Citation Nr: 21008386 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 14-44 092A DATE: February 16, 2021 ORDER Entitlement to a rating in excess of 10 percent for right wrist strain is denied. Entitlement to a rating in excess of 10 percent for left wrist strain is denied. Entitlement to a compensable rating for right hand strain is denied. Entitlement to a compensable rating for left hand strain is denied. Entitlement to an initial rating in excess of 10 percent for right knee strain with degenerative changes is denied. However, a separate 10 percent rating from October 2, 2020, though no earlier and no greater, is granted for right knee instability – subject to the laws and regulations governing the payment of compensation. Entitlement to a rating in excess of 10 percent for a lumbar spine disability is denied.   REMANDED Entitlement to a rating in excess of 10 percent for cavernous hemangioma is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. At no time during the rating period on appeal has the Veteran had ankylosis of either wrist, ankylosis of any finger of either hand, or limitation of motion of any finger of either hand. 2. At no time during the rating period on appeal has the Veteran had right knee flexion limited to 60 degrees or less or extension limited to 5 degrees or greater. 3. Prior to October 2, 2020, the Veteran did not have instability of his right knee; but, resolving all reasonable doubt in his favor, he has had “slight” instability of this knee since that date, but not “moderate” or “severe” instability. 4. At no time during the rating period on appeal has the Veteran had thoracolumbar spine flexion limited to 60 degrees or less, or total range of motion limited to 120 degrees or less, or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour.   CONCLUSIONS OF LAW 1. The criteria are not met for a rating in excess of 10 percent for right wrist strain. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 2. The criteria are not met for a rating in excess of 10 percent for left wrist strain. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 3. The criteria are not met for a compensable rating for right hand strain. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5220. 4. The criteria are not met for a compensable rating for left hand strain. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5220. 5. The criteria are not met for an initial disability rating in excess of 10 percent for right knee strain with degenerative changes. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5260. 6. However, the criteria are met for a separate 10 percent rating as of October 2, 2020, though no higher and no earlier, for instability of the right knee. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 7. The criteria are not met for a rating in excess of 10 percent for the lumbar spine disability. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These claims were previously before the Board in September 2018 and remanded for further development, including for medical examinations reassessing the severity of these service-connected disabilities. There since has been the required compliance with those remand directives, certainly the acceptable substantial compliance, at least as concerning the claims that are now being decided rather than again remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only “substantial” rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In an October 2020 rating decision, on remand, the local Regional Office (RO) increased the ratings for the left (“minor”) and right (“major”) wrist strains from 0 to 10 percent retroactively effective from May 16, 2011, so for the entirety of the period under review. So, the appeal of these claims now concerns whether even higher ratings are warranted. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (receipt of a higher rating, but less than maximum possible rating, does not abrogate a pending appeal). In November 3, 2020 correspondence, the Veteran’s attorney requested an additional 90 days to submit additional evidence in support of the claims. It has now been more than 90 days since that request; therefore, the Board is proceeding to adjudicating the claims.   Increased Ratings Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in 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 evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt is resolved in the Veteran’s favor. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran’s condition. It thus is essential in determining the level of current impairment that the disability is considered in the context of its entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). “Staged” ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings – irrespective of whether an initial or established rating. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 pertaining to functional impairment. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, premature or excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997).   1. Entitlement to a rating in excess of 10 percent for Right Wrist Strain AND 2. Entitlement to a rating in excess of 10 percent for Left Wrist Strain The Veteran’s disabilities are rated under Diagnostic Code (DC) 5215. The maximum rating under DC 5215 is 10 percent, which is the Veteran’s current rating for each wrist. The Veteran would be entitled to a higher rating if he had wrist ankylosis. The overwhelming evidence is against a finding that the Veteran has had ankylosis of either the right or left wrist. A July 2011 VA General Medical Examination report reflects that the Veteran had dorsiflexion from 0 to 70 degrees and palmar flexion from 0 to 80 degrees; this is normal range of motion. There were no flare-ups. An April 2012 again reflects that the Veteran did not have flare-ups. He had full range of motion with no objective evidence of pain, to include after repetitive use testing. The Veteran had localized tenderness or pain on palpation of the right wrist, and full muscle strength of both wrists. An October 2020 Disability Benefits Questionnaire (DBQ) reflects that the Veteran reported current symptoms of achy pain when typing and sharp pain when doing push-ups. He takes Tylenol for his pain. The Veteran also reported pain with use, and pain worse with use over time. He reported mild right and left wrist flare ups occurring 1 to 2 time per week and lasting 1 to 2 minutes. The flare-ups are precipitated by typing, washing dishes, push-ups, and using tools. There was no ankylosis. He had bilateral palmar flexion from 0 to 70 degrees, dorsiflexion from 0 to 70 degrees, ulnar deviation from 0 to 45 degrees, and radiation deviation from 0 to 20 degrees. Pain was noted on dorsiflexion only, and the Veteran continued to have full range of dorsiflexion. There was no evidence of pain with weight bearing, or on passive range of motion testing. Thus, he had full range of motion in all areas with the exception of lacking 10 degrees in palmar flexion. After repetitive use testing, there was no further loss of range of motion. The examiner estimated that the Veteran would have the same ranges of motion after repeated use over time and during a flare up. The Veteran had full muscle strength. The evidence is consistently against a finding of ankylosis, and the Veteran’s reports of flare-ups, pain, and symptoms after repetitive use over time or certain activities has not been shown to manifest in a disability more closely approximating ankylosis of either wrist. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause functional loss, pain itself does not constitute functional loss. The Court in Mitchell explained that the evaluation of painful motion as limited motion only applies when limitation of motion is 0-percent disabling (noncompensable) under the applicable DC. The Court further explained that, although painful motion is entitled to a minimum 10 percent rating under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), when read together with DC 5003 concerning arthritis, it does not follow that the maximum rating is warranted under the applicable DC pertaining to range of motion simply because pain is present throughout the range of motion. Rather, the pain “must actually affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance’ [under] 38 C.F.R. § 4.40 in order to constitute functional loss” warranting a higher rating. See id. at 43. Although the Veteran has reported pain, the objective clinical findings reflect that he still has significant range of motion of each wrist. As such, his existing 10 percent ratings under DC 5215 sufficiently compensate him – again, even when considering his pain. The Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other DCs assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). For these reasons and bases, increased ratings are not warranted. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990).   3. Entitlement to a compensable rating for Right Hand Strain AND 4. Entitlement to a compensable rating for Left Hand Strain The Veteran’s right-hand and left-hand strains are evaluated as 0-percent disabling (so noncompensable) under hyphenated Diagnostic Code 5299-5220. A hyphenated diagnostic code is used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The Veteran would be entitled to compensable evaluation if he had ankylosis of digits (Diagnostic Codes 5220-5223) or limitation of motion of the thumb, index, or long finger to a specific degree noted in the rating criteria for Diagnostic Codes 5228-5229. A July 2011 General Medical Examination report found no impaired strength, no angulation, no ankylosis, no thumb disorder, and no gap between any finger and the proximal transverse crease of the hand on maximal flexion of the fingers. There was no effect on the Veteran’s usual occupation or usual daily activities. The examiner found that the Veteran had normal hands. An April 2012 DBQ reflects that the Veteran did not report flare-ups of hand pain. Upon examination, there was no limitation of motion or evidence of painful motion for any finger or the thumbs, to include after repetitive use testing. The examiner found that there was no functional loss of either hand, thumb, or fingers. The Veteran had full muscle strength and did not have tenderness or pain to palpation. Essentially, he again had normal hands. An October 2020 DBQ shows the Veteran denied any current hand pain but noted that pain was worse with use over time. He did not report any flare-ups. All ranges of motion were normal, and there was no gap between the pad of the thumb and the fingers, or the fingers and the proximal transverse crease of the hand on maximal finger flexion. There was no pain noted on examination. The examiner explained that, after repetitive use, the Veteran would still have the same range of motion. The Veteran did not have muscle atrophy or diminished muscle strength. The examiner determined there was no evidence of pain on passive range of motion testing or on non-weight bearing testing. Although the Veteran has reported some “hand” pain, there is no evidence of ankylosis and no radiographic evidence of arthritis of his fingers or hands. There equally is no evidence that his complaints of occasional “hand” pain in 2020 are different than his complaints of “wrist” pain. He has not alleged experiencing pain in any of his fingers, the palm of his hands, the back of his hands, and he has had full range of motion of all the fingers and thumbs. Essentially, he has not alleged, and the evidence does not support, that he has any symptoms warranting a compensable rating for his hands. Any complaints of pain are adequately rated under his service-connected wrist disabilities. For these reasons and bases, compensable ratings are not warranted. 5. Entitlement to an initial rating in excess of 10 percent for Right Knee Strain with degenerative changes The Veteran’s right knee strain with degenerative changes is evaluated as 10- percent disabling under DC 5299-5260. He would be entitled to a higher rating for his right knee disability under DC 5260 if he had flexion limited to 30 degrees (20 percent) or to 15 degrees (30 percent). To give this some context, consider that normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. A July 2011 VA General Medical Examination report reflects that the Veteran had full range of motion to include after repetitive use testing. There was objective evidence of pain on testing, but no instability. He reported that he uses a brace when he does physical therapy. An April 2012 DBQ reflects that the Veteran did not report flare-ups of the knee. Upon examination, he had full flexion with no objective evidence of pain. He had full extension, with pain beginning at 0 degrees. After repetitive use testing, the Veteran had the same range of motion. The Veteran had tenderness or pain on palpation but had full muscle strength and full stability on testing. There was no history or evidence of recurrent patellar subluxation/dislocation. An October 2020 DBQ reflects that the Veteran reported sharp pain, giving out easily, and aching. He reported that he cannot walk or stand for long periods of time and has pain with lifting and walking up stairs. He reported flare ups occurring three or more times a day, they are moderate in severity, last 3-4 minutes, and are precipitated by standing, walking for long periods, lifting, or walking up stairs. (The Board notes that the Veteran lives in a one-story house and has not had issues accessing any areas of his home. See January 2020 VA caregiver report.) His symptoms, so including his pain, are alleviated by Tylenol, a knee brace, and a heating pad. On examination, he had full extension and flexion to 130 degrees. He had pain on flexion, but not on extension. There was no evidence of pain with weight bearing, and no objective evidence of tenderness of pain on palpation. The examiner surmised the Veteran would have the same range of motion with repeated use over time. During a flare-up, he would have an estimated range of motion of 0 to 120 degrees. Upon examination, he had normal stability on all testing. He was noted to use a brace for pain. The Veteran’s ranges of motion, and anticipated ranges of motion during flare-ups and repeated use, have far exceeded those minimums required for a compensable evaluation under DC 5260 (flexion) or DC 5261 (extension). The Board is mindful of a precedent opinion of VA’s General Counsel, VAOPGCPREC 9-2004 (Sept. 17, 2004), indicating a claimant who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. However, in these claims at hand, there is no time period during which the Veteran’s knee has manifested in both limitation of flexion to a compensable degree and limitation of extension to a compensable degree, or even pain in both flexion and extension at the same examination. Essentially, he was granted a 10 percent rating to compensate him for the effect his pain has on his range of motion, even accepting that he does not have sufficient limitation of motion, per se, to otherwise justify this 10 percent rating (which is the minimum compensable rating to be assigned in this circumstance according to the holdings in Mitchell and its progeny). Although the Veteran has reported pain, the objective clinical findings reflect that he still has significant range of motion and, as such, his existing 10 percent rating under DC 5260 sufficiently compensates him – again, even when considering his chronic pain. To reiterate, the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other DCs assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). “Other” Knee Impairment – Including owing to Recurrent Subluxation or Lateral Instability A separate rating may be assigned for instability (DC 5257) apart from the rating assigned, instead, based on limitation of motion (DCs 5003, 5010, 5260 and 5261). See VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997); VAOPGCPREC 9-98 (August 14, 1998). The 2011 and 2012 examination reports are unremarkable for complaints of instability. The 2012 examination report notes that stability testing was performed and that all joints were stable. The earliest indication of instability is the Veteran’s competent lay statement to the October 2, 2020 examiner. To reiterate, when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. McGrath v. Gober, 14 Vet. App. 28 (2000). However, in the present situation, the earliest date that it is ascertainable that the Veteran had instability of his right knee is October 2, 2020. Although he wore a brace prior to that date, it was specifically noted to be for pain; it was not noted to be for stability. The Veteran is competent to report what he feels to be instability and giving out of his knee. In English v. Wilkie, 30 Vet. App. 347 (2018). the Court held that DC 5257 does not “speak to the type of evidence required and, thus, objective medical evidence [is not] required to establish lateral knee instability under that DC.” The Court further held that “[t]he Board [cannot] categorically find objective medical evidence more probative than lay evidence with respect to [DC 5257] without supporting its conclusion with an adequate statement of reasons or bases.” Id. Here, the Board finds that the clinical examinations are more probative than the lay statements as to the degree of lateral instability (the type noted in DC 5257) because the clinicians are trained in evaluating the different cartilage and ligaments of the knee and in performing the various tests to assess whether the knee is unstable or subluxed (e.g., varus and valgus, Lachman’s, etc.). Moreover, and importantly, no clinician has found instability upon examination. Thus, the Board can reasonably find that any right knee instability the Veteran has is at most “slight” (as opposed to “moderate” or “severe”). 6. Entitlement to a rating in excess of 10 percent for a lumbar spine disability The Veteran’s low back or lumbar spine disability (lumbar strain) is presently rated as 10-percent disabling under DC 5237 of the General Rating Formula for Diseases and Injuries of the Spine. He would be entitled to a higher rating if the evidence supported a finding that he had unfavorable ankylosis of his entire spine (100 percent); unfavorable ankylosis of his entire thoracolumbar spine (50 percent); forward flexion of his thoracolumbar spine to 30 degrees or less or favorable ankylosis of his entire thoracolumbar spine (40 percent); or forward flexion of his thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of his 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 (20 percent). Normal range of motion of the thoracolumbar (thoracic and lumbar) spine is 90 degrees of forward flexion, 30 degrees of backward extension, 30 degrees of left and right lateral flexion (side bending), and 30 degrees of left and right rotation (twisting). See 38 C.F.R. § 4.71a, Note (2) in the General Rating Formula and Plate V.   A July 2011 General Medical Examination report reflects that the Veteran did not report flare-ups. He had full range of motion in all directions with pain throughout. But, as already explained, pain alone does not warrant a compensable rating, even if throughout the range of motion. Rather, it must cause functional loss and, if not resulting in motion limited to a compensable degree, at most warrants a 10 percent rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). It is not shown that any higher rating is warranted, here, even when considering the Veteran’s pain. An April 2012 DBQ reflects that the Veteran had full range of motion with no objective evidence of pain. After repetitive use testing, the Veteran continued to have full range of motion. He did not have guarding or muscle spasm, did not have localized tenderness or pain to palpation, did not have radiculopathy, did not use an assistive device, and did not have bowel or bladder problems. A July 2013 DBQ reflects that the Veteran had flexion to 90 degrees or greater, with objective evidence of pain at 50 degrees. He had extension, bilateral lateral flexion, and bilateral lateral rotation to 30 degrees or greater. Thus, he had full range of motion in all areas except for lacking 10 degrees of flexion. After repetitive use testing, his ranges of motion did not change. He had tenderness or pain on palpation, incoordination, pain on movement, and interference with sitting, standing, and/or weight bearing. He did not have radiculopathy, did not have intervertebral disc syndrome with incapacitating episodes, did not have arthritis, and did not have bowel or bladder problems. He did not report flare-ups. An October 2020 DBQ reflects that the Veteran reported sharp pain and pain when lifting. He reported that he is unable to take groceries from the car to the house, stand for long periods of time, do the dishes or carry the clothes basket. He reported flare ups are severe, lasting at least two minutes, are precipitated by lifting more than 10 pounds, laying on his stomach, or standing or sitting for long periods of time, and walking. Upon examination, he had flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 30 degrees, left lateral flexion to 25 degrees, right lateral flexion to 30 degrees, and left lateral rotation to 25 degrees. Pain was noted in flexion and extension. After repetitive use testing, there was not additional limitation in range of motion. The examiner opined that after repeated use over time or during a flare-up, the Veteran would have 80 degrees of flexion, 20 degrees of extension, 30 degrees of right lateral flexion, 25 degrees of left lateral flexion, 30 degrees of right lateral rotation, and 25 degrees of left lateral rotation. The Veteran did not have radiculopathy or bowel/bladder problems owing to his low back disability. There was no evidence of pain on non-weight bearing, but he had pain on passive range of motion. The normal combined range of motion for the thoracolumbar spine is 240 degrees. During the rating period on appeal, the Veteran has had at least 220 degrees of combined range of motion (meaning when considering the combination of his forward flexion, backward extension, left and right lateral flexion, and left and right lateral rotation), which is far more than the 120-degrees limitation required for a higher 20 percent rating. He also has not had muscle spasm or guarding. Thus, he is not entitled to a higher rating under the General Rating Formula for Disease and Injuries of the Spine. He also is not entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, i.e., DC 5243, because he has not had IVDS with incapacitating episodes having a total duration of at least two weeks during the preceding 12 months. Note (1) in DC 5243 defines an incapacitating episode, including in terms of the requirement of bedrest prescribed by a physician, even before addressing whether there additionally has been this contemplated episode of sufficient frequency and duration to warrant any higher rating. Finally, the Veteran also has not been shown to have objective evidence of any neurological impairment owing to his low back disability to, in turn, warrant assigning a separate rating for it under an appropriate code – such as DC 8520 or similar if, as an example, he had lower extremity radiculopathy. For these reasons and bases, an increased rating is not warranted.   REASONS FOR REMAND 7. Entitlement to a rating in excess of 10 percent for cavernous hemangioma The Veteran’s cavernous hemangioma with intracranial bleed with symptoms of headache, gait, ataxia, diplopia, and memory loss is evaluated as 10-percent disabling under hyphenated DC 8099-8003. Under DC 8003, the disability is to be rated based on residuals with a minimum rating of 10 percent, which is the Veteran’s existing rating. The Veteran contends that a separate rating is warranted for his headaches, as a residual of his hemangioma. An April 2012 VA brain and spinal cord examination report notes that the Veteran had a history of headaches, at least weekly but not daily, lasting minutes, where activity was possible, but limited. A May 2014 VA treatment record notes that the Veteran reported sharp, occipital headaches occurring every two weeks, lasting up to a minute. Additionally, an April 2012 neuropsychological examination reflects that the Veteran reported incidents or “blackouts” where he appeared to fall asleep while driving, having disturbed or restless sleep, lack of adequate sleep, poor sleep, daytime fatigue, snoring, frequent falling asleep in the car while not driving, and morning headaches. The examiner indicated that the Veteran should be referred for a sleep evaluation to rule out sleep apnea or possible decreased arousal due to his previous neurological insult which resulted in a bleed in the brainstem, as the brainstem helps to regulate and maintain proper arousal levels. In April 2014, the Veteran underwent a sleep study, after which he received a diagnosis of sleep apnea. Thus, it at least seems the Veteran’s headaches are not prostrating. According to DC 8100, a 10 percent rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in 2 months over last several months. A 30 percent rating for migraine headaches is warranted when there are characteristic prostrating attacks occurring on an average once a month over last several months. A maximum rating of 50 percent is warranted for very frequent completely prostrating and prolonged headache attacks productive of severe economic inadaptability. The Rating Schedule does not define "prostrating."   However, "prostration" has been defined as "complete physical or mental exhaustion." Merriam-Webster's New Collegiate Dictionary 999 (11th ed. 2007). "Prostration" also has been defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). According to Stedman's Medical Dictionary, 27th Edition (2000), p.1461, "prostration" is defined as "a marked loss of strength, as in exhaustion." See, e.g., Eady v. Shinseki, No. 11-3223, 2013 WL 500460 (Vet. App. Feb. 12, 2013). Additionally, the terms "productive of severe economic adaptability" have not been clearly defined by regulations or by case law. The United States Court of Appeals for Veteran's Claims (Veterans Court/CAVCV) has noted that "productive of" can either have the meaning of "producing" or "capable of producing." See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually "produce" severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. Further, "economic inadaptability" does not mean unemployability, as such would undermine the purpose of regulations pertaining to TDIU. Id. at 446; see also 38 C.F.R. § 4.16. However, that said, migraines must be, at a minimum, capable of producing "severe" economic inadaptability. Furthermore, because the ameliorative effects of medication do not appear to be contemplated by the rating criteria under Diagnostic Code 8100, they should not be considered. See Jones v. Shinseki, 26 Vet. App. 56 (2012). The Board remanded this claim in September 2018 for an examination to determine whether the Veteran’s headaches (even if not migraines) are severe enough to warrant a separate rating, and whether he has a sleep disorder secondary to his hemangioma. The October 2020 DBQ obtained on remand shows the Veteran reported the impact of his disability being he cannot drive, has short attention span, is easily frustrated, has stress headaches, has neck pain, has imbalance on his feet. has occasional blurred vision and has slight memory issues. The October 2020 examiner determined the Veteran did not have sleep disturbances, to include sleep apnea requiring the use of a Continuous Positive Airway Pressure (CPAP) machine. However, the evidence of record contrarily shows he has sleep apnea and has been issued a CPAP machine for treatment of it (see April 2019 VA clinical records).   Thus, the Board is unsure as to whether the examiner was stating that the sleep apnea is not related to the Veteran’s cavernous hemangioma or if the examiner was unaware of the sleep apnea. Moreover, if the sleep apnea is not related to the hemangioma, the examiner should have provided rationale as to why it is not. In addition, the examination report does not state the severity, duration, or frequency of the Veteran’s headaches or whether his claimed morning headaches are as likely as not due to his hemangioma or, instead, his sleep apnea. Also, the report does not state whether the “black out spells” are actually loss of consciousness, fainting, or merely the Veteran falling asleep due to his sleep apnea. Essentially, the DBQ lists the Veteran’s reported symptoms in general but fails to provide rationale or specifics necessary to rate his disability. Thus, more medical comment is needed before deciding the appeal of this claim. 8. Entitlement to a TDIU This TDIU claim is “inextricably intertwined” with the claim for a higher or separate rating for the cavernous hemangioma and associated symptoms. Thus, consideration of this derivative TDIU claim must be deferred pending completion of the additional development being directed concerning the claim for a higher or separate rating for the cavernous hemangioma and associated symptoms. Accordingly, these claims are REMANDED for the following action: Schedule the Veteran for another examination to ascertain the severity of his cavernous hemangioma. The examiner should answer the following specific questions: (A) What is the frequency, duration, and severity of the Veteran’s headaches related to his cavernous hemangioma (as opposed to headaches, if any, related to his sleep apnea)? (B) Is it as likely as not (50 percent or greater) that the Veteran has sleep apnea that is causally related to, or aggravated by, his cavernous hemangioma? If the examiner finds that it is as likely as not that the Veteran’s hemangioma aggravates (worsens) his sleep apnea, the examiner should discuss the baseline severity of the sleep apnea prior to any aggravation as it compares ot the severity after aggravation, if any. (C) Is it as likely as not (50 percent or greater) that the Veteran has “black out spells” that are causally related to his cavernous hemangioma? And if so, what are the frequency, and duration? (D) Is it as likely as not (50 percent or greater) that the Veteran has neck pain, imbalance, short attention, and/or memory problems that is/are causally related to his cavernous hemangioma? If so, what is the frequency, duration, and/or severity? When responding, regardless of whether favorably or instead unfavorably, it is essential the examiner provide rationale – preferably citing to evidence in the file supporting conclusions and/or accepted medical authority.   In rendering opinions, the examiner should consider the pertinent evidence of record, to include: a.) the April 2012 neuropsychological examination report; b.) the April 2014 sleep study; c.) the April 2012 VA brain and spinal cord examination report; d.) a May 2014 VA treatment noting headaches; and e.) the October 2020 DBQ. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.