Citation Nr: 20003580 Decision Date: 01/15/20 Archive Date: 01/15/20 DOCKET NO. 12-02 468A DATE: January 15, 2020 ORDER Entitlement to an initial disability rating in excess of 10 percent for degenerative disc disease (DDD) of the lumbar spine, prior to October 3, 2016, is denied. Entitlement to a disability rating in excess of 20 percent for DDD of the lumbar spine since October 3, 2016, is denied. Entitlement to an initial disability rating in excess of 10 percent for right lower extremity radiculopathy, prior to October 3, 2016, is denied. Entitlement to disability rating in excess of 20 percent for right lower extremity radiculopathy since October 3, 2016, is denied. Entitlement to an initial disability rating in excess of 20 percent for left foot pes planus with pronation is denied. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux (GERD) is denied. FINDINGS OF FACT 1. Prior to October 3, 2016, the Veteran’s lumbar DDD was not manifested by thoracolumbar flexion of less than 65 degrees, or limited combined thoracolumbar motion of less than 120 degrees, or muscle spasm or guarding causing an abnormal gait or abnormality spinal contour. 2. Since October 3, 2019, the Veteran’s lumbar DDD was manifested by thoracolumbar flexion which was not limited to 30 degrees or less and an absence of ankylosis. 3. Prior to October 3, 2016, the Veteran’s right lower extremity radiculopathy was manifested only by complaints of some pain but no actual sensory or motor impairment and he had no more than mild right sciatic radiculopathy. 4. Since October 3, 2016, the Veteran’s right lower extremity radiculopathy has been manifested by significant sensory complaints, but no organic changes or motor impairment and he had no more than moderate right sciatic radiculopathy. 5. The Veteran has left foot pes planus with pronation, plantar fasciitis, degenerative arthritis, and posterior tibial insertional tendonitis with marked deformity and extreme tenderness of the plantar surface of the left foot but no marked inward displacement and severe spasm of the Achilles tendon, and he does not have pronounced functional impairment. 6. The Veteran’s GERD was manifested by pyrosis, regurgitation and substernal pain but is not manifested by material weight loss, hematemesis, melena or anemia and is not productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for DDD of the lumbar spine, prior to October 3, 2016, are not met. 38 U.S.C. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243 (2018) 2. The criteria for a disability rating in excess of 20 percent for DDD of the lumbar spine, from October 3, 2016, are not met. 38 U.S.C. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243 (2018). 3. The criteria for an initial disability rating in excess of 10 percent for right lower extremity radiculopathy, secondary to DDD of the lumbar spine, prior to October 3, 2016, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 8520 (2018). 4. The criteria for a disability rating in excess of 20 percent for right lower extremity radiculopathy, secondary to DDD of the lumbar spine, since October 3, 2016, are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 8520 (2018). 5. The criteria for an initial disability rating in excess of 20 percent for left foot pes planus with pronation are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.21, Diagnostic Code 5276 (2018). 6. The criteria for an initial disability rating higher than 10 percent for GERD are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102,4.1, 4.2, 4.3, 4.7, 4.21, 4.114, Diagnostic Code 7346 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from July 2003 to November 2009. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his spouse (the current appellant) testified in support of his claims on November 23, 2015 before the undersigned Veterans Law Judge (VLJ) and a transcript thereof is on file. In April 2016 the Board remanded this case for additional evidentiary development. In the Board’s April 2016 remand it was stated, at page 3, that: … the issue of entitlement to service connection for irritable bowel syndrome, claimed as secondary to service-connected [DDD] of the lumbar spine (and specifically, the medication prescribed for that disability), was raised at the November 2015 videoconference hearing. His issue has not been adjudicated by the AOJ [Agency of Original jurisdiction]. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). A December 5, 2016 deferred rating decision noted the Board’s referral of a claim for service connection for IBS and that “[s]ince the hearing is after the March 2015 date in which prescribed claim forms are now required, the above noted issue should be considered a request for application.” He was to be sent “the appropriate letter/forms to address the above request for application.” By RO letter of December 7, 2016, the Veteran informed that VA regulations now required all claims to be submitted on a standardized form. He was requested to complete and sign VA From 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. A copy of that letter was sent to the Veteran’s attorney. However, no formal claim for service connection for IBA on a VA prescribed form was ever received; nor was a claim for service connection for IBS adjudicated during the Veteran’s lifetime. Following VA examinations in October 2016, a December 2016 rating decision increased the initial 10 percent rating for lumbar spine DDD, which had been assigned effective November 8, 2009 (day after service discharge) to 20 percent effective October 3, 2016 (date of VA examination). That rating decision also granted service connection for right lower extremity radiculopathy, as due to lumbar spine DDD, and assigned an initial 10 percent rating effective November 8, 2009. An April 2017 rating decision increased the 10 percent rating for right lower extremity radiculopathy to 20 percent effective October 3, 2016 (date of VA examination). The Veteran died on June [REDACTED], 2017. An August 18, 2017 Board decision dismissed the appeal of the deceased Veteran because after his death the Board had no jurisdiction to adjudicate the merits of the appeal. Subsequently, in December 2019, the Veteran’s surviving spouse, the appellant, was substituted to process his appeal. On August 22, 2017, VA Form 21-534EZ, Application for DIC [Death and Indemnity Compensation], Death Pension, and/or Accrued Benefits, was received. In clarifying what was being claimed, a boxed entitled “DIC” and “Accrued Benefits” were checked. A January 2018 rating decision denied service connection for the cause of the Veteran’s death. By RO letter of February 5, 2018, the appellant and her attorney were notified of that decision. The notification letter stated that VA had “denied your claim for dependency and indemnity compensation (DIC), death pension and accrued benefits” and that the rating decision, a copy of which was enclosed, and this letter “constitute [VA’s] decision based on your claim received on August 22, 2017. It represents all claims [VA] understood to be specifically made, implied, or inferred in that claim.” On July 25, 2018, VA Form 21-0958, Notice of Disagreement (NOD), was received from the appellant’s attorney as to the January 2018 rating decision, of which notification was provided in February 2018. In that VA Form 21-0958, it was requested that the appeal be processed by the Decision Review Officer (DRO) Process. The matters of disagreement listed were DIC, death pension, and accrued benefits. Typically, when there has been an RO adjudication of a claim and a NOD has been filed thereto, the appellant is entitled to a Statement of the Case (SOC), and the RO's failure to issue an SOC is a procedural defect requiring remand. Manlincon v. West, 12 Vet. App. 238 (1999). In light of the appellant’s request for further development, by reviewed by a Decision Review Officer (DRO), this situation is distinguishable from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. Accordingly, at this time no action is warranted by the Board. Background On examination in October 2009 it was reported that in general the Veteran could not sustain heavy physical activity without experiencing immediate distress. He was 71 inches in height and weighed 265 lbs. He was well developed and well-nourished but with an obese build. On physical examination the Veteran’s abdomen was soft and without obvious masses or tenderness to palpation. There was no cyanosis, clubbing, edema or varicosities of his lower extremities. He had bilateral pes planus. His posture and gait were normal and there was no spinal kyphosis, lordosis or significant scoliosis. Neurologically, muscle strength was 5/5 and deep tendon reflexes were equal, bilaterally. Coordination was normal. He had strong foot dorsiflexion and plantar flexion. He would walk on his heels and on his toes without difficulty. Sensation to light ouch and proprioception were normal. As to his spine, it was reported that after the Veteran’s initial inservice lifting injury he had had shooting low back pain. He now described the location as being in the paraspinous muscles of his low back, worse on the right side than the left. The pain intensity was mild to severe, with the frequency being severe twice monthly. Aggravating factors were bending, lifting, sleeping on his stomach, prolonged sitting, and running. Thoracolumbar range of motion was flexion to 80 degrees, and the remaining planes of motion were to 30 degrees, i.e., extension, right and left flexion, and right and left rotation. After three repetitions of motion there was no change in these ranges of motion, except that flexion was greater being to 90 degrees. There was no fatigue, weakness, lack of endurance or incoordination on repetitive use. The examiner reported that the Veteran was able to manage routine household chores, including shopping, carrying grocery bags weighing no more than 40 lbs., heavy vacuuming, and mowing the lawn. He could handle routine office administrative work, including typing and carrying office items weighing no more than 40 lbs. Lumbar X-rays revealed mild leftward scoliosis of the mid-lumbar spine and a symmetric appearance of vertebral bodies and intervertebral dis spaces. As to the Veteran’s left foot, it was reported that during service he had been given shoe inserts and later given orthotic inserts, which were not beneficial. He complained of aching and stabbing pain in the anterolateral joint line which was mild to severe. The frequency of severe pain was once or twice monthly, lasting up to a full day. He limped when it was really acting up. Aggravating factors included all heavy weight bearing and high impact activities, especially running or activities requiring sudden changes in direction. Walking was satisfactory. He denied any other significant functional or activity limitations. On examination there was no functional loss and no significant additional limitation of movement due to repetitive use, upon testing by goniometry. A left ankle X-ray revealed no evidence of fracture or dislocation. X-rays of his feet revealed bilateral pes planus. As to the Veteran’s gastrointestinal (GI) system, the Veteran reported that after he had begun taking medication, he had fewer symptoms of pain after eating but still had occasional heartburn after eating certain foods. His acid reflux was gone, as long as he took his medication every night, because his reflux was otherwise worse at night from lying on his back. He had never vomited blood. He had had black tarry stool only irregularly and a stool sample had been negative for the presence of blood. His symptoms were moderately well controlled with taking Esomeprozole daily. He denied any other significant functional or activity limitations. A blood study revealed that his levels of hematocrit and hemoglobin were within normal limits. At the November 23, 2015 Board Hearing the Veteran testified that his low back condition had gradually worsened over the years. He now had constant pain, which worsened with exertion during his working hours. He had missed six (6) days of work so far since June 2015. His back pain interfered with his sleeping and performing his work as a mechanic. He coped with back pain by taking medication. His GERD also interfered with his sleeping. Medication for his back pain had worsened his GERD. The Veteran testified that when his back locked-up he was incapacitated for 2 to 3 days. He testified that following range of motion testing of his back on the last VA examination he had experienced fatigue. He testified that he was unable to repeat bending his back more than once or twice. The Veteran’s then attorney indicated that the interference with the Veteran’s sleep due to low back pain was not a factor in the VA rating schedule and for which an extraschedular low back rating was warranted. The Veteran testified that he had radiating low back pain, which typically radiated down his right leg, although he had felt it in both legs. As to his left foot, the Veteran testified that a physician had told him that two bones in his left foot would rub together because a tendon had worn out. His left foot pain, for which he took medication, caused him to limp, and irritate his low back. However, he also testified that he did not use any crutches or canes to ambulate. As to his GERD, the Veteran testified that he had been given instructions for ulcerative colitis and told that he might need a colostomy in the future. He was later told he did not have ulcerative colitis but, rather, he had IBS. Subsequent to the Board videoconference private clinical records were submitted pertaining primarily to evaluation and treatment of the Veteran for lower GI symptoms, including hemorrhoids. An April 2011 report from Dr. Mills of the Digestive Health Center of Arizona reflects, in part, that in addition to lower GI symptoms the Veteran pain when swallowing, belching, and heartburn. Neurologically, he had normal reflexes and sensations. The assessments include dysphagia and esophagitis. A September 2011 sigmoidoscopy and esophagoduodenostomy revealed Grade 2 esophagitis with no bleeding in the lower third of the esophagus and gastroesophageal junction, compatible with erosive esophagitis, as well as a medium sized hiatal hernia. A December 2011 record noted that his GERD was managed with Dexilant, but with his hiatal hernia and erosive esophagitis and ongoing symptoms, there was a consideration of surgical intervention. Clinical records in 2012 and 2013 show that he denied having abdominal pain, bloating, dysphagia, gas, heartburn, nausea, and vomiting. An August 2012 record noted that, as to psychiatric status, he complained of difficulty sleeping. A March 2014 clinical record noted that he denied having abdominal pain, bloating, dysphagia, gas, heartburn, nausea, and vomiting. An October 2014 clinical record noted that he had fairly controlled GERD “on PPI therapy.” He denied dysphagia, gas, heartburn, nausea, and vomiting. April, May and June 2015 clinical records from Dr. Yu shows that the Veteran had, in part, GERD and esophageal reflux. On VA PTSD Disability Benefits Questionnaire (DBQ) in December 2015 it was reported that the Veteran’s PTSD was manifested by, at least in part, by anxiety, depression, insomnia, and sleep disturbance. He reported having initial insomnia, sometimes taking 4 hours to fall asleep. He had repeated awakenings and restless sleep. He had nightmares most nights. He only got 2 hours of sleep nightly. It was reported that he had “PTSD associated anxiety, depression, insomnia, and sleep disturbance which do not warrant separate diagnosis.” Treatment records of Dr. Yu of Thunderbird Internal Medicine show that in January 2016 the Veteran was seen for diffuse abdominal pain, and he had a history or IBS with constipation. In the past medication for IBS had caused diarrhea. He had missed two days work because of constipation. In April 2016 there was a relevant assessment of esophageal reflux. It was reported that a home sleep study done via VA had been done and the Veteran had been told he had sleep apnea. His esophageal reflux was not under optimal control. On October 3, 2016, the Veteran was afforded VA rating examinations with respect to his low back disability, foot disability, and GERD. On VA spinal examination of October 3, 2016, the Veteran’s electronic records were reviewed. He reported having pain radiating down his right thigh, with tingling and numbness to the foot and ankle. He reported having flare-ups of low back pain at least 4 times monthly. He complained of functional loss due to avoidance of heavy lifting, pushing or pulling, as well as repetitive bending, stooping or squatting, in addition to avoidance of repetitive stair climbing. On physical examination the Veteran’s thoracolumbar flexion was to 55 degrees, extension was to 15 degrees, and lateral bending and rotation were all to 20 degrees in each direction. After three repetitions of motion, there was no change in the ranges of motion, except for a loss of 5 degrees of flexion due to pain, fatigue, and weakness. His limited thoracolumbar motion contributed to functional loss, as described above. Also, pain, which he had in all planes of motion, caused functional loss. He also had pain with weight-bearing. He had mild localized tenderness, bilaterally, without swelling or atrophy. There was no guarding or muscle spasm. Muscle strength in the lower extremities was normal at 5/5, and there was no atrophy. Reflexes were normal at the knees and ankles. Sensation was intact to light touch throughout both lower extremities. It was reported that he had moderate pain, paresthesia, and numbness of the right lower extremity but no other signs of radiculopathy. It was found that he had moderate radiculopathy of the right sciatic nerve. He did not use an assistive device for walking. Imaging studies had documented thoracolumbar arthritis but he did not have a vertebral fracture. On VA examination of October 3, 2016 of the Veteran’s left foot his electronic records were reviewed. It was found that as to his left foot he had pes planus, plantar fasciitis, degenerative arthritis, and posterior tibial insertional tendonitis, all of which were all at least as likely a progression of his pes planus with pronation. He reported having progressively worsening left foot pain, the majority of which was in the dorsolateral aspect, pointing to the sinus tarsi and lis franc areas, and the plantar arches. He complained of a sensation of pins and needles at the great to join and feeling unstable with diminish sensation of balance. He related having functional impairment which limited standing to up to only 1 hour, and having to shift his weight to the right foot. He related being only able to walk for ¼ of a mile and having pain when squatting or running. He had pain and swelling on use as well as pain on manipulation of the left foot. He had characteristic callouses of the left foot. Even with arch supports, built-up shoes, and orthotics he remained symptomatic. He had extreme tenderness of the plantar surface of the left foot, which was improved with use of orthopedic shoes or appliances. The examination also found that the Veteran had marked deformity of the left foot and marked pronation of the left foot. The weight-bearing line fell over or medial to the great toe of the left foot. He had inward bowing of the Achilles tendon, i.e., hindfoot valgus with lateral deviation of the heel. But, he did not have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of the foot. The Veteran had moderately severe pain on palpation to left posterior tibial tendon insertion at the navicular. He had difficulty with single heel raise on left in that he could not lift the left heel more than 1 inch off the ground, and the calcaneus did not supinate when it lifted off the ground. He had moderate pain on palpation to left medial/central band of the plantar fascia at mid-arch. He had moderate pain with motion of the left 1st, 2nd, and 3rd metatarsal-cuneiform joints (lis franc) and with dorsal palpation of the 1st, 2nd, and 3rd metatarsal-cuneiform joints. In relaxed stance there was collapse of the left midfoot. He had moderate pain on motion of the left 1st metatarsophalangeal (MTP) joint without any pain on palpation of that joint. Muscle strength in the left foot/ankle was 4/5 in plantarflexion and 4/5 in dorsiflexion with pain on active resistance. His gait was antalgic, with a left sided limp, and he pronated throughout stance phase of gait. The examiner concluded that the Veteran had moderately severe disability of the left foot, and that it compromised weight-bearing. It also required arch supports, custom orthotic inserts or shoe modifications. Factors contributing to functional loss were painful and limited motion, pain on weight-bearing and nonweight-bearing, swelling, lack of endurance, and instability of station. Functional ability was significantly limited during flare-ups. He regularly used high top boots as an ambulatory aid. His left foot disability impacted his ability to work because of limited mobility and decreased standing. On VA examination of October 3, 2016, for evaluation of the Veteran’s GERD his electronic records were reviewed. It was reported that he took continuous medication for control of his symptoms of reflux. He still had stomach and epigastric discomfort. His signs and symptoms were persistent recurrent epigastric distress, dysphagia, reflux, substernal pain, as well as sleep disturbance caused by esophageal reflux. The frequency of his symptom recurrence was four (4) or more times per year. The average duration of episodes of symptoms was less than 1 day. He also had nausea and the frequency of this symptoms was 4 or more time per year with an average duration of less than 1 day. The Veteran did not have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. A blood study revealed that his levels of hematocrit and hemoglobin (known indicators of anemia) were within normal limits. The examiner reported that the GERD did not impact the Veteran’s ability to work. Rating Principles Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. A higher rating is assigned if a disorder more nearly approximates the criteria therefore but not all disorders will show all the findings specified for a particular disability rating, especially with the more fully described grades of disabilities but coordination of ratings with functional impairment is required. 38 C.F.R. §§ 4.7, 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Separate evaluations may be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A higher rating may not be denied 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). The alleviating effects of medication may not be considered in schedular ratings unless explicitly provided in the applicable schedular rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (noting that such improvement is “relevant to the appellant's overall disability picture”). The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski 1 Vet. App. 49 (1990). An initial disability rating in excess of 10 percent for DDD of the lumbar spine, and in excess of 20 percent from October 3, 2016, thereafter Ratings for a joint based on limitation of motion require consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. Ratings based on limited motion do not ipso facto include or subsume the other rating factors in §§ 4.40 and 4.45, e.g., pain, functional loss, fatigability, and weakness. Thus, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Also with any form of arthritis, painful motion must be considered, and painful motion of a joint with periarticular pathology is to be assigned at least a minimum compensable rating. 38 C.F.R. § 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); and Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011). However, the holding in Mitchell v. Shinseki, 25 Vet. App. 32, 40-41 (2011) that painful motion without functional loss did not constitute compensable limited motion, was premised on 38 C.F.R. §§ 4.40 and 4.45, but in Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011) it was held that painful motion without functional loss did warrant a minimum compensable evaluation under 38 C.F.R. § 4.59. Because Diagnostic Code (DC) 5003 (rating arthritis) requires that “satisfactory of evidence of pain” be “objectively confirmed,” a Veteran's testimony, alone, is not enough. For the minimum compensable rating for painful joint motion which is not actually limited to a compensable degree, a claimant’s bare statement is not satisfactory evidence of painful motion. Petitti v. McDonald, 27 Vet. App. 415 (2015) (per curiam) (painful motion may be “objectively confirmed” by either a clinician, including a claimant's assertion of painful joint motion that is confirmed by a clinician’s statement there is a history of "recurrent" joint pain or a layperson who witnessed the Veteran experience difficulty walking, standing, or sitting, or display a facial expression, such as wincing, indicative of pain). In other words, satisfactory lay evidence includes lay descriptions from other than the Veteran of painful motion; lay observations of witnesses of painful motion, lay statements of observed visible behavior or facial expressions during painful motion, as well as lay reports of difficulty walking, standing, sitting, or undertaking other activity. Petitti v. McDonald, 27 Vet. App. 415 (2015) (per curiam). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for DC 5235 to 5242) but degenerative disc disease (DDD), i.e., intervertebral disc syndrome (IVDS) is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching of the spine. The disabilities rated under this General Rating Formula include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003). Under the DC 5243, IVDS is rated 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, whichever method results in the higher rating, but both methods may not be used as this would result in prohibited pyramiding. 38 C.F.R. § 4.14; see Bierman v. Brown, 6 Vet. App. 125 (1994), Brady v. Brown, 4 Vet. App. 203, 206 (1993), and Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (the critical element is if symptoms of one condition are duplicative of or overlapping of another). Thus, a rating for IVDS may not be assigned while at the same time assigning separate ratings for the orthopedic and the neurologic components of IVDS. As to incapacitating episodes, under DC 5243, if there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months, a 10 percent rating is warranted. If there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent rating is warranted. If there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent rating is warranted. If there are incapacitating episodes having a total duration of at least six weeks during the past 12 months, a maximum 60 percent rating is warranted. The revised IVDS rating criteria do not provide for an evaluation in excess of 60 percent on the basis of the total duration of incapacitating episodes. Note 1 to the revised DC 5293 defines an incapacitating episode as a period of acute signs and symptoms that requires bed rest prescribed by and treatment by a physician. Supplementary Information in the published final regulations states that treatment by a physician would not require a visit to a physician's office or hospital but would include telephone consultation with a physician. If there are no records of the need for bed rest and treatment, by regulation, there are no incapacitating episodes. 67 Fed. Reg. 54345, 54347 (August 22, 2002). The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The Note 1 following the General Rating Formula for Diseases and Injuries of the Spine provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that 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 these motions and the normal combined range of motion 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. See also Plate V, 38 C.F.R. § 4.71a. However, Note 3 provides that, 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 should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note 2 provided the examiner supplies an explanation, and the examiner's assessment that the range of motion is normal for that individual will be accepted. Note 4 provides that range of motion measurement is to be rounded off to the nearest five degrees. Note 5 provides that, 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; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Analysis Inasmuch as the Veteran had never been prescribed bed rest by a physician, he could not have had "incapacitating episodes" within the meaning of the rating criteria in the Formula for Rating IVDS Based on Incapacitating episodes at 38 C.F.R. § 4.71a, Diagnostic Code 5243. It necessarily follows that the appropriate ratings may be assigned only for the orthopedic manifestations, for combination with any appropriate and separate rating for neurologic manifestations. 10 percent for DDD of the lumbar spine prior to October 3, 2016 For a rating for the orthopedic manifestations of the lumbar DDD and DJD in excess of 10 percent prior to October 3, 2016, the Veteran must have had either (a) limited thoracolumbar flexion of greater than 30 degrees but not greater than 60 degrees; or, (b) combined range of motion of no greater than 120 degrees; or, (c) muscle spasm or guarding severe enough to cause an abnormal gait or abnormal spinal contour. The October 2009 VA rating examination revealed the thoracolumbar flexion was to 80 degrees, and 30 degrees in all other planes of motion. When the range of motion in all planes is added together, the Veteran's combined range of motion was 230 degrees, which is only 10 degrees less than the normal combined range of motion for the thoracolumbar spine. Moreover, prior to October 3, 2016, there was no evidence of muscle spasm or guarding of the thoracolumbar spine. Equally significant the 2009 examination found that his posture and gait were normal and there was no abnormal spinal curvature. Additionally, although the Veteran testified at the 2015 videoconference that at the 2009 examination he had not had testing of repetitive motion but had had fatigue after range of motion testing, these statements are specifically refuted by the report of the 2009 examination that there was no change in his ranges of motion in the planes of motion which were tested after three repetitions of motion. There was also testimony that the Veteran did not recall that a goniometer had been used at the 2009 examination, but the report of that examination specifically cites to a “goniometry report.” That examination report further stated that after repetitive motion testing there was no observable fatigue, weakness, lack of endurance or incoordination. The Veteran’s complaints of pain and his reports of its effect on his functioning were recorded at the 2009 examination but the examiner specifically noted that he was able to manage routine house hold chores and routine office and administrative work provided he did not have to carry anything weighing more than 40 lbs. After the 2009 VA examination, the record does not show that the Veteran had any further testing of his ranges of thoracolumbar motion, or even a thorough examination, of his spine until his examination on October 3, 2016. As such, the Veteran did not meet the schedular criteria for an orthopedic rating in excess of 10 percent prior to the October 3, 2016, VA rating examination. 20 percent for DDD of the lumbar spine since October 3, 2016 The 20 percent rating for lumbar DDD based on orthopedic manifestations was premised upon the findings of the October 3, 2016, VA orthopedic rating examination, which was the last such rating examination during his lifetime. For a rating for the orthopedic manifestations of the lumbar DDD and DJD in excess of 20 percent since October 3, 2016, the Veteran must have either (a) limitation of thoracolumbar flexion of 30 degrees or less; or, (b) favorable ankylosis of the entire thoracolumbar spine. A review of the entire evidentiary record makes is indisputable that the Veteran does retain some thoracolumbar motion and, so, this precludes finding that he had any thoracolumbar ankylosis. In this regard, the October 3, 2016, VA rating examination found that thoracolumbar flexion was to 55 degrees and extension was to 15 degrees, while motion in all other planes was to 20 degrees. This adds to 150 degree which is more than half of the normal combined range of motion of the thoracolumbar spine. Even after three repetitions of motion, there was no change in the ranges of motion, except for a loss of 5 degrees of flexion due to pain, fatigue, and weakness. However, even so, his combined range of motion of the thoracolumbar spine which was more than half of the normal combined range of motion. That examination noted that the Veteran had pain in all planes of motion and in weight-bearing. However, the pain did not preclude his having more than half of normal flexion, half of normal extension, and two-thirds of motion, to the right and to the left, in rotation and in lateral bending. Additionally, the October 3, 2016, examination found that the Veteran did not have any guarding or muscle spasm. Furthermore, the evidence does not show that he had ever used a back brace or truss or that he had ever use any ambulatory aid, e.g., a cane or crutches. While he did have a limp, the examiner found that this was due to his service-connected left foot disability. Accordingly, the Veteran did not meet the schedular criteria for an orthopedic rating in excess of 20 percent since the October 3, 2016, VA rating examination. An initial disability rating in excess of 10 percent for right lower extremity radiculopathy, and in excess of 20 percent since October 3, 2016 Typically, in cases of thoracolumbar IVDS a lower extremity peripheral nerve that is commonly affected is the sciatic nerve which is rated based on neurological manifestations are rated under Diagnostic Code (DC) 8520, 8620, or 8720 as, respectively, paralysis, neuritis or neuralgia of the sciatic nerve. The DCs provide for a 10 percent rating for mild incomplete paralysis; 20 percent for moderate incomplete paralysis and 40 percent when moderately severe. When severe with marked muscular atrophy, 60 percent is warranted and 80 percent is warranted for complete paralysis in which the foot dangles and drops, and there is no active movement possible of muscles blow the knee, and flexion of the knee is weakened or (very rarely) lost. See also 38 C.F.R. § 4.124a, Diagnostic Codes 8620, 8720 (for sciatic neuritis and neuralgia). Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate diagnostic codes for paralysis, neuritis, and neuralgia of each nerve. See 38 C.F.R. § 4.124a, Diagnostic Codes 8205 to 8730. Peripheral neuropathy which is wholly sensory is mild or, at most, moderate. With dull and intermittent pain in a typical nerve distribution, it is at most moderate. With no organic changes it is moderate or, if of the sciatic nerve, moderately severe. 38 C.F.R. § 4.20. Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis. 38 C.F.R. § 4.123. As to neurological impairment from spinal disability, this consists of dysfunction of peripheral nerves and attention is directed to the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. While 38 C.F.R. § 4.120 does not define trophic changes, 38 C.F.R. § 4.104, Diagnostic Code 7115 (for rating thrombo-angitis obliterans (Buergers’ Disease) describes trophic changes as, in pertinent part, “thin skin [and] absence of hair.” An initial disability rating in excess of 10 percent for right lower extremity radiculopathy prior to October 3, 2016 A review of the evidentiary record shows that prior to the October 3, 2016, VA examination the Veteran’s complaints of his right lower extremity sciatic radiculopathy were limited solely to having radicular pain. Specifically, the 2009 VA examination, while noting that he could not sustain heavy physical activity, found that he had normal muscle strength, deep tendon reflexes, motor strength, coordination, and sensation to light touch and proprioception. In sum, prior to the October 3, 2016, VA examination the Veteran had no more than mild right-side sciatic radiculopathy. Thus, the preponderance of the evidence is against finding that a rating in excess of 10 percent was warranted prior to October 3, 2016. A disability rating in excess of 20 percent for right lower extremity radiculopathy since October 3, 2016 The earliest evidence of moderate right sciatic radiculopathy are the findings of the October 3, 2016, VA examination. At that time, he had normal muscle strength, no muscle atrophy, normal deep tendon reflexes, and even normal sensation to light touch. However, that examination also found that he had intermittent, but not constant, right sciatic pain and moderate paresthesia and moderate numbness. These sensory abnormalities were not shown to affect his functional impairment inasmuch as he had never required an assistive device, e.g., a cane, for ambulation. Significantly, there was no evidence prior to the Veteran’s death of any organic changes due to right sciatic radiculopathy which would have been characteristic of moderately severe sciatic radiculopathy. Accordingly, while the additional findings of sensory impairment found at the time of the October 3, 2016, VA examination warranted an increase to a 20 percent disability rating, at that time and since that VA examination the Veteran had no more than moderate right-side sciatic radiculopathy. Thus, the preponderance of the evidence is against a rating in excess of 20 percent since October 3, 2016. An initial disability rating in excess of 20 percent for left foot pes planus with pronation Pes planus, flatfoot, is rated as acquired flatfoot under 38 C.F.R. § 4.71a, Diagnostic Code 5276. A noncompensable rating is assigned when symptoms are relieved by a built-up shoe or arch supports. A 10 percent rating is assigned when moderate, either unilaterally or bilaterally, with weight-bearing line over or medial to the great toe, inward bowing of the tendo-achillis, pain on manipulation and sue of the feet. A 20 percent disability rating contemplates severe unilateral flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Id. A 50 percent rating contemplates unilateral pronounced flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo-Achilles on manipulation, not improved by orthopedic shoes or appliances. Id. The 50 percent rating is the highest disability rating assignable. Analysis The only Diagnostic Codes providing for a rating in excess of 20 percent for a disability of the foot are 38 C.F.R. § 4.72, Diagnostic Code 5278, Claw foot (pes cavus), acquired, under which a maximum 30 percent rating may be assigned for unilateral pes cavus if there is marked contraction of the plantar fascia with dropped forefoot, all toes being hammer toes, with very painful callosities, and marked varus deformity. Here, the Veteran never had pes cavus of the left foot. Rather, he had the opposite of pes cavus, i.e., pes planus. Also, a maximum 30 percent rating would be assigned for unilateral (one foot) malunion or nonunion of tarsal or metatarsal bones if severe, under 38 C.F.R. § 4.72, Diagnostic Code 5283. Here, the Veteran never had any service-connected fracture of a tarsal or metatarsal bone. Otherwise, 38 C.F.R. § 4.72, Diagnostic Code 5284 provides for a maximum rating of 30 percent for other severe foot injuries. However, the Veteran has been specifically diagnosed with and is evaluated for unilateral pes planus and, so, he must be evaluated under Diagnostic Code 5276 for pes planus. The 2009 VA examination recorded the Veteran’s report of functional impairment consisting of pain which fluctuated from mild to severe, and his report of limping when productive of severe pain. Also, his past use of inserts and orthotics had not been helpful. Aggravating factors were heavy weight-bearing and high impact activities, but he could walk satisfactorily and at the time of that examination his gait was normal. The record indicates that the Veteran’s left foot disorder has worsened since the 2009 VA examination. Specifically, the 2016 examination found that in addition to pes planus he had plantar fasciitis, degenerative arthritis, and posterior tibial insertional tendonitis, all of which were opined by the 2016 examiner to be related. As such, all manifestations of these disorders must be considered in arriving at the proper disability evaluation. Here, the 20 percent rating encompassed marked deformity, and accentuated pain on manipulation and use, as well as swelling on use and callosities. The 2016 VA examination recorded the Veteran’s complaints of functional impairment and on physical examination he was found to have extreme tenderness of the plantar surfaces of his foot and marked deformity. These symptoms and findings were consistent with the criteria for the next higher rating of 30 percent for unilateral involvement. However, that examination also found that he did not have marked inward displacement and severe spasm of the Achilles tendon, although he had inward bowing of the Achilles tendon. However, the primary prerequisite for a 30 percent rating is that the Veteran’s symptomatology was productive of pronounced impairment. This is because the 2016 examiner found that even considering the Veteran’s report of functional impairment and the abnormal physical findings on examination, including moderately severe pain on palpation and moderate pain on motion, with some minor decrease in strength, which compromise ambulation and weight-bearing, the overall severity of the multiple conditions affecting the Veteran’s right foot was no more than moderately severe. This falls short of the pronounced impairment required for the next higher schedular rating of 30 percent. The Board has considered the extensive treatment which the Veteran has undergone for his left foot disorder and his statements and testimony as to the impact on his ability to function, including his pain. However, the criteria for pes plans specifically encompass pain, particularly on manipulation of the feet. Further, consideration has been given to his not obtaining significant relief from inserts or custom-built shoe wear. Thus, the preponderance of the evidence is against the assignment of an evaluation greater than 20 percent for the service-connected left foot disorder. An initial disability rating higher than 10 percent for GERD Because there is no specific Diagnostic Code (DC) for rating GERD, service-connected GERD may be rated analogously by use of a “built-up” DC as a hiatal hernia under DC 7346. A disorder not listed in the rating schedule may be rated as if it were a closely related disease or injury, when (1) the functions affected, (1) the anatomical localization, and (3) symptoms are closely analogous. See generally 38 C.F.R. §§ 4.20, 4.27; see also Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992); Archer v. Principi, 3 Vet. App. 433 (1992). Gastroesophageal reflux is the “reverse flow of material from stomach to esophagus.” Cox v. Brown, 5 Vet. App. 95, 97 (1993). Gastroesophageal reflux is the most disabling manifestation of a hiatal hernia. 76 Fed. Reg. 39160, 39174 (Jul. 5, 2011). Accordingly, the evaluation for GERD is most appropriately determined by the application of the schedular criteria for evaluating a hiatal hernia. 38 C.F.R. § 4.114, DC 7346 provides that a minimum 10 percent rating is warranted for a hiatal hernia when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The criteria for a 60 percent rating are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.112 provides that minor weight loss means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. Substantial weight loss means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer. “Hematemesis is vomiting of blood.” Vega v. Shinseki, No. 10-3483, slip op. (U.S. Vet. App. March 13, 2012); 2012 WL 803299; (nonprecendential memorandum decision) (citing DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 831 (32d ed. 2011)). “Melena is ‘the passage of dark-colored feces stained with blood pigments or with altered blood’.” Gilmore v. Shinseki, No. 10-2085 (U.S. Vet. App. Sept. 29, 2011); Slip Copy, 2011 WL 4489187 (Table); (nonprecendential memorandum decision) (citing DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1126 (32d ed. 2012)).“’Pyrosis’ is defined as ‘[s]ubsternal pain or burning sensation, usually associated with regurgitation of acid-peptic gastric juice into the esophagus.’ STEDMAN'S MEDICAL DICTIONARY 1494 (27th ed.2000).” Melendez-Pimentel v. Peake, slip op. (U.S. Vet. App. September 2, 2008) (non-precedential Memorandum decision) (Slip Copy, 2008 WL 4118042 (Vet. App.)). “’Dysphagia’ is ‘difficulty in swallowing’.” Silimon v. Shinseki, No. 12–0668, slip op. (U.S. Vet. App. Jan. 17, 2013) 2013 WL 174423 (Vet. App.) (citing DORLAND’s at 579). Analysis It is neither shown nor contended that the Veteran has ever had material weight loss, hematemesis, melena or any anemia. In asserting that a rating greater than 10 percent was warranted for the Veteran’s GERD, a number of his symptoms have been addressed. The characteristic symptoms are not recited in the criteria for a 10 percent rating, which requires two or more symptoms recited in the criteria for a 30 percent rating, including pyrosis, regurgitation (which is also called reflux) and substernal arm or shoulder pain. Other symptoms are listed in the criteria for a 60 percent rating. Because a 10 percent rating is warranted for two or more symptoms listed for a 30 percent rating, it is argued that because the Veteran has more than two symptoms, a 30 percent rating should be assigned. However, the primary prerequisite for a 30 percent rating is that the Veteran’s symptomatology of GERD be productive of considerable impairment, which the Board concludes is not shown in this case. Here, the 2009 examiner noted that the Veteran was well nourished. It was noted that he had not had hematemesis or melena. A blood study at that time noted that his hemoglobin and hematocrit, known indicators of anemia, were within normal limits. There was also no evidence at that time of significant weight loss inasmuch as he was then noted to be obese. With respect to functional assessment, it was noted that he continued to have occasional heartburn after eating certain food but, while his condition had the potential for causing future functional impairment, it was currently under moderate controlled. No significant change in the Veteran’s condition was found at the time of the October 3, 2016, VA rating examination. At that time a blood study found that his hemoglobin and hematocrit levels were within normal limits. He had persistently recurrent epigastric distress, dysphagia, reflux, and substernal pain, as well as nausea four or more times year. However, the Board concludes that he did not have considerable impairment, as required for a 30 percent rating, because the 2016 examiner found that the Veteran’s GERD did not impact the Veteran’s ability to work. Accordingly, the Board finds that the preponderance of the evidence establishes that the Veteran’s GERD was manifested at least in part by pyrosis, regurgitation, and substernal pain but was not productive of at least considerable impairment of health and, so, did not warrant an evaluation in excess of 10 percent. Extraschedular Consideration At the videoconference it was argued that the Veteran’s service-connected disorders, including pain from his service-connected lumbar DDD, interfered with his sleep and, as such, was not contemplated under the VA Schedule for Rating Disabilities. However, the Veteran’s then attorney also stated that the Veteran’s PTSD also interfered with his sleep. See pages 24 through 27 of the transcript. An extraschedular disability rating is warranted if a service-connected disorder presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). This requires a three-set inquiry. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). First, is whether the evidence presents such an exceptional disability picture that the schedular evaluations are inadequate, necessitating a comparison between the level of severity and symptoms with the rating criteria, and if the criteria reasonably describe the symptoms and level of severity, the assigned schedular rating is adequate and no referral is required. Second, if the schedular rating does not contemplate the symptoms and level of severity and is inadequate, it must be determined if there exists and exceptional disability picture which exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, if the first two inquiries are met, then the case is referred to the appropriate VA official for consideration. Id. If either (1) the claimant's disability picture is adequately contemplated by the rating schedule or (2) there are no other related factors, for example, frequent hospitalizations or marked interference with employment, then a referral is not warranted, and the other element need not be considered. Thun, 22 Vet. App. at 116; see also Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). On December 8, 2017, VA issued a Final Rule amending 38 C.F.R. § 3.321(b)(1), effective January 8, 2018, to clarify that an extraschedular rating is not available based on the combined effect of multiple service-connected disabilities. See Final Rule, 82 Fed. Reg. 57830, 57,835 (Dec. 8, 2017). This revision is applicable to all applications for benefits that are received by VA on or after January 8, 2018 or that are pending before VA, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit (Federal Circuit) on January 8, 2018. In Thurlow v. Wilkie, No. 16-3633, slip op. (U.S. Vet. App. Sept. 12, 2018) (precedential panel decision) the Veterans Court held that the recent amendment to 38 C.F.R. § 3.321(b)(1), which eliminated the possibility of extraschedular consideration based on the collective impact of multiple disabilities (in response to the Federal Circuit’s holding in Johnson v. McDonald, 462 F.3d. 1362 (Fed. Cir. 2014) to the contrary), was validly made applicable to cases pending before the Court. While it is true that the schedular rating criteria do not always address the symptoms specifically described by a veteran, this alone does not mean that the rating criteria are inadequate. 38 C.F.R. § 4.1 provides "that percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations" and that "the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." As to any contention, express or implied, that because the rating criteria are silent as to effects of occupational and daily activities, the rating schedule does not contemplate the total disability picture, this is insufficient to conclude that the rating criteria are inadequate because this is precisely what the rating criteria are designed to do and, as will be explained, the appellant has not demonstrated that the rating schedule is inadequate in any way. See 38 C.F.R. §§ 3.321(a), 4.1; see also Dedrick v. Shinseki, No. 13-1166, slip op. at 9 (U.S. Vet. App. Apr. 4, 2014) (nonprecedential memorandum decision). The holding in Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria) precludes consideration of improvement in disability by medication when not provided for in applicable schedular rating criteria. But, that holding was limited specifically to the application of schedular rating criteria and does not preclude such consideration in the context of extraschedular consideration and, in fact, the Court noted that the use of medication was “relevant to the [Veteran’s] overall disability picture.” See Jones v. Shinseki, 26 Vet. App. at 61, footnote 4. As to the specific contention of interference with sleep, the Board notes that the criteria for a 30 percent evaluation for service-connected psychiatric disability encompasses sleep disturbance. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Here, the Veteran was service-connected for PTSD which was evaluated as 50 percent disabling at his death. Thus, to compensate the Veteran for disturbance of sleep due to thoracolumbar pain, or disturbance of sleep, as found by a 2016 VA examiner, due to esophageal reflux from the Veteran’s GERD, when he was already compensated for sleep disturbance on the basis of his service-connected PTSD, would result in double compensation, also called pyramiding, which is prohibited under 38 C.F.R. § 4.14. Aside from the assertion that sleep disturbance from service-connected disorders warrants extraschedular consideration, no other specific contention is set forth for the assignment of an extraschedular rating. Nevertheless, as to extraschedular consideration for the service-connected lumbar DDD, the Veteran had never required any surgical intervention and his treatment had consisted of the continued use of prescribed medication. With respect to impairment as to specific activities, as for functional impairment with dressing oneself, the specific acts of bending or twisting of the low back that may be required to dress oneself are contemplated by the schedular rating criteria based on limited and painful motion. For example, to the extent that dressing oneself requires thoracolumbar flexion, such motion is explicitly part of the schedular rating criteria and a schedular rating may be based on forward flexion alone. To some lesser extent, dressing oneself may require thoracolumbar extension, lateral flexion, and rotation, which are all part of the schedular rating criteria under combined range of motion of the thoracolumbar spine. See 38 C.F.R. § 4.71a, General Rating Formula for Spine Disabilities, Plate V. As to functional impairment with respect to exercise, to the extent that exercise involves prolonged standing, sitting, walking, bending, disturbance of locomotion, or instability of station, such functional impairment has been considered by the Board and is contemplated under the schedular rating criteria. See 38 C.F.R. § 4.45 (disturbance of locomotion, instability of station, and interference with sitting, standing, and weight-bearing are considered as functional limitation under the schedular rating criteria). As to potential functional impairment with respect to grocery shopping, or shopping generally, including any possible use of a cart when shopping, as well as lifting, including the lifting of day-to-day objects, the slight lateral or twisting movements required for lifting objects such as groceries or other day-to-day objects (to the extent the lifting is performed by the thoracolumbar spinal segment rather than only arms and shoulders) suggests lifting of the objects in the position of slight forward flexion, although simply lifting objects may also involve minimal thoracolumbar flexion together with movement when lifting by primarily using the legs, arms, and shoulders. As such, to the extent that these activities may involve thoracolumbar flexion, such forward flexion is explicitly part of the schedular rating criteria and a schedular rating may be based on forward flexion alone. To the extent that lifting shopping items or other items may require extension, lateral flexion, and rotation, such movements are part of the schedular rating criteria under combined range of motion. As to any possible functional impairment with respect to house cleaning, to the extent that house cleaning involves any type of thoracolumbar spine motion, all limitations of motion of the spine in any direction, including in flexion, extension, lateral flexion, and rotation of the spine are considered in arriving at a rating for the orthopedic manifestations of a spinal disorder. See 38 C.F.R. § 4.71a, Plate V. To the extent that any of these activities causes incidental pain, such pain is considered as part of the schedular rating criteria, to include as due to orthopedic DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59 factors such as weakness or weakened movement, incoordination, and fatigability, which are incorporated into the schedular rating criteria as applied to the particular diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (the schedular rating criteria contemplate limitation of spine motion with or without symptoms such as pain, whether or not it radiates); Schafrath, at 589 (1991); Burton, at 1, 4 (2011); Sowers, at 472, 479 (2016); Mitchell, at 32, 33-36 (2011). Lastly, as to the argument that each of his service-connected disorders interfered with his sleep, it must be noted that not only was medication available for treating symptoms, including pain, of his service-connected disorder, but also medication was available to assist him in sleeping. Thus, the Board does not find that there has been marked interference with employment or frequent periods of hospitalization or such other circumstances as to any of the service-connected disorders at issue which would render the application of the schedular rating criteria inadequate. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.