. The Board will next consider whether separate ratings are warranted for any associated bowel or bladder dysfunction. Impairment of rectal sphincter control with fecal incontinence is rated under Diagnostic Code 7332. Under this code, the following ratings apply: a noncompensable rating is warranted for healed or slight impairment of sphincter control without leakage; a 10 percent rating is warranted for constant slight impairment of sphincter control, or occasional moderate leakage; a 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of a pad; a 60 percent rating is warranted for extensive leakage and fairly frequent involuntary bowel movements; and a 100 percent rating is warranted for complete loss of sphincter control. 38 C.F.R. § 4.114, Diagnostic Code 7332. Diagnostic Code 7542 provides that neurogenic bladder is to be rated as voiding dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7542 (2017). For voiding dysfunction, particular conditions are to be rated as urine leakage, frequency, or obstructed voiding. For continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence: Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day (60 percent); requiring the wearing of absorbent materials which must be changed 2 to 4 times per day (40 percent); and requiring the wearing of absorbent materials which must be changed less than 2 times per day (20 percent). 38 C.F.R. § 4.115a. For urinary frequency with daytime voiding interval less than one hour, or; awakening to void five or more times per night (40 percent); with daytime voiding interval between one and two hours, or; awakening to void three to four times per night (20 percent); and with daytime voiding interval between two and three hours, or; awakening to void two times per night (10 percent). 38 C.F.R. § 4.115a. For obstructed voiding characterized by urinary retention requiring intermittent or continuous catheterization (30 percent); and with marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1. Post void residuals greater than 150 cc, 2. Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec), 3. Recurrent urinary tract infections secondary to obstruction, and 4. Stricture disease requiring periodic dilatation every 2 to 3 months (10 percent). 38 C.F.R. § 4.115a. Here, the private IME specifically attributes the Veteran's bladder and bowel leakage issues to his cervical spine disability and such finding was affirmed by his private primary care physician of 20 years. The Board finds this medical evidence probative and aligns with the Veteran's competent reports of urinary and bowel leakage. As such, the Board grants a 10 percent rating is warranted for occasional moderate leakage under Diagnostic Code 7332. The Veteran has competently testified as to bowel leakage, and the IME physician as well as the Veteran's private physician reported multiple bouts of leakage. As to the urinary dysfunction, the Board assigns a 10 percent rating under Diagnostic Code 7542 based on medical and lay evidence of voiding frequency. Lastly, during this period on appeal, the competent evidence does not reflect any other objective neurologic abnormalities associated with the cervical spine disability to warrant any additional separate ratings. Rating Schedule- Migraine Headaches In this case, the RO rated the Veteran's migraine headaches as zero percent (non-compensable) disabling. The Veteran contends that his migraines are more severe than currently rated. Migraine headaches are rated under Diagnostic Code 8100. 38 C.F.R. § 4.124a. Migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as non-compensable. Migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. The term "prostrating attack" is not defined in regulation or case law, but can be defined as extreme exhaustion or powerlessness. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999)(quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack); DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d ed. 2012). Further, "severe economic inadaptability" is also not defined in VA law. See Pierce v. Principi, 18 Vet. App. 440, 446 (2004). In addition, the Court has held that nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Id. In this regard, it was explained by the Court that if "economic inadaptability" were read to import unemployability, the appellant, should he or she meet the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating. Id., citing 38 C.F.R. § 4.16. The Court discussed the notion that consideration must also be given as to whether the disability was capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. See Pierce, 18 Vet. App. at 446. In this regard, VA conceded that the words "productive of" could be read to mean either "producing" or "capable of producing." Id. at 446-447. The Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Headaches -Factual Background and Analysis The RO granted the Veteran's claim for service connection for headaches and assigned a 10 percent disability rating, effective April 14, 2003 (the date of claim); it was later increased to 30 percent, effective September 6, 2006. The Veteran asserts that his disability was more severe during the entire appeal period. The Board acknowledges that during his November 2017 hearing testimony, the Veteran raised the issue of entitlement to an earlier effective date for his service-connected headache disability. Notably, in his February 2003 notice of disagreement, he specifically indicated that his headache claim dating back to February 2002 was not yet adjudicated. Nevertheless, the Board will address this concern in the analysis of the initial rating claim already on appeal here. Prior to September 6, 2006 Turning to the evidence during this period on appeal, the Veteran underwent a VA examination in June 2003, where he reported headaches since the 1980s prior to his discharge from the military. He stated that the headaches start in the posterior aspect of his head just above the axis and then go up over the forehead, most of the time on the left side. There was no visual disturbance of photophobia. The Veteran stated that he underwent frequent massage therapy and acupuncture treatments performed by his chiropractor. He further added that prior to receiving epidural injections in the fall of 2002, he was having two to three headaches per week, which could last more than a day, but after he received the injections, he experienced one headache per week. Private treatment notes from Pensacola Physical Medicine and Rehabilitation dated July 2003 show reports of ongoing severe headaches. Trigger point injections were noted to be helping, but the Veteran stated that he still had severe headaches. He further noted that he had traction done, which was very helpful, but when traction was removed the pain severity increased immediately. The headaches were still described as constant. Progress notes dated August 2003 show reports of headaches that last approximately 1 to 3 days on average. Additional progress notes dated October 2003 indicate that the Veteran reported therapy was helping with reducing his neck spasms, which resulted in less frequent headaches that were now occurring only 1-2 times a week, but still were described as severe. The Veteran was seen again in November 2003, where he complained of headaches with constant pain once or twice a week, that last 12 to 24 hours, and were rated as 9-10 on a scale of 1-10 in severity. Progress treatment notes dated December 2003 indicate that his headaches improved after he was taking Pamelor. The Veteran reported that the headaches decreased in frequency and occurred about once every one and half to two weeks. He was taking Fioricet when he had headaches, which was noted to eliminate them. When he did have headaches, they were described as mild to moderate in severity and dull in quality. In January 2004, the Veteran reported to the emergency department with chief complaint of migraine headache. It was noted that he was awakened by a fairly significant headache that stemmed from his cervical spine and extended upward, and was associated with increased pain, rated as 8 out of 10. There were no complaints of visual disturbances and no evidence of fever or chills. The Veteran was given 60mg of Toradol, and was prescribed Percocet and Ultram to take at home. Follow-up treatment notes dated April 2004 show reports of severe headaches two times a week, described as persisting posterior occipital headaches that were radiating up into the skull. Private treatment notes from Baptist Walk-In Care dated October 2004 show reports of headaches that start in the back of the neck and go around the top of the head and forehead. The Veteran noted that sometimes light will exacerbate the symptoms, and noise certainly caused aggravation. The medical professional noted that the headaches were probably mixed muscle contraction with possibly a vascular component. In December 2004, the Veteran's Battalion Fire Chief Officer and paramedic provided a statement which indicated that he was working with the Veteran for approximately 14 years. He stated that during this time, the Veteran has battled a constant problem with headaches, and he witnessed him taking all types of medications in attempt to get a relief. It was further noted that the headaches have become so bad that they have impaired the Veteran's work performance on many occasions. The Chief indicated that the Veteran had to go lie down while at work, and even leave work to go to the local emergency department for treatment. An additional statement from a Lieutenant/Paramedic coworker note that they have been working together for the previous 7 years, where the Veteran experienced constant headaches which in several occasions caused him to lie down or take sick time and go to see his doctor for relief. The coworker noted that he personally witnessed that the Veteran had severe headaches three to four times a month. During an April 2005 VA spine examination, the Veteran reported headaches that occur once or twice a week and last approximately 4 to 24 hours each time. These headaches occasionally woke him up from his sleep. The Veteran was taking Fiorinal every four hours on as needed basis. It was noted that he received six epidural injections for his headaches. The Veteran denied any weakness during the migraines or functional loss, but stated that he had fatigue afterwards. It was further noted that he was working as a firefighter supervisor, and was told that he could lay down when he has headaches despite working full time. He further stated that he missed three days of working in the previous 12 months due to his headaches. The examiner concluded that the headaches had no effect on activities of daily living, and caused minimal effect on the Veteran's occupation. Private treatment notes from the Veteran's chiropractor dated March 2006 noted that the chiropractor was in the opinion that the Veteran's headaches were becoming very debilitating when they occur, and stem from the areas in his neck [for which he is treated for], and will continue to worsen. It was further stated that conservative chiropractic care was attempted, but did not obtain very good results. Based on the foregoing, the Board finds that the Veteran's headaches more nearly approximate a 50 percent disability rating. In this regard, the Board notes that for the 30 percent criteria, evidence must show headaches with characteristic prostrating attacks occurring on average once a month. Here, the Veteran reported severe headaches that occurred at least once a week or more frequently. As such, at the least, he had severe headaches that occurred four times a month, which is more frequent than required by the 30 percent rating criteria. Notably, the headaches were always referred to as "severe headaches," and the Veteran's lay reports and the above mentioned medical evidence suggests that these headaches were very frequent, completely prostrating, and prolonged. With regards to the requirement that such headache attacks are productive of "severe economic inadaptability," the Board notes that the Court in Pierce specifically held that severe attacks "capable of producing" economic inadaptability should also be considered. Here, the lay assertions made by the Veteran, his supervisor, and his co-workers, all suggest that his headaches were so severe that it interfered with his ability to work. Therefore, the fact that he was still working does not indicate that his headaches were not productive of severe economic inadaptability. As noted above, the Board analysis is focused on whether the disability is capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. Furthermore, during his November 2017 hearing testimony, the Veteran affirmed that despite keeping his job, it has caused a tremendous impairment on his ability to function, which eventually led to his retirement. Based on this body of evidence, the Board finds that the Veteran's headaches more nearly approximate the criteria for a 50 percent disability rating, the highest available rating for this disability under the rating schedule, from the beginning of the claim. From September 6, 2006, Forward As noted above, during this period on appeal, the Veteran's headache disability rating was increased to 30 percent. Turning to the evidence during this period on appeal, private treatment notes dated September 2006 show reports of prostrating headaches that occur once a month. In January 2007, the Veteran was referred for an independent medical evaluation, in which he reported headaches that begin at the occipital region and traverse to the frontal region. The headaches were noted to occur approximately two to three times per week. Treatment notes dated March 2007 indicate that 20 minutes after he received Toradol injection, the Veteran noted that his headaches were about 75 percent relieved. Pain charts dated from August 2007 to October 2008, show consistent notations of completely prostrating migraine headaches that lasted between 24 hours and four days. Additional private treatment notes from Baptist Walk-In Care dated August 2007 show reports of headaches twice a week. It was noted that he received Toradol shots that provide temporary relief. Private treatment notes dated September 2007 indicate that the Veteran reported headaches in the occipital region with radiation around the temporal areas, for which he received treatment by multiple pain management and physical medicine physicians over the last several years. These treatments included epidurals, trigger point injections, and occasional Toradol injections. It was noted that the Veteran was taking many medications during the years, and was at the time of this visit regularly taking Fiorinal and Maxalt. The Veteran submitted a private opinion from his chiropractic physician dated September 2007. The chiropractor noted that the entire medical record was reviewed prior to rendering the opinion and examining the Veteran. The Veteran's reported frequent completely prostrating and prolonged headaches, which occurred approximately twice a week with an intensity of 10/10 and lasted from several hours to several days at a time. The headaches were described as usually throbbing in nature, starting on the left occipital area and radiating to one side of the hemicranium and then involving the whole head. He further reported that at times when the pain was intense, he was unable to get out of bed or hold his head up. During such attacks, he was also getting nauseous and had stomach sickness. The Veteran further stated that his prescribed headache medications did not affect these severe headache attacks, and his spouse had to help him out of bed, and drive him to either the ER or an urgent care facility. The Veteran stated that on various occasions he attempted to report to his local VA clinic, but was told by the Pensacola Outpatient Clinic personnel that they could not accept walk-in patients with medical emergencies, and that he had to drive to Biloxi VA hospital during such emergencies. Nevertheless, the Veteran stated that due to the incapacitating pain along with the bright sun, noise, and motion, it was unbearable to report to the VA hospital, which was two and half hours away. The chiropractor concluded that based on a professional medical opinion, the Veteran experienced very frequent, completely prostrating, and prolonged migraine headaches, capable of severe economic inadaptability. The headaches were noted to have major effect on the Veteran's activities of daily living and occupation. Notably, the provider stated that the frequency and intensity of these incapacitating headaches were severe enough to lead the Veteran to seek private care despite access to free VA care. Private treatment notes dated July 2008 indicate that the Veteran had a migraine that was persistent for the previous two weeks, and during an August 2008 follow-up visit, the Veteran reported severe headaches which required him to take four Fiorinal in addition to his Maxalt. Injections received during these times were noted to provide a 20 percent relief. Additional private treatment notes from Baptist Walk-In Care dated August 2008 show complaints of intermittent headaches that primarily begin in the back of the neck and then radiate around the head and behind the eyes. Toradol was indicated to provide some relief. In an August 2008 statement, a Veteran's coworker who knew him since April 2005 indicated that he witnessed him in excruciating pain and unable to complete his firefighter duties and tasks. The coworker further stated that as an Emergency Medical Technician, he had to assist the Veteran to get to a quiet and dark room to seek some relief. It was further noted that the coworker witnessed the Veteran having migraine headaches two to three times a week with many of those so severe that he could not function normally as a Lead Fire Fighter. The coworker further indicated that he witnessed these headaches last from several hours to being completely incapacitating, and requiring the Veteran to leave work to seek medical intervention, which sometimes led to him not coming back due to doctor orders of complete bed rest. It was noted that since approximately March 2008, the coworker noted that these headaches became more frequent, and now appear to happen almost daily with him reporting that it is so severe, and that he "just can't take them anymore." In an October 2008 correspondence, the Veteran noted that he suffered from these debilitating headaches since 1986. He stated that these migraines generally manifest without a warning, and their frequency varies from four per month to several per week, which last from four hours to seventy two hours. The intensity of each migraine was also noted to vary with at least one per week being incapacitating, during which time, he is unable to get out of bed. He described that the headaches usually start out in his neck, generally on the left side with the neck becoming stiff and painful with reduced range of motion, then progress over to his head above his eyebrows, behind the eyes, through both temples, and behind the ears. He further noted that the onset is usually gradual over several hours, which then becomes intense and throbbing, and aggravated by routine physical activity. During such headaches, he stated that he becomes nauseous, with sensitivity to light and noise. He further stated that he experienced concentration problems and mood changes a well. In addition, he stated that he would become confined to his bed, where it is darker and quieter. The Veteran noted that once the headaches "finally break," he feels "washed out," irritable, depressed, and unable to concentrate. At this time, his scalp is tender and the back of his head feels bruised, a feeling that lasts for several days after the attack. The Veteran added that the migraine headache may reappear multiple times, peaking and waning, as the medication tries to work, but indicated that the medications do not always break the cycle of multiple migraines, at which time he ends up going to an urgent care facility for an injection of Toradol, that may or may not work. At times when the Toradol injection did not provide relief, he stated that he reported to Pain Management for a nerve block. He stated that the migraines have been so severe that even these treatments do not always provide relief. He indicated that in 2008, he missed 172 hours of work due to debilitating migraine headaches, which "disrupted every aspect of [his] life," to include impaired concentration and memory, sleep disturbances, irritability, decreased energy and interest, personality changes, and decreased ability to handle even simple tasks." The Veteran's Station Chief submitted a statement dated October 2008, in which he indicated that he worked with the Veteran since 1989, and noted that the Veteran throughout his career battled with debilitating migraine headaches. The Chief noted that he became the Veteran's supervisor in January 2008, and since that time witnessed that the Veteran was in severe pain and unable to perform his duties as a firefighter. He further noted that the Veteran was taking various medications, which "appeared to do very little for the headaches." He further noted that the Veteran had to consistently take sick leave and schedule doctor appointments to deal with the migraines. He further indicated that the headaches caused problems at work due to his mood swings and irritability when dealing with other coworkers. In June 2009, the Veteran underwent a VA examination to assess the severity of his headaches. The examiner indicated that he had approximately 25 incapacitating headaches, 2-3 a month, lasting from 12 hours to 3 days. The examiner further noted that there were no reported effects on activities of daily living. With regards to effect on usual occupation, the examiner noted that the Veteran's helmet strap causing him a headache as well as any twisting movement. It was further noted that the Veteran's headaches were always severe, but over the years increased in frequency and duration. The Veteran stated that he has migraine headaches at least four times a month, which last between 12 and 72 hours. He indicated that on a scale from 1 to 10, his pain is 15. During headaches he had symptoms of photophobia, phonophobia, blurred vision, and any movement will aggravate these symptoms. He would first attempt bed rest, then medication, and if that is not effective, he would begin to feel nauseous, as a last resort, he would report to the ER. The examiner noted that during a migraine, the Veteran is 100 percent incapacitated and bedridden. In May 2010, the Veteran obtained a private independent medical expert (IME) evaluation of his claim by a neuro-radiologist. The expert indicated that the Veteran's 10 percent disability rating is incorrect, since he has prostrating headaches about two times a week, which warrants a higher rating. In a correspondence dated February 2013, the Veteran indicated that he continued to have very frequent, completely prostrating, and prolonged migraine attacks productive of severe economic inadaptability. He stated that he experiences these headaches about eight times a month. During headache attacks, he stated that he has to lie down in a quiet dark room, and after the attack he always feels "washed out." In an additional correspondence dated September 2013, the Veteran indicated that he has a minimum of 8, and up to 15, very frequent, completely prostrating, and prolonged attacks. During a February 2015 VA examination for an ankle disability, the Veteran reported that he missed one month of work due to his back pain, neck pain, and headaches. In February 2017, the Veteran underwent an additional VA examination to assess the severity of his headaches. The Veteran's headaches were described as pulsating or throbbing with pain on both sides of the head. Non-headache symptoms included nausea and sensitivity to light and sound. The examiner noted that the duration of a typical head pain was less than one day. The examiner noted that the Veteran had a prostrating attack once every month, which was not a very prostrating and prolonged attack productive of severe economic inadaptability. The examiner noted that the headaches impact the Veteran's ability to work, but only caused mild functional impact. In a July 2017 statement in support of claim, the Veteran indicated that the medication list for his headaches noted by the February 2017 VA examiner was incomplete, and stated that the examiner's notation that his headaches were stable since his last VA examination was incorrect, since the condition was much more severe. He further stated that the examiner's statement that he has not been to the ER or urgent care for migraines in 10 years was inaccurate, but also failed to acknowledge that the local VA does not accept emergency walk-ins, and paying out-of-pocket for ER visits or urgent care caused him economic hardship, while driving to the closest VA hospital in Biloxi, three hours away was not ideal. Further, the Veteran stated that the examiner erroneously indicated he had prostrating attacks once every month which was not a very prostrating and prolonged attack productive of severe economic inadaptability, while in fact even during the examination he reported completely prostrating headaches at least once to twice a week, during which time he has to lie down in a quiet dark room, take medications, and stay in there for four to six hours. Lastly, the Veteran indicated that the examiner's statement that his headaches result only in mild functional impact was incorrect. He stated that he chose to retire from his civilian position as a firefighter, because he was moved off a firetruck to an office position, which resulted in aggravation of his headaches, and caused him to use over 300 hours of sick leave. The Board finds the February 2017 VA examination to be inadequate for rating purposes as it misstated the Veteran's lay reports of the intensity and frequency of his headaches. Moreover, the conclusions made by the February 2017 VA examiner appear inconsistent with the rest of the medical evidence of record. In this regard, the Board finds the Veteran's competent and credible lay assertions to be of a more probative value. During his November 2017 hearing testimony, the Veteran indicated that his migraines were severe and occurred six to eight times a month. He stated that these headaches "put you in bed, and keep you in bed for days on end." He stated that he finally had to retire, because he "couldn't do it no more, because of the migraines." Each headache was noted to last a minimum of six hours, but sometimes two to three days. With regards to his retirement, the Veteran stated that he was offered to take medical leave, but decided to retire, because the benefits were better. The Veteran's spouse noted that his incapacitating episodes for two or three days, between three and five times a month, began many years ago. She remembered it was before 2003, but clearly remembered 2003 and 2004. She stated that during these headaches, the Veteran was always in bed, and no one could go in there to talk to him. She further stated that after he takes medication, sometimes he would do better 10 or 11 hours later, but usually it takes about three days "before we want to deal with him ourselves." The Board finds the spouse's statements both competent and credible as well. Also, the Veteran noted that his last headache attack was Friday and Saturday prior to the hearing. The Veteran stated that he took over 400 hours of sick leave. Lastly, the Veteran indicated that he covered the room's windows with aluminum foil to make sure it is completely dark. Based on the foregoing, for the same aforementioned reasons, the Board finds that the Veteran's headaches more nearly approximate the symptoms outlined under the rating criteria for 50 percent disability rating. Notably, there is clearly no improvement in the severity of the Veteran's headaches during this period on appeal. Accordingly, for the entire period on appeal, a 50 percent disability rating is warranted. Finally, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Prior to July 29, 2003, a rating of 20 percent, but not higher, for cervical spine disability is granted. From July 29, 2003, forward, a rating in excess of 20 percent for cervical spine disability is denied. From December 16, 2002, the criteria for a separate 20 percent rating, but no higher, for radiculopathy of the left upper extremity secondary to service-connected cervical spine disability is granted. From May 12, 2010, a separate, 10 percent rating for neurogenic bladder impairment, as secondary to service-connected cervical spine disability, is granted. From May 12, 2010, a separate, 10 percent rating for neurogenic bowel impairment, as secondary to service-connected cervical spine disability, is granted. For the entire period on appeal, an initial rating of 50 percent, but not higher, for headache disability is granted. REMAND The Board finds that a remand is necessary for the RO to implement the Board's decisions herein and to develop the derivative TDIU claim. Accordingly, the case is REMANDED for the following action: 1. Implement the Board's decision herein granting a 20 percent rating prior to July 29, 2003, for cervical spine disability; a separate 20 percent rating for left upper extremity radiculopathy; separate 10 percent ratings for neurogenic bladder and bowel impairment secondary to service-connected cervical spine disability; and a 50 percent initial rating for the entire period on appeal for headache disability. 2. Send the Veteran the (i) appropriate notice as to how to substantiate a claim for TDIU, and (ii) provide him with a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for completion, with instructions to return the form to the RO. The rating specialist's attention is called to the following: (i) Buddy statement from the Veteran's Battalion Fire Chief. VBMS entry 12/15/2004; (ii) Statement in support of claim. VBMS entry 03/24/2006; (iii) Private medical evaluation authored by Dr. D.W.F. dated in September 2007. VBMS entry 01/29/2007 at p.5; (iv) Private medical treatment "Pain Chart" dated in August 2007. VBMS entry 07/31/2008 at p.10; (v) Correspondence and buddy statement dated in October 2008. VBMS entry 10/23/2008; (vi) Correspondence dated in December 2009. VBMS entry 01/04/2010; (vii) VA examination dated February 2015. VBMS entry 02/19/2015. 3. Then, after completing any other development that may be warranted, readjudicate the TDIU claim. If the benefit sought is not granted, the Veteran and his representative must be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs