Citation Nr: 21075013 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-07 495 DATE: December 17, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 is denied. Entitlement to a rating in excess of 20 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 is denied. Entitlement to an initial rating in excess of 20 percent for right upper extremity muscle weakness with pronator drift for the appeal period prior to January 14, 2016 is denied. Entitlement to a rating in excess of 40 percent for right upper extremity muscle weakness with pronator drift for the appeal period beginning on January 14, 2016 is denied. Entitlement to an initial rating in excess of 20 percent for left upper extremity muscle weakness as residuals of stroke associated with diabetes mellitus is denied. Entitlement to an initial rating of 10 percent, but no higher, for slurred speech with difficulty swallowing as residuals of a stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 is granted. Entitlement to a rating in excess of 30 percent for slurred speech with difficulty swallowing as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 is denied. Entitlement to a rating in excess of 20 percent for voiding dysfunction associated with diabetes mellitus is denied. Entitlement to an initial compensable rating for chronic constipation is denied. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU) for the appeal period from October 15, 2014 to January 22, 2016 is granted. Entitlement to special monthly compensation based on the need for the aid and attendance of another or on being housebound is granted. REMANDED Entitlement to service connection for hiatal hernia is remanded. FINDINGS OF FACT 1. For the appeal period prior to January 14, 2016, the Veteran's right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus resulted in no more than mild incomplete paralysis of the sciatic nerve. 2. For the appeal period beginning on January 14, 2016, the Veteran's right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus has been productive of no more than moderate incomplete paralysis of the sciatic nerve. 3. For the appeal period prior to January 14, 2016, the Veteran's right upper extremity muscle weakness with pronator drift as residuals of stroke associated with diabetes mellitus resulted in mild incomplete paralysis of the upper radicular groups. 4. For the appeal period beginning on January 14, 2016, the Veteran's right upper extremity muscle weakness with pronator drift as residuals of stroke associated with diabetes mellitus resulted in moderate incomplete paralysis of the upper radicular groups. 5. At no point during the period on appeal is the Veteran's left upper extremity muscle weakness is shown to produce more than mild, incomplete paralysis of all radicular groups. 6. For the appeal period prior to January 14, 2016, the Veteran's slurred speech and with difficulty swallowing was manifested by moderate incomplete paralysis of the hypoglossal nerve. 7. For the appeal period beginning on January 14, 2016, the Veteran's slurred speech with difficulty swallowing as a result of a stroke associated with diabetes mellitus has not been characterized by complete paralysis. 8. Throughout the appeal period, the Veteran's voiding dysfunction associated with diabetes mellitus does not require the use of an appliance, wearing of absorbent materials which must be changed two to four times per day, or awakening to void five or more times per night. 9. Throughout the period on appeal, the Veteran's chronic constipation did not manifest as frequent episodes of bowel disturbance and abdominal distress, diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 10. For the appeal period prior to October 15, 2014, there is not sufficient evidence to substantiate a reasonable possibility that the Veteran is unable to obtain and maintain gainful employment due to service-connected disabilities. 11. For the appeal period from October 15, 2014 to January 22, 2016, the Veteran was unable to secure or follow substantially gainful employment as a result of his service-connected disabilities. 12. For the appeal period beginning on January 23, 2016, the Veteran had a 100 percent combined schedular rating and entitlement to a TDIU is moot. 13. The Veteran's service-connected disabilities result in the need for aid and attendance as he requires care or assistance on a regular basis in order to feed himself, keep himself clean and presentable, and protect him from the hazards or dangers inherent in his daily environment. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8520. 2. The criteria for a rating in excess of 20 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8520. 3. The criteria for an initial rating in excess of 20 percent for right upper extremity muscle weakness with pronator drift for the appeal period prior to January 14, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8513. 4. The criteria for a rating in excess of 40 percent for right upper extremity muscle weakness with pronator drift for the appeal period beginning on January 14, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8513. 5. The criteria for a rating in excess of 20 percent for left upper extremity muscle weakness as residuals of stroke associated with diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8513. 6. The criteria for an initial rating of 10 percent, but no higher, for slurred speech with difficulty swallowing as residuals of a stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.124a, Diagnostic Code 8212. 7. The criteria for a rating in excess of 30 percent for slurred speech with difficulty swallowing as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.124a, Diagnostic Code 8212. 8. The criteria for a rating in excess of 20 percent for voiding dysfunction associated with diabetes mellitus have not been met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.115, Diagnostic Code 7518. 9. The criteria for an initial compensable rating for chronic constipation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.114, Diagnostic Code 7319. 10. The criteria for entitlement to a TDIU for the appeal period prior to October 15, 2014 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 11. The criteria for a TDIU for the appeal period from October 15, 2014 to January 22, 2016 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16. 12. The claim for TDIU is rendered moot by the assignment of a 100 percent schedular rating for the appeal period beginning on January 23, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. 13. The criteria for special monthly compensation based on aid and attendance have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1965 to October 1967. These matters come before the Board of Veterans' Appeals (hereinafter Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, Nebraska dated in January 2015, August 2016 and November 2017. The Veteran perfected a timely appeal of those decisions. In December 2018, the Board remanded the above issues to the RO for further evidentiary development. Specifically, the matters were remanded to obtain the Veteran's updated VA treatment records, obtain an etiology opinion related to the Veteran's claimed hiatal hernia and to obtain an examination to determine the current nature and severity of the Veteran's voiding, constipation, muscle weakness and slurred speech disabilities. Updated VA treatment records have been associated with the record and a VA etiology opinion as to the claimed hiatal hernia was obtained in May 2019. VA nerve and muscle examinations were conducted in July 2021 and a VA urinary tract examination was conducted in May 2019. Following the requested development, a supplemental statement of the case (SSOC) was issued in August 2021. The Board therefore finds that there has been substantial compliance with its previous remand. In October 2021, the Veteran's agent sent a letter to the Board indicating that he wished to withdraw from the Veteran's case. The Board sent a November 2021 letter to the Veteran and his agent detailing what steps were to be conducted in order to withdraw from a case after its certification to the Board. The letter indicated that the agent was permitted to withdraw from representation only if their motion was granted by the Board and that they would otherwise continue as the Veteran's representative. The letter further indicated that the Veteran's appeal would be left in abeyance for 30 days and that the Board would assume that the agent wished to remain as the Veteran's representative if a response was not received within 30 days. This timeframe was elapsed and the Veteran's agent has not responded to this letter. Therefore, the agent will remain as the Veteran's representative. Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. 1. Entitlement to an initial rating in excess of 10 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 is denied. 2. Entitlement to a rating in excess of 20 percent for right lower extremity muscle weakness as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 is denied. The Veteran essentially contends that his right lower extremity is more disabling than reflected by the ratings currently assigned. Specific argument in support of this appeal has not been submitted. Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve, a 20 percent rating is assigned for moderate incomplete paralysis, a 40 percent rating is assigned for moderately severe incomplete paralysis, and a 60 percent rating is assigned for severe incomplete paralysis with marked muscular atrophy. Id. An 80 percent rating is assigned for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. Id. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). The words "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Mild is generally defined as "not being or involving what is extreme" or "not severe." Merriam-Webster's Collegiate Dictionary, 787 (11th ed. 2003). Moderate is generally defined as "tending toward the mean or average amount." Id. at 798. Severe is generally defined as "of a great degree" or "serious." Id. at 1140. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis-characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating-is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The evidentiary record, including VA as well as private treatment reports indicate that the Veteran has received ongoing clinical evaluation for right sided muscle weakness ever since he experienced a stroke in 2013. Following a December 2014 VA examination of the central nervous system in December 2014, the examiner reported a diagnosis of a transient ischemic attack (TIA) or cerebral infarction. The examiner noted that the central nervous system condition does not require continuous medication for control. The examiner indicated that the Veteran had muscle weakness in the upper and lower extremities. Muscle strength in the right elbow, wrist, grip and pinch was 4/5; muscle strength in the left upper extremity was 5/5. Muscle strength in the right knee and ankle was also 4/5. Deep tendon reflexes were 2+. The examiner described the muscle weakness in the right upper and right lower extremity as mild. There was no muscle weakness noted in the left extremities. The examiner indicated that the Veteran had difficulty walking. During an April 2016 VA examination of the central nervous system, it was noted that the Veteran experienced constant inability to communicate by speech, moderate swallowing difficulties, and fluent and expressive aphasia with noticeable word finding aphasia. The examiner noted that Veteran's speech was fluent, but he had difficulty with primarily expressive aphasia with decreased word finding, however, he will also make some errors in comprehension with verbal commands and in conversation. Muscle strength testing was 3/5 in the right knee and ankle. There was muscle atrophy in the right with the right calf measuring one cm difference compared with the left. Deep tendon reflexes were 3+ in the right knee and 4+ in the right ankle. It was noted that the Veteran had moderate muscle weakness in the right upper extremity and the right lower extremity. There was no muscle weakness in the left upper or lower extremities. It was noted that the Veteran had right pronator drift due to weakness. On examination of the knees in November 2017, muscle strength testing in the right lower extremity was 3/5. During a social work telephone encounter in November 2018, it was noted that the Veteran had right sided weakness subsequent to a cerebrovascular accident (CVA) and right hip fracture. The Veteran was afforded a May 2019 VA examination for peripheral nerves that reflected his reports of numbness in both feet. It was noted that the Veteran had mild paresthesias and mild numbness in both lower extremities. Muscle strength testing was 4/5 in the right upper and lower extremities, and 5/5 in the left upper and lower extremities. No muscle atrophy was noted. Deep tendon reflexes were 2+. Sensory examination was normal, except for the feet which had decreased sensation. The examiner noted that the Veteran had abnormal gait due to weakness on the right side. The examiner indicated that the Veteran had mild incomplete paralysis of the right and left sciatic nerves. The pertinent diagnosis was peripheral neuropathy, bilateral lower extremities. It was noted that the Veteran uses wheelchair and brace on a regular basis, and he uses a walker on a constant basis. The peripheral nerves condition causes numbness at night. On the occasion of a May 2019 VA examination of the central nervous system in May 2019, the Veteran indicated that he has had difficulty with walking and weakness on the right side. It was noted that the Veteran had weakness in the upper and lower extremities; his speech is not intelligible, and he has mild swallowing difficulties. The examiner noted that the Veteran needs support to walk like a walker or a wheelchair, and he wears an ankle-foot orthosis (AFO) on the right foot. During a VA examination of the hips and thighs in May 2019, the examiner noted that the Veteran had a total hip joint replacement in 2016; and, he now has moderately severe residuals of weakness, pain and limitation of motion. In October 2020, the Veteran was afforded another VA examination of the hip and thighs. The Veteran claimed muscle weakness in the right lower extremity, which is a symptom of the diagnosed hip joint replacement. The Veteran reported right hip pain with limited movement with weakness. It was noted that he had difficulty with turns, pivots, prolonged sitting, walking, standing and direct pressure. Pain was noted on examination and caused functional loss. The examiner noted that the right side had less movement than normal, weakened movement, disturbance of locomotion, interference with sitting and interference with standing. More recently, in March 2021, the Veteran underwent a VA examination for diabetic sensory-motor peripheral neuropathy. The Veteran indicated that his symptoms had worsened; he reported pain, numbness and tingling in both lower extremities. The pertinent diagnosis was diabetic peripheral neuropathy of both lower extremities. The examiner indicated that the Veteran had moderate intermittent pain, moderate paresthesias and moderate numbness in both lower extremities. Motor strength testing was 4/5 in the right upper extremity, and 4/5 in the lower extremities. The examiner reported decreased sensation in the ankles and toes of both lower extremities. No muscle atrophy was noted. It was noted that the Veteran had hair loss of both lower extremities. The examiner indicated that the Veteran had moderate incomplete paralysis of the sciatic and femoral nerves in both lower extremities. The examiner indicated that the Veteran's diabetic peripheral neuropathy caused difficulty with prolonged walking, sanding and impaired balance. The examiner noted that the severity of the sensory neuropathy of the lower extremity was moderate. The Veteran was afforded another VA examination of the central nervous system in March 2021. It was noted that the Veteran incurred left pontine lacunar infarct in September 2013 with residual right sided weakness to upper and lower extremities. The pertinent diagnosis was left pontine lacunar infarct associated with diabetes mellitus, with residual muscle weakness with pronator drift, right upper. It was noted that the Veteran currently continues to have residuals of right sided weakness of upper and lower extremities, requiring assistive devices to walk, either walker, wheelchair, cane and AFO brace to right lower extremity, speech slurred and delayed, and moderate swallowing difficulties. His gait was antalgic. Muscle strength was 4/5 in the right upper extremity and 3/5 in the right lower extremity. No muscle atrophy was noted. The examiner reported moderate muscle weakness in the right upper and lower extremity, and mild muscle weakness in the left lower extremity. It was noted that the Veteran required constant use of walker, AFO brace, wheelchair and cane. The examiner further noted that the Veteran's condition causes difficulty with impaired balance, walking and standing. Further review of the record shows that the Veteran receives treatment at VA medical centers and from private treatment providers for various disabilities, to include his right lower extremity muscle weakness. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms of such disorder that are worse than those noted in the various VA examination reports and treatment records of record. For the appeal period prior to January 14, 2016, the Board finds that a rating in excess of 10 percent for right lower extremity muscle weakness is not warranted. As noted above, on examination in December 2014, it was noted that the Veteran's gait was abnormal, and he needed support to walk. Muscle strength in the right knee and ankle was 4/5; deep tendon reflexes were 2+. No muscle atrophy was noted. The examiner described the muscle weakness in the right lower extremity as mild. The Veteran's muscle weakness in the right lower extremity has caused disability comparable to no more than mild incomplete paralysis, manifested by complaints of weakness in the right leg, but with no loss of muscle mass, strength, or function attributed to this service-connected disability. The record did not establish, and the Veteran has not alleged, muscle atrophy or a loss of reflexes. As noted, where, as here, the involvement is wholly sensory; the rating should be for the mild, or, at most, the moderate degree. Here, only sensory impairment was noted on the neurological evaluation, and the record does not otherwise provide a basis for more than a 10 percent rating. For the appeal period beginning on January 14, 2016, the Board finds that a rating in excess of 20 percent for right lower extremity muscle weakness is not warranted. On examination in April 2016, muscle strength testing was 3/5 in the right knee and ankle; there was muscle atrophy in the right with the right calf measuring one cm difference compared with the left. Deep tendon reflexes were 3+ in the right knee and 4+ in the right ankle. It was noted that the Veteran had moderate muscle weakness in the right lower extremity. It was noted that the Veteran had right pronator drift due to weakness. On examination of the knees in November 2017, muscle strength testing in the right lower extremity was 3/5. In May 2019, the examiner noted that the Veteran had abnormal gait due to weakness on the right side. The examiner indicated that the Veteran had mild incomplete paralysis of the right and left sciatic nerves. More recently, a March 2021 VA examination report noted that the Veteran had moderate intermittent pain, moderate paresthesias and moderate numbness in both lower extremities. Motor strength testing was 4/5 in the right lower extremity. The examiner reported decreased sensation in the ankles and toes of both lower extremities. No muscle atrophy was noted. It was noted that the Veteran had hair loss of both lower extremities. The examiner indicated that the Veteran had moderate incomplete paralysis of the sciatic and femoral nerves in both lower extremities. The record does not establish, and the Veteran has not alleged, the loss of reflexes. Therefore, a rating in excess of 20 percent for the appeal period beginning on January 14, 2016 is not warranted. In reaching its conclusions, the Board acknowledges the Veteran's belief that his right lower extremity muscle weakness is more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical 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 reports regarding the severity of his right lower extremity muscle weakness. The Board has considered whether a further staged rating under Hart, supra, is appropriate for the Veteran's service-connected right lower extremity muscle weakness; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning a further staged rating for such disability is not warranted. The Veteran and his representative have not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In light of the above, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent prior to January 14, 2016 and in excess of 20 percent for the Veteran's right lower extremity muscle weakness. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Entitlement to an initial rating in excess of 20 percent for right upper extremity muscle weakness with pronator drift for the appeal period prior to January 14, 2016 is denied. 4. Entitlement to a rating in excess of 40 percent for right upper extremity muscle weakness with pronator drift for the appeal period beginning on January 14, 2016 is denied. 5. Entitlement to an initial rating in excess of 20 percent for left upper extremity muscle weakness as residuals of stroke associated with diabetes mellitus is denied. The Veteran seeks increased ratings for muscle weakness with pronator drift in the right and left upper arms. Specific argument in support of these appeal has not been submitted. The Veteran's right and left upper extremity muscle weakness with pronator drift is presently rated under Diagnostic Code 8513, which compensates for paralysis of the peripheral nerves, applying to all radicular groups. Under this diagnostic code, mild incomplete paralysis of the peripheral nerves is compensated with a 20 percent rating for both the dominant and non-dominant extremity. Moderate incomplete paralysis is afforded a 30 percent rating for the minor extremity, and a 40 percent rating for the major extremity. Severe incomplete paralysis is afforded a 60 percent rating for the minor extremity and a 70 percent rating for the major extremity. Finally, complete paralysis of the peripheral nerves is assigned an 80 percent rating for the non-dominant extremity, and a 90 percent rating for the dominant extremity. 38 U.S.C. § 4.124a, Diagnostic Code 8513. The Board takes notice that the Veteran's right hand is his dominant hand. The evidentiary record, including VA as well as private treatment reports indicate that the Veteran has received ongoing clinical evaluation for right sided muscle weakness ever since he experienced a stroke in 2013. A speech pathology report dated in July 2014 indicated that the Veteran was unable to write secondary to right upper extremity weakness. Of record is a private treatment report from Dr. T. D., dated in October 2014, indicating that the Veteran had a stroke due to his poorly controlled hypertension and diabetes. Dr. D. indicated that secondary complications of diabetes include peripheral neuropathy of the legs and hands. The Veteran was afforded a VA examination in December 2014, at which time the examiner reported a diagnosis of TIA or cerebral infarction. The examiner noted that the central nervous system condition does not require continuous medication for control. The examiner indicated that the Veteran had muscle weakness in the upper extremities. Muscle strength in the right elbow, wrist, grip and pinch was 4/5; muscle strength in the left upper extremity was 5/5. Deep tendon reflexes were 2+. The examiner described the muscle weakness in the right upper extremity as mild. There was no muscle weakness noted in the left upper extremity. During another April 2016 VA examination for evaluation of the central nervous system in April 2016, it was noted that the Veteran has had difficulty walking and weakness on the right side. It was noted that the Veteran was currently taking aspirin daily for his condition. Muscle strength testing was 3/5 with right elbow flexion, 4/5 with right elbow extension, 4/5 with right wrist flexion, 4/5 with right grip, and 3/5 right pinch. Deep tendon reflexes were 2+. The examiner noted that there was muscle atrophy in the right forearm; he noted a one cm difference when compared with the left forearm. The examiner indicated that the Veteran had moderate muscle weakness in the right upper extremity. There was no muscle weakness noted in the left upper extremity. The examiner noted that the Veteran had right pronator drift due to weakness. The examiner noted that the Veteran required the constant use of a brace and walker as a result of his stroke. A May 2019 VA examination reflected the Veteran's reports that he has had difficulty with walking and weakness on the right side. It was noted that the Veteran had weakness in the upper and lower extremities; his speech is not intelligible, and he has mild swallowing difficulties. Muscle strength testing in the right upper extremity was 4/5. Deep tendon reflexes were 2+. Muscle weakness in the right upper and lower extremities was described as moderate. The examiner indicated that the Veteran had right pronator drift. It was also noted that the Veteran required the use of brace, cane and walker on a constant basis. The examiner related that, as a result of the Veteran's central nervous system, he has difficulty in ambulating, and he needs support to stand or walk and he has slurred speech. Muscle strength testing was 4/5; the examiner indicated that the decreased muscle strength was related to the Veteran's stroke and not the diagnosed hip replacement. No ankylosis was noted. The examiner noted that the Veteran had moderately severe residuals of weakness, pain and limitation of motion of the right lower extremity. A March 2021 VA examination noted the Veteran incurred left pontine lacunar infarct in September 2013 with residual right sided weakness to upper extremities. The pertinent diagnosis was left pontine lacunar infarct associated with diabetes mellitus, with residual muscle weakness with pronator drift, right upper. It was noted that the Veteran currently continues to have residuals of right sided weakness of upper and lower extremities, requiring assistive devices to walk, either walker, wheelchair, cane and AFO brace to right lower extremity, speech slurred and delayed, and moderate swallowing difficulties. Muscle strength was 4/5 in the right upper extremity and 3/5 in the right lower extremity. No muscle atrophy was noted. The examiner reported moderate muscle weakness in the right upper extremity, and mild muscle weakness in the left lower extremity. It was noted that the Veteran required constant use of walker, AFO brace, wheelchair and cane. The examiner further noted that the Veteran's condition causes difficulty with impaired balance, walking and standing. Further review of the record shows that the Veteran receives treatment at VA medical centers and from private treatment providers for various disabilities, to include his right and left upper extremity muscle weakness. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms of such disorder that are worse than those noted in the various VA examination reports and treatment records of record. For the appeal period prior to January 14, 2016, the Veteran's right upper extremity muscle weakness does not warrant a rating in excess of 20 percent. During the December 2014 VA examination, the examiner described the muscle weakness in the right upper extremity as mild. The Veteran has not alleged, and the record does not establish, muscle atrophy or the loss of reflexes. Therefore, a rating in excess of 20 percent is not warranted. For the appeal period beginning on January 14, 2016, the Veteran's right upper extremity muscle weakness does not warrant a rating in excess of 40 percent. At the March 2016 VA examination, the examiner reported a finding of muscle atrophy in the right upper extremity; the examiner described the muscle weakness in the right upper extremity as moderate. Again, on the occasion of a VA examination in May 2019, the examiner noted that muscle strength testing was 4/5; the examiner indicated that the decreased muscle strength was related to the Veteran's stroke. Muscle weakness in the right upper was described as moderate. More recently, in March 2021, the VA examiner reported a diagnosis of left pontine lacunar infarct associated with diabetes mellitus, with residual muscle weakness with pronator drift, right upper. It was noted that the Veteran currently continues to have residuals of right sided weakness of upper and lower extremities. Muscle strength was 4/5 in the right upper extremity and 3/5 in the right lower extremity. The examiner described the muscle weakness in the right upper extremity as moderate. There is no evidence to indicate the muscle weakness in the right upper extremity was more than moderate in severity. The Veteran has not alleged, and the record does not establish, the loss of reflexes. As such, the Board finds that the preponderance of the evidence does not support a finding that the Veteran's right upper extremity muscle weakness warrants a rating in excess of 40 percent. With regards to the left upper extremity muscle weakness, the Board finds that a rating in excess of 20 percent is not warranted during any appeal period. Significantly, throughout the appeal period, the Veteran has been assessed to suffer from mild peripheral neuropathy of the upper extremities, both by his private physician and on multiple VA examinations. In this regard, on examination in December 2014, muscle strength in the left upper extremity was 5/5, deep tendon reflexes were 2+ and no muscle weakness noted in the left upper extremity. During another VA examination for evaluation of the central nervous system in April 2016, it was noted that there was no muscle weakness noted in the left upper extremity. On the occasion of a more recent examination of the central nervous system in May 2019, it was noted that the Veteran had weakness in the upper extremities. A March 2021 VA examination noted that the Veteran had loss of power and weakness in muscle groups I through XVIII, impairment of coordination and uncertainty of movement of muscle groups XI through XII, muscle strength in the left upper extremity was 5/5 and No muscle atrophy was noted. The record does not establish, and the Veteran has not alleged, muscle atrophy or the loss of reflexes. Therefore, a rating in excess of 20 percent for left upper extremity muscle weakness is not warranted. In reaching its conclusions, the Board acknowledges the Veteran's belief that his left and right upper extremity muscle weakness is more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical 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 reports regarding the severity of his left and right upper extremity muscle weakness. The Board has considered whether a further staged rating or a staged rating under Hart, supra, is appropriate for the Veteran's service-connected right and left upper extremity muscle weakness; however, the Board finds that his symptomatology has been stable for each disability throughout each period on appeal. Therefore, assigning a staged rating for such disabilities are not warranted. The Veteran and his representative have not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, supra. In light of the above, the Board finds the preponderance of the evidence is against the assignment of a rating in excess of 20 percent prior to January 14, 2016 and in excess of 40 percent for the Veteran's right upper extremity muscle weakness as well as a rating in excess of 20 percent for left upper extremity muscle weakness. The appeals are denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 6. Entitlement to an initial rating of 10 percent, but no higher, for slurred speech with difficulty swallowing as residuals of a stroke associated with diabetes mellitus for the appeal period prior to January 14, 2016 is granted. 7. Entitlement to a rating in excess of 30 percent for slurred speech with difficulty swallowing as residuals of stroke associated with diabetes mellitus for the appeal period beginning on January 14, 2016 is denied. The Veteran generally alleges that a higher rating is warranted for his service connected slurred speech. Specific argument in support of this appeal has not been submitted. The Veteran's service-connected slurred speech with difficulty swallowing is currently rated under Diagnostic Code 8212, which provides rating criteria for paralysis of the hypoglossal nerve. Diagnostic Code 8212 provides for a 10 percent rating when the evidence shows moderate, incomplete paralysis, a 30 percent rating when the evidence shows severe, incomplete paralysis, and a 50 percent rating with complete paralysis. A noncompensable rating is warranted for symptoms not meeting these criteria. 38 C.F.R. § 4.31. A corresponding Note suggests that rating is dependent upon the loss of motor function of the tongue. 38 C.F.R. § 4.124a, Diagnostic Code 8512. A December 2014 VA examination indicated that a neurological evaluation revealed slightly slurred speech. An April 2016 VA examination noted that the Veteran had constant inability to communicate by speech, moderate swallowing difficulties and fluent, expressive aphasia with noticeable word finding aphasia. A May 2019 VA examination noted that the Veteran's speech was not ineligible, or the individual was aphonic, and he had mild swallowing difficulties. The Veteran was afforded another VA examination of the central nervous system in March 2021. It was noted that the Veteran currently continues to have speech that was slurred and delayed, and moderate swallowing difficulties. Further review of the record shows that the Veteran receives treatment at VA medical centers and from private treatment providers for various disabilities, to include his slurred speech. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms of such disorder that are worse than those noted in the various VA examination reports and treatment records of record. For the appeal period prior to January 14, 2016, the Board finds that the Veteran's symptomatology rose to the level of moderate, incomplete paralysis of the hypoglossal nerve. Report of a VA examination for Aid and Attendance, dated in August 2013, indicated that the Veteran had expressive aphasia but was able to express his wishes to some extent. A November 2014 cranial nerves examination indicated that the Veteran had moderate difficulty swallowing and moderate difficulty speaking. The examiner concluded that the Veteran had moderate incomplete paralysis of the hypoglossal nerve. Given the description of symptoms during the appeal period prior to January 14, 2016, the Board finds that the Veteran's slurred speech with difficulty swallowing more closely approximates the criteria contemplated for moderate incomplete paralysis. A 10 percent rating is therefore warranted. For the appeal period beginning on January 14, 2016, the Veteran's slurred speech did not manifest as complete paralysis. Specifically, during the April 2016 and March 2021 VA examinations, the examiners noted that the Veteran had delayed and slurred speech, and moderate swallowing difficulties. The evidence does not establish, and the Veteran has not alleged, complete paralysis. Therefore, a rating higher than 30 percent is not warranted. In reaching its conclusions, the Board acknowledges the Veteran's belief that his slurred speech is more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical 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 reports regarding the severity of his slurred speech. The Board has considered whether a further staged rating under Hart, supra, is appropriate for the Veteran's service-connected slurred speech; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning a further staged rating for such disability is not warranted. The Veteran and his representative have not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, supra. In light of the above, the Board finds the preponderance of the evidence supports the assignment of a rating in excess of 10 percent prior to January 14, 2016. To that extent, the appeal is granted. However, the preponderance of the evidence is against a rating in excess of 30 percent for the Veteran's slurred speech. To that extent, the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 8. Entitlement to a rating in excess of 20 percent for voiding dysfunction associated with diabetes mellitus is denied. The Veteran generally contends that his voiding dysfunction is more disabling than reflected by the rating currently assigned. Specific argument in support of this appeal has not been submitted. The Veteran's voiding dysfunction has been rated under Diagnostic Code 7518. The criteria for voiding dysfunction state that the disability should be rated as urine leakage, frequency, or obstructed voiding. Under 38 C.F.R. § 4.115a, where diagnostic codes refer the decisionmaker to these specific areas of dysfunction, only the predominant area of dysfunction is to be rated. Voiding dysfunction is rated based on urine leakage, frequency, or obstructed voiding. For urinary leakage, a 20 percent rating contemplates leakage requiring the wearing of absorbent materials, which must be changed less than two times per day. When there is leakage requiring the wearing of absorbent materials, which must be changed two to four times per day, a 40 percent disability rating is warranted. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day, a 60 percent rating is warranted. 38 C.F.R. § 4.115a. For urinary frequency, a 10 percent rating is warranted for daytime voiding interval between two and three hours or awakening to void two times per night. A 20 percent rating is warranted for daytime voiding interval between one and two hours or awakening to void three to four times per night warrants. A 40 percent rating is warranted for daytime voiding interval less than one hour; or awakening to void five or more times per night. 38 C.F.R. § 4.115a. For obstructed voiding, a noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a. An October 2014 private treatment report from Dr. T.D., a private physician, indicated that the Veteran had a stroke due to his poorly controlled hypertension and diabetes. The physician indicated that the symptoms and signs of the Veteran's diabetes mellitus including thirst, hunger, weight loss, and frequency of urination. A December 2014 VA examination indicates that the Veteran does not have voiding dysfunction causing urine leakage. A May 2019 VA examination noted that the Veteran had daytime voiding with intervals between two and three hours and that he had nighttime awakening to void five or more times. He did not have voiding dysfunction causing findings, signs and/or symptoms of obstructed voiding. The examiner further noted that the Veteran does not have voiding dysfunction requiring the use of an appliance. He does not have a history of recurrent symptomatic urinary tract infections. A May 2019 VA examination noted that the Veteran had a voiding dysfunction due to a benign prostatic hyperplasia (BPH). It was also noted that the voiding dysfunction caused urine leakage and required absorbent material which must be changed less than two times per day. The voiding dysfunction did not require the use of an appliance, did not cause increased urinary frequency, did not cause any signs or symptoms of obstructed voiding or any other obstructive symptoms. A May 2019 VA urinary tract examination reflected the Veteran's reports of urinating twice during the day and four to five times at night. It was also noted that the voiding dysfunction caused urine leakage and required absorbent material which must be changed less than two times per day. The voiding dysfunction did not require the use of an appliance. It was noted that the Veteran had daytime voiding with intervals between two and three hours and he also had nighttime awakening to void five or more times. He did not have voiding dysfunction causing signs or symptoms of obstructed voiding. A March 2021 VA central nervous system examination noted that the Veteran experienced voiding dysfunction that does not require the use of absorbent material, voiding dysfunction that causes daytime voiding interval less than one hour and nighttime awakening to void three to four times. It was noted that the Veteran had a voiding dysfunction that causes hesitancy, slow or weak stream, and decreased force of stream. The Veteran does not have voiding dysfunction requiring the use of an appliance. Further review of the record shows that the Veteran receives treatment at VA medical centers and from private treatment providers for various disabilities, to include his voiding dysfunction. However, there is no indication from the treatment notes of record that the Veteran has reported symptoms of such disorder that are worse than those noted in the various VA examination reports and treatment records of record. Based on the foregoing, the Board finds that a rating in excess of 20 percent for voiding dysfunction is not warranted. The Veteran reported voiding dysfunction that causes daytime voiding interval less than one hour and nighttime awakening to void three to four times in March 2021. He reported wearing absorbent material that must be changed less than two times per day in the May 2019 VA examination, although he subsequently denied using absorbent materials. The record does not establish, and the Veteran has not alleged, leakage requiring the changing of absorbent materials at least two to four times a day, the use of an appliance, a daytime voiding interval of less than one hour, awakening to void five or more times per night or urinary retention requiring intermittent or continuous catheterization. Therefore, a higher rating is not warranted for a voiding dysfunction. In reaching its conclusions, the Board acknowledges the Veteran's belief that his voiding dysfunction is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical 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 reports regarding the severity of his voiding dysfunction. The Board has considered whether a staged rating under Hart, supra, is appropriate for the Veteran's service-connected voiding dysfunction; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. The Veteran and his representative have not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, supra. In light of the above, the Board finds the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for voiding dysfunction. The appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 9. Entitlement to an initial compensable rating for chronic constipation is denied. The Veteran is seeking a compensable rating for his chronic constipation. Specific argument in support of this appeal has not been submitted. The Veteran's constipation has been assigned an initial noncompensable rating under Diagnostic Code 7319, as analogous to irritable colon syndrome. Under Diagnostic Code 7319, a noncompensable rating is warranted for mild irritable bowel syndrome, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for moderate irritable bowel syndrome with frequent episodes of bowel disturbance and abdominal distress. A maximum schedular 30 percent rating is warranted for severe irritable bowel syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114. VA treatment records show that the Veteran has been prescribed medication for constipation. During a VA examination in August 2014, review of systems noted a finding of constipation. It was noted that he was prescribed Sennosides for his constipation. An April 2016 VA central nervous system examination noted that the Veteran had bowel functional impairment which was manifested by chronic constipation. In December 2016, Veteran's wife reported that he is incontinent of bladder and bowel; however, a general note reported that the Veteran was not incontinent of stool. During a primary care visit in March 2017, the Veteran complained of occasional constipation with relief with Miralax and an examination of the abdomen revealed normal bowel sounds without mass, tenderness or organomegaly. In January 2018, it was noted that the Veteran has a normal appetite without loss of taste, no dysphagia, and has no new symptoms of diarrhea or constipation; he had no significant reflux or hiatal hernia symptoms. In November 2018, the Veteran reported having roughly two bowel movements per week. The Veteran was afforded a VA examination in May 2019. At that time, the Veteran reported problems with constipation two to three times a week for which he used over the counter laxatives. It was noted that continuous medication is required for control of the Veteran's intestinal condition. The examiner reported a diagnosis of chronic constipation. The examiner indicated that the Veteran did not have weight loss, malnutrition, serious complications or any other general health effects attributable to the intestinal condition. The examiner further noted that the Veteran does not have any other pertinent physical findings, complications, conditions, signs or symptoms related to his intestinal conditions. Given the above, the Board finds that a compensable rating for chronic constipation is not warranted. The Veteran's symptoms do not more nearly approximate moderate symptoms such as frequent episodes of bowel disturbance with abdominal distress or severe symptoms such as diarrhea, or alternating diarrhea and constipation with more or less constant abdominal distress. Despite the Veteran's report of having occasional constipation, for which he has been prescribed medication, he has not reported frequent episodes of abdominal distress at any time during the appeal period. Therefore, a compensable rating is not warranted. The Board has considered whether the Veteran is entitled to a compensable rating under other relevant diagnostic codes. However, there is no evidence that his chronic diarrhea and or constipation is due to impairment of sphincter control, stricture of the rectum and anus, or prolapse of the rectum. The Veteran has no problems with weight loss, malnutrition, serious complications or other general health effects attributable to the chronic diarrhea and/or constipation. Thus, a compensable rating under an alternative diagnostic code, including Diagnostic Codes 7332, 7333, and 7334, is not warranted. In reaching its conclusions, the Board acknowledges the Veteran's belief that his chronic constipation is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical 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 reports regarding the severity of his chronic constipation. The Board has considered whether a staged rating under Hart, supra, is appropriate for the Veteran's service-connected chronic constipation; however, the Board finds that his symptomatology has been stable for each disability throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. The Veteran and his representative have not raised any other issues, and no other issues have been reasonably raised by the record. See Doucette v. Shulkin, supra. Accordingly, the preponderance of the evidence is against the claim for a compensable rating for chronic constipation. The benefit of the doubt doctrine is not applicable, and a higher initial rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 10. Entitlement to a TDIU for the appeal period from October 15, 2014 to January 22, 2016 is granted. The Veteran contends that he is unemployable as a result of his service-connected disabilities. In a December 2011 Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran indicated that he last worked in sales in August 2009 and he reported that he completed high school. Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering a veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering a veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering a veteran's master's degree in education and his part-time work as a tutor). The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. For purposes of determining whether a claimant is entitled to a TDIU, marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Id. Marginal employment may also be held to exist, on facts found basis (including but not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Id. Consideration shall be given in all claims to the nature of the employment and the reason for termination. Id. The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). In this case, the Veteran has been awarded service connected for: posttraumatic stress disorder (PTSD), rated as 50 percent disabling, effective July 11, 2011; unipolar right hip replacement associated with diabetes mellitus with erectile dysfunction, rated as 100 percent disabling from January 23, 2016, 30 percent from March 1, 2017, and 50 percent from May 17, 2019; right upper extremity muscle weakness with pronator drift associated with diabetes mellitus with erectile dysfunction, rated as 20 percent effective October 15, 2014, and 40 percent effective January 14, 2016; osteoarthritis of the right knee, limitation of extension, rated 40 percent disabling, effective October 20, 2020; slurred speech with difficulty swallowing associated with diabetes mellitus with erectile dysfunction, rated 0 percent disabling effective October 15, 2014, and 30 percent from January 14, 2016; left upper extremity mild muscle weakness residual of stroke associated with diabetes mellitus with erectile dysfunction, rated 20 percent disabling from October 15, 2014; voiding dysfunction rated 20 percent disabling, effective from January 14, 2016; right lower extremity muscle weakness associated with diabetes mellitus with erectile dysfunction, rated 10 percent disabling, effective October 15, 2014 and 20 percent disabling from January 14, 2016; diabetes mellitus with erectile dysfunction, rated 20 percent disabling from December 31, 2008, and 10 percent disabling from November 20, 2014; osteoarthritis, right knee, limitation of flexion, rated 10 percent disabling from October 17, 2017; chronic constipation, rated zero percent from January 14, 2016; and surgical scar, right hip, rated zero percent from February 25, 2017. The Veteran's combined rating has been 20 percent from December 31, 2008, 60 percent from July 11, 2011, 80 percent from October 15, 2014, 90 percent from January 14, 2016 and 100 percent from January 23, 2016. Therefore, the Veteran has met the schedular criteria for a TDIU since October 15, 2014. 38 C.F.R. § 4.16(a). For the appeal period prior to October 15, 2014, the Veteran does not meet the schedular criteria for TDIU. However, there is not sufficient evidence to substantiate a reasonable possibility that the Veteran is unable to obtain and maintain gainful employment due to service-connected disabilities. An April 2012 VA examiner stated that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The examiner indicated that while the Veteran may have some level of occupational impairment, there was no indication that PTSD symptoms were responsible for an inability to secure or maintain viably gainful employment. Following an April 2012 VA examination for evaluation of his diabetes mellitus, the examiner indicated that the diabetes mellitus does not impact the Veteran's ability to work. Similarly, the July 2014 VA examiner found that there is no evidence that PTSD symptoms has any substantive effect on his ability to work. Following a July 2014 diabetes mellitus examination, the examiner again stated that the diabetes mellitus does not impact the Veteran's ability to work. Therefore, a TDIU is not warranted for the appeal period prior to October 15, 2014. Considering all evidence of record, the Board finds that the evidence is at least in relative equipoise on the question of whether the Veteran is unable to work as a result of the combined effects of his service-connected disabilities for the appeal period from October 15, 2014 to January 22, 2016. The Veteran meets the schedular criteria for TDIU. In this regard, a November 2014 statement from Dr. D. indicates that the Veteran had a CVA directly due to his diabetes mellitus; he also noted that the Veteran must use a walker for activity and is unable to do any common activity that do not allow use of a walker. Following the December 2014 central nervous system examination, the examiner indicated that the Veteran's disorder impacted his ability to work because he has difficulty walking. During an April 2016 examination of the central nervous system, the examiner indicated that the Veteran's weakness would significantly impair his ability to do physical jobs, or those which required fine motor skills, walking, bending, carrying, lifting, or prolonged standing. His slurred speech and difficulty with aphasia would impair his ability to function in sedentary occupations and impair his ability to communicate with coworkers and others at work or to understand and remember assigned tasks. The Board has carefully considered the Veteran's statements, and the medical evidence of record, regarding the combined effects of his PTSD and stroke residuals as it impacts his employment. The Board concludes that the Veteran experienced significant limitation as a result of the combination of his service-connected disabilities, and that the combined effect of these disabilities impacted his daily functioning and earning capacity that rendered the Veteran unable to secure or follow a substantially gainful occupation for the appeal period from October 15, 2014 to January 22, 2016. Generally, the fact that he was having impairments or difficulties does not provide a basis to grant TDIU. However, based on the evidence as discussed above, the Board notes the combined effects of his psychiatric limitations and the physical impairments as a result of his physical symptoms, to include a decreased ability to do prolonged walking and standing and difficulty with bending, pulling, pushing, and lifting. In addition, the Veteran has slurred speech and aphasia, which would impact his ability to work with others, understand or remember tasks. For the appeal period beginning on January 23, 2016, the Veteran is in receipt of a 100 percent combined rating for his service-connected disabilities. In addition, the Veteran has been awarded special monthly compensation under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) on account of unipolar right hip replacement rated as 100 percent disabling, with additional disabilities of muscle weakness with pronator drift, right upper extremity, voiding dysfunction, mild muscle weakness of the left upper extremity, and slurred speech with difficulty swallowing, independently ratable at 60 percent or more from January 23, 2016. Thus, the Board finds that the issue of TDIU for the appeal period beginning on January 23, 2016 is moot. Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2011). Therefore, based on the foregoing, the Board finds that the combined effects of the Veteran's service-connected disabilities rendered his unable to secure and follow a substantially gainful occupation and entitlement to a TDIU for the appeal period from October 15, 2014 to January 22, 2016 is warranted. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 11. Entitlement to special monthly compensation based on the need for the aid and attendance of another or on being housebound is granted. The Veteran contends that he is entitled to aid and attendance because of his service-connected disabilities. Specific argument in support of this appeal has not been submitted. Special monthly compensation is payable at a specified rate if the veteran, as the result of service-connected disability, needs regular aid and attendance. Need for aid and attendance means helplessness or is so nearly helpless as to require the regular aid and attendance of another person. A veteran will be considered to be in need of regular aid and attendance if he or she is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; if the veteran is a patient in a nursing home because of mental or physical incapacity; or if the evidence establishes a factual need for aid and attendance or "permanently bedridden" status under the criteria set forth in 38 C.F.R. § 3.352(a). 38 U.S.C. § 1114(l); 38 C.F.R. § 3.351(b). Factual need for aid and attendance is based on the following criteria: the inability of the veteran to dress or undress himself or herself, or to keep himself or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); the inability of a veteran to feed himself or herself through the loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). Although a veteran need not show all the disabling conditions identified in 38 C.F.R. § 3.352(a) to establish entitlement to aid and attendance, the Court has held that it is logical to infer there is a threshold requirement that "at least one of the enumerated factors be present." Turco v. Brown, 9 Vet. App. 222, 224 (1996). In this case, the Veteran's is service-connected for posttraumatic stress disorder (PTSD); unipolar right hip replacement associated with diabetes mellitus with erectile dysfunction; right upper extremity muscle weakness with pronator drift associated with diabetes mellitus with erectile dysfunction; osteoarthritis of the right knee, limitation of extension; slurred speech with difficulty swallowing associated with diabetes mellitus with erectile dysfunction; left upper extremity mild muscle weakness residual of stroke, associated with diabetes mellitus with erectile dysfunction; right lower extremity muscle weakness associated with diabetes mellitus with erectile dysfunction; diabetes mellitus with erectile dysfunction; osteoarthritis, right knee, limitation of flexion; chronic constipation, and surgical scar of the right hip. The record does not show nor does the Veteran contend that he is blind or nearly blind or that he is a patient in a nursing home because of mental or physical incapacity. A November 2014 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance (VA Form 21-2680) completed by Dr. E.L., a private physician, noted that the Veteran had gait disturbance. The provider stated that the Veteran required assistance due to the residuals of his stroke and right hemiplegia. The provider indicated that the Veteran was unable to prepare his own meals, that he required assistance in bathing and tending to other hygiene needs, that he required medication management and that he used mobility aides for locomotion. The provider noted that the Veteran had hemiplegia in right extremities, right foot drop, right knee pain and required an AFO for this right foot. A December 2016 social worker note indicated that the Veteran's wife reported that she resides in the home with Veteran, that she is his primary caregiver, that the Veteran required assistance with his activities of daily living and that the Veteran used a walker and cane for mobility. The social worker further indicated that the Veteran is unable to walk long distances and that he therefore he uses a wheelchair when traveling outside of the home. The social worker also reported that the Veteran is incontinent of bladder and bowel and he has short-term memory difficulties. A March 2017 VA treatment note indicates the Veteran require the use of a wheelchair and was bladder incontinent. During a consultation in May 2020, the Veteran's wife reported that he needs assistance with toileting at times and utilizes his walker and cane. The Veteran's wife also reported that he is unable to complete light housekeeping or light house chores. It was also noted that the Veteran's wife is unable to do a lot as she helps with is aide and care as well. After review of the criteria for determining the need for aid and attendance, the Board finds that the evidence shows that the Veteran was unable to keep himself ordinarily clean and presentable without assistance, unable to feed himself, unable to attend to the wants of nature, and physically required care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his daily environment. Namely, the Veteran was unable to prepare his own meals, needed assistance in bathing and tending to hygiene needs and had a right sided hemiplegia. The Veteran also ambulated using a wheelchair and was unable to walk or stand for prolonged periods of time, was unable to run or jog, was unable to bend and pick up things, and was unable to stand, dress, or shower. The November 2014 opinion provided an extensive explanation as to how the Veteran's service connected disabilities were the cause of his inability to function. As such, his service-connected disabilities affected his ability to performs activities of daily living. As such, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran has a factual need for the regular aid or attendance of another person; therefore, the criteria for special monthly compensation benefits based on the need for regular aid and attendance of another person have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to service connection for a hiatal hernia remanded. The Veteran maintains that he has hiatal hernia which is related to his period of active military service. A May 2019 VA examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that hiatus hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. The examiner further noted that type I hiatus hernia results from progressive disruption of the gastroesophageal junction. In this regard, the examiner did not provide adequate rationale explaining why the Veteran's current hiatal hernia is not related to service. Nieves-Rodriguez v. Peake, supra. Moreover, the examiner did not address the Veteran's assertion his current gastrointestinal disorder began during service. On remand, an addendum etiology opinion should be obtained. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of any currently present hiatal hernia. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present hiatal hernia had its onset during his active service or is otherwise etiologically related to such service, to include exposure to calcium carbide. The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Suzie S. Gaston, 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.