Citation Nr: 21003506 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-19 103 DATE: January 21, 2021 ORDER A rating of 40 percent, but no higher, for chronic lumbar strain is granted, subject to the laws and regulations governing the payment of monetary payments. REMAND Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to October 29, 2018, or due solely to a single service-connected disability other than posttraumatic stress disorder (PTSD) thereafter is remanded. FINDING OF FACT For the entire appeal period, the Veteran’s service-connected chronic lumbar strain is manifested by pain with forward flexion limited to 30 degrees or less, to include in consideration of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, intervertebral disc syndrome (IVDS) with incapacitating episodes, or associated objective neurologic abnormalities. CONCLUSION OF LAW The criteria for a 40 percent rating, but no higher, for chronic lumbar strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1975 to April 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in March 2011 by a Department of Veterans Affairs (VA) Regional Office. In June 2017, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2018 and August 2019, the Board remanded the case for additional development and it now returns for further appellate review. While on remand, a February 2020 rating decision awarded a 100 percent rating for the Veteran’s PTSD as of October 28, 2019. However, VA has a “well-established” duty to maximize a claimant’s benefits. Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant’s disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114. See Bradley at 294 (finding that SMC “benefits are to be accorded when a veteran becomes eligible without need for a separate claim”). Subsection 1114(s) requires that a disabled veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for SMC provided by that statute. Under the law, subsection 1114(s) benefits are not available to a veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. For SMC purposes, a TDIU based on a single service-connected disability satisfies the requirement of a “service-connected disability rated as total.” See Buie at 251; Bradley at 293. Therefore, the claim of entitlement to a TDIU based on all service-connected disabilities prior to October 28, 2019, and based on a single disability thereafter is properly before the Board. In September 2020, the Veteran submitted additional evidence for consideration in his appeal and indicated that he would be submitted further evidence and argument within 90 days; however, 90 days has passed and no additional evidence or argument has been received. 1. Entitlement to a rating in excess of 20 percent prior to December 20, 2018, and in excess of 40 percent thereafter for chronic lumbar strain. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods 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 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The period on appeal begins April 9, 2010, the date VA received the Veteran’s claim for an increased rating for his back disability, plus the one year look-back period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Veteran’s back disability has been rated as 20 percent disabling as of April 9, 2010, and 40 percent disabling as of December 20, 2018, pursuant to DC 5237 for chronic lumbar strain, which is rated under the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). 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 in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating where there is 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 rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. IVDS may be evaluated under either the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The IVDS Rating Formula provides that a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he ever had an incapacitating episode of IVDS that required physician prescribed bed rest. In this regard, while he reported that he was confined to bed for four days due to severe back pain following treatment in July 2010 at the October 2010 VA examination, there is no indication that he has IVDS or such bed rest was prescribed by a physician. In fact, all VA examinations conducted during the appeal period fail to reflect a diagnosis of IVDS. Therefore, the IVDS Formula is inapplicable and a higher rating under such criteria is not warranted at any point during the appeal period. Turning to consideration of the General Rating Formula, the Board notes that, throughout the appeal period, VA and private treatment records indicate the Veteran underwent radiofrequency ablation, cortisone injections, and nerve blocking procedures to treat his back pain, which he reported radiated down his legs. He also endorsed flare-ups of his chronic lower back pain. However, such records do not include range of motion results that are more limited than those reflected in the VA examinations conducted during the appeal period, or associated objective neurologic abnormalities In fact, in March 2020, the Veteran’s private treatment provider found that he did not have sciatica. In this regard, at an October 2010 VA examination, the Veteran reported continuous low back pain, which gets worse through the course of the day due to walking and lifting, and pain, stiffness, weakness and fatigability. He reported daily flare-ups of such episodes, but denied radiation to the legs, tingling/numbness, and urine/bowel incontinence. It was noted that the Veteran did not initially cooperate with range of motion testing due to extreme pain. However, he was later able to perform full flexion, extension, and rotation once his medication for fibromyalgia became effective. Nonetheless, the examiner found that, upon examination, forward flexion was limited to 60 degrees, without objective evidence of pain, and he had full range of motion in all other planes without objective evidence of pain. No additional limitation of motion following three repetitions was noted and there was no objective evidence of painful motion, muscle spasm, weakness or tenderness. Neurological examination, to include strength and sensation testing, and straight leg raising, was normal. In June 2016, the Veteran underwent another VA examination, in which he reported flare-ups described as pain with prolonged sitting, standing and walking. Upon physical examination, forward flexion was limited to 50 degrees, with objective evidence of pain and functional loss. The Veteran was unable to perform repetitive use testing, stating that the pain level was too intense, and he was unable to complete the examination. Moreover, while the Veteran was not examined after repetitive use over time or during a flare-up, the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing function loss and found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over time and during flare-ups. However, it was noted that the Veteran had less movement than normal due to ankylosis, adhesions, etc., disturbance of locomotion, and interference with sitting and standing. Muscle strength testing, reflex, sensory, straight leg raising test, and radiculopathy was not tested as the Veteran was unable to complete the examination due to intense lower back pain and instability. At his June 2017 Board hearing, the Veteran reported chronic back pain along with additional symptoms of constant bowel incontinence; occasional bladder incontinence; radiating pain into his arms and feet; muscle spasms; numbness in his legs; and erectile dysfunction. Thus, in light of his reported increase in symptomatology, in January 2018, the Board remanded the case for a new VA examination, which included joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, pursuant to Correia, supra, and consideration of whether flare-ups resulted in additional limitation of motion pursuant to Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), to include a retrospective opinion regarding the findings at the prior VA examinations. Accordingly, the Veteran was afforded a VA examination in December 2018, at which time he reported flare-ups, described as constant lower back pain, which increases when exposed to extreme heat and cold weather, or a moderate amount of sitting, standing, walking, stair climbing, bending, and lifting. On examination, active, passive, weight-bearing, and nonweight-bearing range of motion testing showed flexion limited to 50, 30, 20, and 30 degrees, respectively, with pain that caused functional loss on active and passive motion. See Correia, supra. There was no pain on weight-bearing or nonweight-bearing. Id. There was no additional loss of range of motion following three repetitions. However, the examiner found that, while the examination was not being conducted following repeated use over time or during a flare-up, the Veteran’s flexion would be limited to 30 degrees as a result of such factors. See Sharp, supra. There was no ankylosis. Muscle strength, reflex, and sensory testing was normal. No radiculopathy or other neurologic abnormalities, to include bladder or bowel problems, were found on examination. In a January 2019 addendum opinion, a VA examiner opined that, based on the Veteran’s pain level and activity during flare-up at the time of the October 2010 VA examination, his range of motion was further limited during flare-ups and resulted in flexion limited to 30 degrees at such time. However, he indicated that he was unable to offer an opinion regarding the findings at the June 2016 VA examination as such was not completed due to the Veteran’s lower back pain and instability. However, as the examiner did not address the range of motion findings at the October 2010 and June 2016 VA examinations pursuant to Correia, supra, the Board again remanded the claim in August 2019 in order to obtain such opinion. Thereafter, the Veteran underwent another VA examination in November 2019, at which time he reported constant low back pain radiating into his upper back and neck and frequent numbness, tingling, and cramping in both legs. However, he denied recalling having a diagnosis of radiculopathy. The Veteran reported flare-ups, described as more severe and frequent back pain, during winter months and activity. Range of motion testing revealed flexion limited to 30 degrees, with pain that caused functional loss. There was pain on weight-bearing, but no pain on nonweight-bearing, and passive range of motion was not performed as it was not feasible to do so in a safe and reasonable manner. See Correia, supra. While the Veteran was not examined after repetitive use over time or during a flare-up, the examiner stated that the examination was neither medically consistent or inconsistent with his statements describing function loss and found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over time and during flare-ups. In this regard, he indicated that, in reaching such conclusion, he reviewed the examinations, history, and subjective complaints, but, using his medical knowledge and expertise, there remained no basis to find an additional loss of function or motion due to such factors. There was objective evidence of tenderness with light touch the spine, which developed in conjunction with the service-connected low back condition through the years and co-existing fibromyalgia. There was no ankylosis. Muscle strength testing showed a slight decrease in bilateral hip flexion and knee extension, rated 4 out of 5, but normal strength in bilateral ankle plantar flexion and dorsiflexion, and great toe extension. Reflexes of the bilateral knees and ankles were hypoactive at +1, and sensory examination showed decrease sensitivity in the bilateral lower legs/ankle and foot/toes, but normal sensation in the bilateral upper anterior thigh and thigh/knee. However, the examiner ultimately found that the Veteran did not have radicular pain or other signs or symptoms due to radiculopathy, neither of his lower extremities was affected by radiculopathy, and there were no other neurologic abnormalities, to include bladder or bowel problems, found on examination. In July 2020, the VA examiner provided a retrospective opinion regarding range of motion testing at the October 2010 and June 2016 VA examinations pursuant to Correia, supra, and found that there was pain on active and passive range of motion testing, and no change in pain with nonweight bearing. Based on the foregoing, the Board finds that, for the entire appeal period, a 40 percent rating, but no higher, for the Veteran’s back disability is warranted for the entire appeal period. In this regard, as noted previously, while the Veteran’s flexion was limited to 60 and 50 degrees at the October 2010 and June 2016 VA examinations, respectively, the January 2019 VA examiner opined that, based on the Veteran’s pain level and activity during flare-up at the time of the October 2010 VA examination, his range of motion was further limited during flare-ups and resulted in flexion limited to 30 degrees at such time. Consequently, based on such retrospective opinion, the Board finds that, for the entire appeal period, the Veteran’s back disability results in forward flexion limited to 30 degrees or less, to include in consideration of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Thus, a 40 percent rating under the General Rating Formula is warranted for the entire appeal period. However, as there is no evidence demonstrating that the Veteran’s back disability results in ankylosis, a rating in excess of 40 percent under the General Rating Formula is not warranted at any time during the appeal period. Specifically, while the multiple VA examinations conducted during the course of the appeal reflect very limited motion of the thoracolumbar spine, the Veteran nonetheless maintains motion thereof and all VA examiners found no evidence of ankylosis. Thus, a higher rating for the Veteran’s back disability is not warranted. The Board has also considered whether a separate rating is warranted for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, pursuant to Note (1) of the General Rating Formula. In this regard, the Board notes that, at his June 2017 Board hearing, the Veteran reported constant bowel incontinence; occasional bladder incontinence; radiating pain into his arms and feet; numbness in his legs; and erectile dysfunction. However, VA and private treatment records are negative for any complaints, treatment or diagnoses of any neurological abnormalities associated with the Veteran’s back disability, and all examinations conducted during the course of the appeal fail to reveal any objective neurological impairments associated with the Veteran’s back disability. Additionally, in March 2020, the Veteran’s private physician indicated that he did not have sciatica. Further, radiating pain is specifically contemplated in the 40 percent rating currently assigned under the General Rating Formula. Consequently, separate ratings for associated objective neurological abnormalities are not warranted. In reaching the foregoing determinations, the Board acknowledges the Veteran’s sincerely held belief that his back disability is more severe than as reflected by the currently assigned rating. While the Board recognizes that he is competent to describe his symptomatology and resulting functional impairment, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his own reports regarding the severity of his back disability. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s back disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching the foregoing determinations, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor, which has resulted in a partial award of an increased rating for his back disability. However, insofar as the Board has denied higher or separate ratings, the preponderance of the evidence is against such aspects of the Veteran’s claim. Therefore, the benefit of the doubt doctrine is not applicable and such increased rating claim must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 2. Entitlement to a TDIU due to service-connected disabilities prior to October 28, 2019, and due solely to a single service-connected disability other than PTSD thereafter. The Veteran contends that he is unable to maintain substantially gainful employment due to his service-connected disabilities, to include medications taken for such disabilities, to specifically include his back disability. Thus, in light of such allegation, the Board assumed jurisdiction over a TDIU claim as part and parcel of his claim for an increased rating for his back disability, which stems from April 9, 2010, the date of claim, in the August 2019 remand. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Furthermore, as noted in the Introduction, based on the award of a 100 percent rating for the Veteran’s service-connected PTSD as of October 28, 2019, the pertinent matter before the Board is whether a TDIU based on all of his service-connected disabilities is warranted prior to October 28, 2019, and whether a TDIU based solely on a single service-connected disability, other than PTSD, is warranted thereafter. See Buie, supra; Bradley, supra. As relevant, for the entire appeal period, the Veteran is service-connected for chronic lumbar strain, evaluated as 40 percent disabling for the entire appeal period based on the award herein; PTSD, evaluated as 30 percent disabling prior to October 28, 2019, and a scar of the right sacro-iliac joint, evaluated as noncompensably disabling. Thus, prior to October 28, 2019, the Veteran’s combined disability was 60 percent; however, as such disabilities may not be considered as one under 38 C.F.R. § 4.16(a), he does not meet the schedular criteria for consideration of a TDIU. In this regard, the Board is precluded from assigning a TDIU rating on an extra-schedular basis under 38 C.F.R. § 4.16(b) in the first instance. However, the relevant regulation further provides that rating boards should submit to the Director of Compensation Service for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). In the instant case, the Board finds that, as the evidence suggests that his service-connected back disability renders him unemployable, the Veteran’s claim for a TDIU should be submitted to the Director of Compensation Service for consideration of a TDIU on an extra-schedular basis. Bowling v. Principi, 15 Vet. App. 1 (2001); Barringer v. Peake, 22 Vet. App. 242 (2008). In the instant case, the Board finds that as the evidence suggests that the Veteran’s back disability and PTSD rendered him unable to secure or follow a substantially gainful occupation prior to October 28, 2019, and suggests that his back disability alone renders him unable to secure or follow a substantially gainful occupation thereafter, a remand is necessary in order to refer the case to the Director of Compensation Service for extra-schedular consideration of a TDIU under the provisions of 38 C.F.R. § 4.16(b). Specifically, pertinent to the Veteran’s work history, his October 2019 Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940) reflects that he last worked full-time in September 1998 as a tractor-trailer driver. Additionally, throughout the appeal period, the Veteran reported that he worked at Kroger until 2005, as a part-time driver for 9 months in 2006, and for the railroad for 6 months, but last worked in any capacity was in 2007. In regard to his education history, the Veteran reported receiving his GED and completing one year of college. In regard to the Veteran’s PTSD, which is for consideration only for the period prior to October 28, 2019, at the August 2010 VA examination, it was noted that, while such did not result in total occupational impairment, it caused significant problems with concentration, which has reduced his reliability and productivity, and led to some verbal reprimands. Additionally, the Veteran reported that his anti-depressant made him forgetful on occasion. As pertinent to the Veteran’s back disability, the October 2010 VA examiner found that such disability had no effect on his usual occupation. However, he was not working at such time, and reported that he was incapacitated for 4 days after a back treatment where pain was very severe, limits driving as pain increases with driving, can only walk a maximum of minutes at a time, has difficulty standing due to pain, can only sit for 35 minutes at a time, and avoided heavy lifting. The June 2016 VA examiners also found that the Veteran’s back disability impacts his ability to work, as pain interfered with prolonged sitting, standing, and walking. Furthermore, in June 2017, the Veteran’s private treatment provider, Dr. KH, reported that the Veteran had severe back pain and, on five out of seven days, he was unable to complete his activities of daily living. A December 2018 VA examiner indicated that the Veteran’s back disability impacts his ability to work as pain increased with a moderate amount of sitting, standing, walking, stair climbing, bending, and lifting. In January 2019, Dr. KH reported that the Veteran was totally unemployable due to his serious back injury, Agent Orange exposure, and depression and anxiety. Additionally, at a November 2019 VA examination, the examiner found that the Veteran’s back disability impact his ability to work in that the Veteran reported that he was no longer fit to drive a tractor trailer because of his back pain and associated exhaustion. He also had difficulty with bending, lifting, twisting and laterally flexing to reach items or perform certain tasks. Finally, in a November 2019 individual unemployability statement, a VA examiner opined that, based on his contemporaneous VA examination, the Veteran is unable to sustain any employment outside the home based on severely limited range of motion noted at the time of examination, hypersensitivity to pressure place on the spine, generalized weakness and fatigue. He further noted the Veteran was unable to complete the examination and experienced dizziness and near-syncope that he attributed to pain. The examiner also observed that the Veteran’s wife had to assist him to the car and drove him to the appointment. As such, he opined that the Veteran had trouble maintaining any employment. Thus, the Board finds that, for the appeal period prior to October 28, 2019, the Veteran’s claim for TDIU based on service-connected disabilities, and a claim for TDIU based solely on a single service-connected disability, other than PTSD, should be submitted to the Director of Compensation for extra-schedular consideration pursuant to 38 C.F.R. § 4.16(b). The matter is REMANDED for the following action: Refer the case to the Director of Compensation Service for extra-schedular consideration of a TDIU based on all service-connected disabilities prior to October 28, 2019, and based solely on the Veteran’s chronic lumbar strain thereafter under the provisions of 38 C.F.R. § 4.16(b). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite 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.