Citation Nr: 21012992 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 16-50 238 DATE: March 8, 2021 ORDER Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating higher than 10 percent prior to February 4, 2020, for a thoracolumbar spine disability is denied. Entitlement to a rating higher than 40 percent as of February 4, 2020, for a thoracolumbar spine disability is denied. Entitlement to an initial 20 percent rating, but not higher, for right lower extremity radiculopathy is granted. Entitlement to an initial 20 percent rating, but not higher, for left lower extremity radiculopathy is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. Prior to February 4, 2020, the Veteran’s thoracolumbar spine disability was manifested by symptomatology of forward flexion of the thoracolumbar spine to 90 degrees and flare-ups. 2. As of February 4, 2020, the Veteran’s thoracolumbar spine disability has been manifested by symptomatology of forward flexion of the thoracolumbar spine to 20 degrees, pain, stiffness, reduced motion, daily intermittent spasms, and flare-ups. 3. The Veteran’s bilateral lower extremity radiculopathy symptomatology has more nearly has approximated moderate incomplete paralysis of the sciatic nerve. 4. Throughout the appeal period, PTSD symptoms were productive of occupational and social impairment with reduced reliability and productivity. 5. The evidence is at least in equipoise regarding whether the service-connected disabilities alone preclude the Veteran from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to February 4, 2020, the criteria for a rating in excess of 10 percent for a thoracolumbar spine disability were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 2. As of February 4, 2020, the criteria for a rating in excess of 40 percent for a thoracolumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for an initial rating of 20 percent, but not higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 4. The criteria for an initial rating of 20 percent, but not higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6. 4.7, 4.10, 4.71a, 4.124a, Diagnostic Code 8520. 5. The criteria for a rating higher than 50 percent for PTSD have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411. 6. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1997 to March 1998 and November 2003 to February 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In January 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In March 2019, the Board remanded the case for further development. 1. Entitlement to increased ratings for a thoracolumbar spine disability Disabilities of the spine are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome is rated under the General Formula for Rating Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). VA outpatient records throughout the period on appeal generally show ongoing treatment for back pain. The Veteran received lumbar epidural steroid injections for radicular pain in 2017 and 2018. At an April 2015 VA examination, the Veteran reported flare-ups with sharp pains that caused shortness of breath and twitching in the lower legs. The Veteran experienced functional loss during flare-ups and had to lay down and take medication. The examiner diagnosed lumbosacral strain. Range of motion testing was normal with forward flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. There was pain on examination with each measurement. There was no additional loss of function or range of motion with repetitive use. The examiner was unable to say whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time or during flare-ups. There was no guarding or muscle spasm. The Veteran did not have additional factors contributing to the thoracolumbar spine disability. Muscle strength, reflex, and sensory testing was normal. There were no signs of radicular pain or radiculopathy. The Veteran did not have any ankylosis. At the February 2020 VA examination, the Veteran reported back pain of 7/10 for several years. The Veteran had been under chiropractic care for the past year. The Veteran had flare-ups twice a week with pain of 10/10 for up to one day. The Veteran also reported stiffness, reduced motion, and daily intermittent spasms. During flare-ups, she got off of her feet for a couple hours and then resumed ambulation on a limited basis. The examiner noted pain, weakness, fatigability, and loss of motion after flare-ups and repeated use. Range of motion testing showed forward flexion to 60 degrees, extension to 5 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. There was pain on each measurement, and the pain noted on the examination caused functional loss. Repetitive use testing showed additional loss in the Veteran’s range of motion due to pain with forward flexion to 50 degrees, extension to 0 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. The examiner described range of motion with repeated use over time as forward flexion to 20 degrees, extension to 0 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 15 degrees, and left lateral rotation to 15 degrees. Although the examination was not conducted during a flare-up, the Veteran’s range of motion was reduced due to pain, fatigue, weakness, and lack of endurance. The examiner described range of motion during a flare-up as the same range of motion with repeated use over time. There was no additional limitation with weight-bearing, nonweight-bearing, and passive range of motion. There was a muscle spasm that did not result in abnormal gait or spinal contour. The Veteran did not have any ankylosis. On review of all the evidence of record, both lay and medical, the Board finds that the Veteran’s thoracolumbar spine disability has not more nearly approximated a rating in excess of 10 percent at any time prior to February 4, 2020, and in excess of 40 percent as of February 4, 2020. Prior to February 4, 2020, the evidence did not show forward flexion of the thoracolumbar spine limited to 60 degrees or less. Specifically, the Veteran’s forward flexion was limited to 90 degrees at worst, and the combined range of motion was 240 degrees. A 20 percent rating requires forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Pain, by itself, throughout a joint’s range of motion does not constitute a functional loss entitling a claimant to a higher rating based upon range of motion loss in the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 43 (2011). The examiner noted no current symptoms of muscle spasms, guarding, or abnormal spinal contour. Additionally, the objective evidence and lay evidence indicates that the Veteran did not experience any fatigability, incoordination, pain on movement, and weakness during the applicable period. DeLuca v. Brown, 8 Vet. App. 202 (1995). The evidence does not show that during any flareups the symptoms would approximate the criteria for a higher rating. Therefore, a rating higher than 10 percent is not warranted. As of February 4, 2020, the Board finds that the thoracolumbar spine disability has not more nearly approximated a rating in excess of 40 percent. Specifically, range of motion testing performed did not show any occasion where the Veteran’s thoracolumbar spine disability was limited to any less than 20 degrees, even when considering the impact of pain and other factors limiting the range of motion. No ankylosis, either favorable or unfavorable, has been shown. To warrant a higher rating than 40 percent, unfavorable ankylosis would have to be shown affecting the entire thoracolumbar spine. The objective medical evidence by the VA examiners shows no ankylosis of the entire lumbosacral spine. Therefore, a rating higher than 40 percent is not warranted. The Board has also considered the Veteran’s reported impairment of function and has considered additional limitations of motion due to pain, incoordination, fatigability, excess motion, weakened motion, or on flare up. Even considering additional limitation of motion or function of the spine due to pain or other symptoms such as weakness, fatigability, pain, or incoordination the evidence still does not show that the back disability more nearly approximates the criteria for higher ratings. Prior to February 4, 2020, on repetitive use testing, range of motion of the spine did not show any additional loss of range of motion. As of February 4, 2020, flexion of the thoracolumbar spine was limited to 20 degrees, but the evidence did not indicate any loss of motion that was consistent with ankylosis. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The factors that may additionally limit motion and function were considered and assessed by the examination reports. The February 2020 VA examiner noted less movement than normal, pain on movement, instability of station, disturbance of locomotion, and interference with standing. The Veteran described flare-ups that were manifested by increased pain, stiffness, reduced motion, and intermittent spasms. The Board finds that pain and reduced range of motion is fully contemplated in the current 10 and 40 percent ratings assigned. The evidence does not show that any additional factors approximate thoracolumbar flexion to 60 degrees or less prior to February 4, 2020, or approximate ankylosis thereafter. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent for a thoracolumbar spine disability prior to February 4, 2020, and higher than 40 percent as of February 4, 2020. Therefore, the claim for increased ratings must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to an initial 20 percent rating, but not higher, for right lower extremity radiculopathy, 3. Entitlement to an initial 20 percent rating, but not higher, for left lower extremity radiculopathy An October 2020 rating decision established service connection for bilateral lower extremity radiculopathy and assigned 10 percent ratings for each extremity, effective February 4, 2020. Since the Veteran’s radiculopathy of the bilateral lower extremity symptoms are related to the service-connected thoracolumbar spine disability, the Board must consider a claim for a higher rating for the radicular symptomatology as part of the claim for a higher rating for the thoracolumbar spine disability. Paralysis of the sciatic nerve is rated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under those criteria, mild incomplete paralysis is rated 10 percent. Moderate incomplete paralysis is rated 20 percent. Moderately severe incomplete paralysis is rated 40 percent. Severe incomplete paralysis, with marked muscular atrophy is rated 60 percent. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated 80 percent. 38 C.F.R. § 4.124a. The words mild, moderate, moderately severe, and severe as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. 38 C.F.R. §§ 4.123, 4.124. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum rating for conditions that are wholly sensory, as opposed to a minimum rating for conditions that are more than wholly sensory. Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. 38 C.F.R. § 4.123. The only medical evidence regarding the severity of the Veteran’s radiculopathy symptoms is contained in the February 2020 VA medical examination report. In that report, a VA examiner stated that the Veteran had overall mild bilateral lower extremity radiculopathy symptoms related to the thoracolumbar spine disability. However, when discussing the specific radicular symptoms, the examiner noted that the Veteran experienced bilateral moderate numbness, and severe intermittent pain and paresthesias, and/or dysesthesias in the lower extremities. There was no constant pain. The Board finds that the combination of moderate numbness, and severe intermittent pain and paresthesias and/or dysesthesias more nearly approximates moderate incomplete paralysis of the sciatic nerve contemplated by the 20 percent rating under Diagnostic Code 8520. 38 C.F.R. § 4.124a. The Board also finds that the preponderance of the evidence weighs against the assignment any even higher rating under the appropriate Diagnostic Code. Specifically, the record contains no evidence indicating that the Veteran’s radicular symptoms have more nearly approximated the moderately severe incomplete paralysis of the sciatic nerve required for a next higher 40 percent rating under Diagnostic Code 8520. 38 C.F.R. § 4.124a. The evidence does not show any trophic changes or other organic changes that would support the finding of a higher level of disability. Accordingly, the Board finds that the criteria for initial 20 percent ratings, but not higher, for bilateral lower extremity radiculopathy have been met. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. As the preponderance of the evidence is against the assignment of higher ratings, the claim for any higher ratings must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) Psychiatric disabilities other than eating disorders are rated pursuant to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 0 percent rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. The symptoms listed in the rating formula are only examples, and evidence of those specific symptoms is not required to show that the Veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary consideration is whether the manifestations of the service-connected psychiatric disability result in a level of social and occupational impairment, regardless of whether the Veteran demonstrates the specific symptoms listed in the rating formula. When rating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. At an April 2015 VA examination, the Veteran reported living with her husband of five years and two stepchildren. She had friends and was active in the children’s lives. Her leisure activities including fishing, camping, and assisting with the children’s program at church. The Veteran reported trouble sleeping, intrusive thoughts, hypervigilance, and an exaggerated startle response. On examination, she was adequately groomed, maintained good eye contact, and readily responded to questions. The Veteran demonstrated adequate insight and judgment. The PTSD manifested with depressed mood and a chronic sleep impairment. The examiner found that PTSD caused occupational and social impairment with occupational decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. At a June 2019 VA examination, the Veteran reported marital difficulties with her husband. She last worked at Dairy Queen in 2011. The disability manifested with depressed mood; anxiety; suspiciousness; near-continuous panic or depression addicting the ability to function independently, appropriately, and effectively; chronic sleep impairment; flattened affect; disturbances of motivation and mood; and difficulty adapting to stressful circumstances, including work or a work like setting. On examination, the Veteran appeared to be over-medicated and reported that she had not slept in many days. The Veteran could not drive. The examiner asked the Veteran to repeat herself as she was difficult to understand. The examiner found the disability caused occupational and social impairment with reduced reliability and productivity. At a February 2020 VA examination, the Veteran reported that she had a couple of friends, enjoyed socializing, and generally got along with others. In her spare time, she read, played games on her phone, and went hunting and fishing. The disability manifested with depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The Veteran drove to the examination and arrived on time. On examination, she maintained good eye contact, and readily responded to questions. The Veteran demonstrated adequate insight and judgment. The examiner found that PTSD caused occupational and social impairment with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. VA medical records show treatment for PTSD and depression. The Veteran reported nightmares, sleep issues, low self-esteem, anxiety, and depression. Throughout the appeal period the Veteran continued to struggle with the grief from miscarriages and difficulties in marriage. Recent records showed biweekly therapy sessions. Throughout the appeal period, the Board finds that a rating higher than 50 percent is not warranted. The Board notes that a 70 percent rating is provided for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The Board finds that the competent medical evidence of record, to include the VA psychiatric examination reports, does not show the Veteran had any obsessional rituals, continuous panic attacks, impaired impulse control, spatial disorientation, actual neglect of personal hygiene, or an inability to maintain effective relationships, as demonstrated by her ability to make and maintain friends and relationships at church. Medical records consistently show that the Veteran was always appropriately dressed and adequately groomed, cooperative and oriented, and with normal speech, thought process, and judgment. The Board places great weight on the outpatient treatment records and the examination reports, as they were created by objective medical personnel in the process of providing professional care to the Veteran. The Board acknowledges the June 2019 examiner reported that the Veteran appeared to be over-medicated on examination. VA treatment records show that the Veteran wanted to reduce her medication around that time due to feeling over-sedated. The Board notes that the April 2015 and February 2020 VA examiners found the PTSD manifested with an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. While each examiner noted sleep impairment, those examiners did not address violent and intrusive nightmares that accompanied that impairment. Taken as a whole, the Board finds that a review of the medical records shows an overall condition that more nearly approximates the criteria for a 50 percent rating. Considering the totality of the Veteran’s symptomatology, the Veteran’s disability has not shown to manifest to the severity required for the next higher rating of 70 percent. The Board finds that the Veteran’s psychiatric symptoms more nearly approximate a condition that is productive of occupational and social impairment with reduced reliability and productivity, as noted by the June 2019 VA examiner, rather than deficiencies in most areas. The Board finds that the Veteran’s symptomatology does not support any higher rating. The Board has additionally considered the Veteran’s statements regarding the severity of the psychiatric symptoms throughout the period of appeal. The Veteran is competent to report the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). However, the opinions and observations of the Veteran do not meet the burden for even higher ratings imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected psychiatric disability throughout the appeal. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher rating and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. If the schedular rating is less than total, a total disability rating can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated 60 percent or higher; or two or more service-connected disabilities, with one disability rated 40 percent or higher and a combined rating of 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran’s service-connected disabilities make him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The Veteran has service-connected ratings of 50 percent for posttraumatic stress disorder (PTSD), 40 percent for a thoracolumbar spine muscular strain with degenerative disc disease, 20 percent for migraine headaches, 20 percent for radiculopathy in each lower extremity, 10 percent for cervical muscular strain, 10 percent for a left toe injury residuals, 10 percent for gastroesophageal reflux disease (GERD), 0 percent for a right finger contusion, and 0 percent for bilateral pes planus. The combined service-connected disability rating is 90 percent. As the Veteran has a combined rating of at least 70 percent, the service-connected disabilities meet the percentage requirements for consideration of the assignment of TDIU. 38 C.F.R. § 4.16(a). The question that remains is whether the service-connected disabilities preclude the Veteran from obtaining or retaining substantially gainful employment. The central inquiry is whether the service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). On a VA Form 21-8940 submitted in November 2015, the Veteran indicated that she last worked full-time in October 2010, when she had worked as an assistant fast food manager. She completed four years of high school. On VA spine examination in April 2015, the examiner opined that the Veteran’s thoracolumbar spine disability had a functional impact on the Veteran’s ability to work. The examiner noted debilitating back pain that required muscle relaxers and pain medications that were no longer prescribed. On VA psychiatric examination in April 2015, the examiner opined that the Veteran’s PTSD caused occupational and social impairment with occupational decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported trouble sleeping, intrusive thoughts, hypervigilance, and an exaggerated startle response. On examination, she was adequately groomed, maintained good eye contact, and readily responded to questions. The Veteran demonstrated adequate insight and judgment. On VA headache examination in April 2015, the examiner opined that the Veteran’s migraine disability precluded working due to debilitation when migraines occurred. The Veteran experienced prostrating attacks averaging once a month that were productive of severe economic inadaptability. At the January 2017 Board hearing, the Veteran testified that she had last worked in October 2010 as a fast food manager. She stated that she could not perform that position now due to the progression of the service-connected disabilities. The Board notes the Veteran mentioned nonservice-connected knee disabilities as one of the reasons that she would have difficulty performing that job. The Veteran stated that she would need a significant amount of time off from any job to attend various medical appointments since she usually had at least one per week. In addition, the Veteran testified that working in small groups or a one on one setting would be easier than interacting with a larger group of co-workers, supervisors, and customers. On VA spine examination in February 2020, the examiner indicated that the thoracolumbar spine disability limited the Veteran to sitting for two hours, standing for 10 minutes, walking 100 feet, and lifting 10 pounds. The Veteran could not squat or climb. At a February 2020 VA psychiatric examination, the examiner opined that PTSD may hinder the Veteran from being able to work in loud environments or in situations where she was frequently required to interact with others with whom she was not familiar. The Veteran would function best in work environments where she had some control over the work setting, could work independently, or work in small group settings with persons with whom she was familiar. Based on all the evidence of record of the Veteran’s various service-connected disabilities of PTSD, thoracolumbar spine muscular strain, migraine headaches, bilateral lower extremity radiculopathy, cervical muscular strain, left toe injury residuals, GERD, a right finger contusion, and bilateral pes planus, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran is precluded from securing or following gainful employment due to the combined effects of the service-connected disabilities. The Board acknowledges the opinions of the VA examiners who opined that the Veteran’s PTSD would not preclude sedentary work. However, those opinions appear to have simply considered the psychiatric disability singly and in isolation without consideration of all of the service-connected disabilities, to specifically include the service-connected thoracolumbar and cervical spine disabilities, migraines, and bilateral lower extremity radiculopathy. Taken as a whole, the evidence suggests that the service-connected thoracolumbar and cervical spine disabilities, migraines, and bilateral lower extremity radiculopathy restrict the Veteran to sedentary work, while the service-connected psychiatric disability severely hampers the ability to work at a sedentary job. The Board further notes that the Veteran’s occupational experience in fast food management requires physical labor, and the Veteran does not have education that is readily applicable to a sedentary occupation based on the ordinary meaning of the term. Withers v. Wilkie, 30 Vet. App. 139 (2018). Taken as a whole, the evidence is at least in equipoise regarding whether the Veteran would be able to function in any occupational setting due to her service-connected disabilities, as demonstrated by the evidence. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that entitlement to TDIU is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Kass, 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.