Citation Nr: 21020756 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 10-15 662 DATE: April 8, 2021 ORDER Prior to April 9, 2013, a disability rating higher than 10 percent for the service-connected low back disability is denied. From April 9, 2013, to October 14, 2014, a disability rating of 20 percent, but not higher, for the service-connected low back disability, is granted. Since October 14, 2014, a disability rating higher than 40 percent for the service-connected low back disability is denied. FINDINGS OF FACT 1. Prior to April 9, 2013, the service-connected low back disability was manifested by forward flexion greater than 60 degrees, but not greater than 85 degrees. 2. From April 9, 2013, to October 14, 2014, the service-connected low back disability was manifested by forward flexion greater than 30 degrees, but not greater than 60 degrees. 3. Since October 14, 2014, the service-connected low back disability is manifested by range of motion approximating favorable ankylosis of the thoracolumbar spine, but not approximating unfavorable ankylosis. CONCLUSIONS OF LAW 1. Prior to April 9, 2013, the criteria for a disability rating higher than 10 percent for the service-connected low back disability were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 2. From April 9, 2013, to October 14, 2014, the criteria for a disability rating of 20 percent for the service-connected low back disability were met; the criteria for a rating higher than 20 percent were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 3. Since October 14, 2014, the criteria for a disability rating higher than 40 percent for the service-connected low back disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from August 1983 to March 1988. This appeal comes before the Board of Veterans’ Appeals (Board) from an April 2020 Order of the United States Court of Appeals for Veterans Claims (Veterans Court). The appeal originates from an April 2010 rating decision of the RO in Winston-Salem, North Carolina. In December 2014, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e). At the Board hearing, the Veteran was informed of the basis for the RO’s denial of his claims and he was informed of the information and evidence necessary to substantiate each claim. 38 C.F.R. § 3.103. A transcript of the hearing is associated with the claims file. In June 2017, the Board denied a rating higher than 10 percent for the service-connected low back disability, prior to September 19, 2016. The Board also denied a rating higher than 40 percent for the service-connected low back disability, since September 19, 2016, denied a disability rating higher than 10 percent for the service-connected left wrist disability, denied a total disability rating based on individual unemployability due to service connected disabilities (TDIU), prior to February 1, 2013, and granted TDIU, since February 1, 2013. The Veteran appealed that decision. In a November 2018 Joint Motion for Partial Remand, the parties to the Joint Motion agreed that the June 2017 decision should be vacated to the extent of the denial of a higher rating prior to September 19, 2016, for the service-connected low back disability. The parties agreed that the Board’s decision with respect to the other issues would not be challenged. Accordingly, the question of TDIU entitlement prior to February 1, 2013, is no longer a component of this appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009); but see Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) (under the “law of the case” doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case). In a June 2019 decision, the Board granted an increased rating of 40 percent for the low back disability for the period from October 14, 2014, to September 19, 2016, and denied a rating higher than 10 percent prior to October 14, 2014, and a rating higher than 40 percent since October 14, 2014. The Veteran appealed that decision to the Veterans Court. In an April 2020 Order, pursuant to a Joint Motion for Remand, the Veterans Court vacated the Board’s June 2019 decision in part, and remanded these issues to the Board for additional development consistent with the Joint Motion. The Board remanded these claims in August 2020 for additional evidentiary development in compliance with the April 2020 Order of the Veterans Court. The appeal has since been returned to the Board for additional appellate action. Increased Ratings—Law and Regulations Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include lumbosacral strain (Diagnostic Code 5237). A rating of 100 percent requires unfavorable ankylosis of the entire spine. A rating of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. A rating of 40 percent requires forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A rating of 20 percent requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A rating of 10 percent is assigned with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, note (2) (See also Plate V). After the evidence has been assembled, it is the Board’s responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Entitlement to a disability rating for low back disability, currently rated 10 percent prior to October 14, 2014, and 40 percent since October 14, 2014. The current appeal arises from a claim of entitlement to service connection for a low back disability that was received at VA on August 31, 2009. In an April 2010 rating decision, VA granted service connection for a low back disability and assigned a disability rating of 10 percent under Diagnostic Code 5237, effective August 31, 2009. In a June 2019 rating decision, a rating of 40 percent was assigned, effective January 14, 2014. The report of a VA Spine Examination dated February 2010 reveals the Veteran’s account that he had limitation in walking because of his spine condition. He stated that, on average, he could walk 50 yards. He indicated it would take 15 minutes to accomplish this. He stated he had not experienced falls due to his spine condition. He reported symptoms of stiffness, spasms, decreased motion, paresthesias, and numbness. He reported he did not experience fatigue, but had weakness of the leg. He reported no bowel problems, bladder problems, or erectile dysfunction. He described severe pain located on the low back and the pain occurred constantly and traveled to left leg. During flare ups, he experienced functional impairment which was described as pain with bending and driving. He reported no incapacitation in the past 12 months. The Veteran’s posture was normal. He walked with a normal gait. There was no evidence of radiating pain with movement. Muscle spasms were absent. No tenderness was noted. There was no guarding of movement. The examination did not reveal any weakness. Muscle tone was normal, and musculature was normal. There was no atrophy present in the limbs. There was no ankylosis of the thoracolumbar spine. Forward flexion of the thoracolumbar spine was measured to 90 degrees with onset of pain at 45 degrees. After three repetitions, flexion was measured to 90 degrees. Extension was measured to 30 degrees with onset of pain at 10 degrees. After three repetitions, extension was measured to 30 degrees. Lateral flexion was measured bilaterally to 30 degrees with onset of pain at 15 degrees. After three repetitions, lateral flexion was measure to 30 degrees. Lateral rotation was measured bilaterally to 30 degrees with onset of pain at 0 degrees. After three repetitions, lateral rotation was 30 degrees. The joint function of the spine was not additionally limited by pain, fatigue weakness, lack of endurance, or incoordination after repetitive use. Inspection of the spine revealed normal head position with symmetry in appearance. There was symmetry of spinal motion with normal curves of the spine. There was no motor weakness. There was negative straight-leg-raise testing on the right, but positive on the left. There was a sensory deficit of the left lateral leg associated with L5. Reflexes were 2+ bilaterally. There were no pathologic reflexes. The diagnosis was intervertebral disc syndrome affecting the left sciatic nerve (Record 03/15/2010). An April 30, 2010, Private Clinical Note reveals complaint of low back pain. On examination of the back and lower extremities, there was no tenderness to palpation to the spinous processes of the thoracic or lumbar spine. There was some tenderness to palpation to the paraspinous muscle groups of the lumbar spine. There was no real tenderness to palpation to the sacroiliac joints, bilaterally. There was no tenderness to palpation to the remainder of the bony pelvis. There was a negative straight-leg-raise test. There was no discomfort with internal and external rotation of the hips, bilaterally. There was no tenderness to palpation to the greater-trochanteric areas, bilaterally. There was no tenderness to palpation to the muscle groups of the upper or lower legs. Neurovascularly, the Veteran was intact distally. X-rays of the lumbar spine showed essentially a normal spine with no significant degenerative changes apparent, degenerative disc disease, or stenosis noted at any level of the lumbar spine (Record 06/23/201). An October 7, 2010, MRI reveals slight indentation of the dural sac at L5-S1 and L4-5 with no evidence of nerve displacement or significant spinal stenosis (Record 06/27/2013). A VA Spine Examination dated March 2011 was conducted by the same examiner as conducted the February 2010 examination and many parts of the report are similar. It reveals the Veteran’s report of limitation in walking because of his spine condition. He stated that, on average, he can walk 50 yards. He indicated it takes 4 minutes to accomplish this. He stated he had not experienced falls due to his spine condition. He reported stiffness, spasms, paresthesias, and numbness. He reported no fatigue, decreased motion, or weakness. He reported no bowel problems, bladder problems or erectile dysfunction in relation to the spine condition. He reported experiencing severe pain located on the lower back and the pain occurs constantly and travels to left leg. At the time of pain, he would have to tilt his body in order to function. During flare ups, he would experience limitation of motion. He reported no incapacitation in the prior 12 months. Examination revealed no evidence of radiating pain on movement. Muscle spasms were absent. No tenderness was noted. There was no guarding of movement. The examination did not reveal any weakness. Muscle tone was normal. Musculature was normal. There was no atrophy present in the limbs. There is no ankylosis of the thoracolumbar spine. Forward flexion of the thoracolumbar spine was measured to 5 degrees with onset of pain at 0 degrees. After 3 repetitions, flexion was to 5 degrees. Extension was measured to 5 degrees with onset of pain at 5 degrees. After 3 repetitions, extension was to 5 degrees. Right lateral flexion was measured to 1 degree with onset of pain at 1 degree. After 3 repetitions, right lateral flexion was to 1 degree. Left lateral flexion was measured to 0 degrees with onset of pain at 0 degrees. After 3 repetitions, left lateral flexion was to 0 degrees. Right rotation was measured to 10 degrees with onset of pain at 10 degrees. After 3 repetitions, right rotation was to 10 degrees. Left rotation was measured to 20 degrees with onset of pain at 10 degrees. After 3 repetitions, left rotation was to 20 degrees. The joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Inspection of the spine revealed normal head position with symmetry in appearance. There was symmetry of spinal motion with normal curves of the spine. The examiner noted left-great-toe motor weakness on extension of 0/5. Reflexes were normal bilaterally. There was negative straight leg raise testing on the right, positive on the left. The March 2011 examiner noted that the Veteran’s report of pain was out of proportion with the examination results. She found the examination was marginally reliable due to the Veteran’s expression of pain with minimal motion of the lumbar spine. The effect of the condition on the claimant’s usual occupation was assessed as moderate, in that the Veteran worked for a cable company and had difficulty bending, crawling, and crouching. According to the examiner, his daily activities would not be affected by his condition (Record 06/21/2011). A June 2012 statement submitted by the Veteran’s spouse states that his medical issues of back pain (and wrist pain) had affected his home life. Many nights, he would start out sleeping in bed but would wake up and get in the recliner because of his back pain. Even with a new mattress he still would wake up at night and get in the recliner to get some relief from his back pain. He used to exercise, but now he does not because of his back (and wrist) (Record 06/27/2012). A statement of the Veteran received in June 2012 reveals he was working as a cable technician and it was difficult to work with the pain in his back (and wrist). Carrying the ladder and crawling under houses and in attics was very difficult to do (Record 06/27/2012). A buddy statement received in June 2012 notes the Veteran was working as a cable technician. Cable technicians are responsible for repairing cable lines, cable poles or amplifiers at the home or business of people who have subscribed to the company’s cable service. There are times when the Veteran had to lift his ladder to go up the cable pole. Other times he might have to crawl in an attic or under a house. His medical issues with his back (and wrist) had affected his work. The number of jobs that he completed daily had dropped. He had been out sick more (Record 06/27/2012). An August 14, 2012, Physical Medicine Rehabilitation Note reveals complaint of chronic back pain. The examiner noted that he was in stable condition (Record 07/23/2015 at 25). An August 20, 2012, MRI notes “You have some disc bulging at the lower two levels of your back more so on the right. This is a common finding and difficult to correlate with pain symptoms. I would not recommend surgery based on these findings” (Record 12/29/2014 at 4). An April 9, 2013, Private Clinical Note reveals no evidence of neural tension, normal motor strength, symmetry in tone, bulk, and reflexes of the lower extremities were normal and maintained. The Veteran had reduced forward flexion/extension, lateral bending and rotation, which were all limited to approximately 60-75 percent of normal due to end range pain (Record 06/27/2013). A May 8, 2013, MRI reveals no worsening since August 2012. Mild neural foramen narrowing at L5/S1 was noted with moderate narrowing at L4-5 (Record 06/18/2013). A November 19, 2013, letter from a private physician reveals a recommendation for permanent light duty restrictions (Record 05/27/2014). A May 2, 2014, Physical Therapy Note reveals the Veteran ambulated into the clinic with a slowed, antalgic gait pattern without an assistive device. He had limited lumbar motion in standing. Flexion, extension, and right lateral flexion were at 50 percent; left lateral flexion was to 75 percent. In sitting, he had normal lower extremity reflexes at patellar and Achilles tendons. Strengths were down throughout the right lower extremity, at 4-/5. Hips were 3+/5. All strengths are within normal limits on the left lower extremity. In supine position, he had equal leg lengths and pelvic symmetry. In prone position, he was hypersensitive to touch in a large area across his back. Checking hip rotations made him jump with reports of pain. Attempts to try repeated extension in prone position were not successful. He could not push into extension more than about 20 percent in prone, versus 50 percent in standing (Record 12/08/2020 at 414). An October 14, 2014, Physical Therapy Consult reveals the Veteran’s complaint of chronic low back pain. The Veteran had been working for a cable company doing installations and repairs, and supervising, but had been out of work for 16-18 months. The Veteran was very restricted with lifting. The pain got worse in his legs at least a year ago. He has had a few falls. The Veteran reported constant pain. In standing position, he was unwilling to push lumbar ROM in any direction. He has about 25 percent of motion in all planes except extension which is slightly lacking neutral extension. In a sitting position, all reflexes were elicited in the lower extremities except the left Achilles tendon. Strength in the right lower extremity was 3+/5 with cogwheeling. Strength in the left lower extremity was 4+/5. He described numbness in bottom of the right foot only. He was able to lie prone, even though he could not extend to neutral in a standing position. He was very tender to palpation at L4 and L5. The examiner’s impression was that no findings had worsened from the prior examination of August 14, 2012 (Record 12/07/2015 at 68). An October 20, 2014, letter from T. Wright, MD, at Roanoke Chowan Community Health Center states that the Veteran is assigned a permanent work restriction to light duty. He would therefore not be able to return to his work as a cable man which involves a moderate amount of heavy lifting (Record 12/29/2014 at 14). A June 8, 2015, Pain Clinic Note shows very limited lumbar range of motion (Record 12/08/2020 at 340). A July 2016 letter from private physician T. Wright, MD, states that the Veteran has chronic lower back pain from his military service from which he has not recovered. He continues to have constant lower back pain radiating to the lower extremity where there is pain and weakness that worsens with activity. He also has limitation in lumbar range of motion due to pain. He has chronic lower back pain which affects his ability to work. His pain is being managed with medication and physical therapy. He has made minimal progress with physical therapy. Due to the consistency of the symptoms reported, physical exam findings consultation with specialist providers, and chronicity of these issues, it is unlikely that he is malingering. He cannot stand or walk for greater than 30 minutes at a time during the course of an 8-hour workday. He also has limitations with respect to weight-lifting and carrying objects. He should lift and carry no more than 10 pounds frequently, i.e., 1/3–2/3 of an 8-hour workday. But the constant stress and strain of maintaining this production rate can be physically demanding even though the amount of force exerted is negligible and he may need to reduce the pace to less than 3 hours per day from time to time. It is reasonable that he will have to change positions every 30 minutes for sitting and standing due to the pain. He does not need to elevate his legs during the day. His pain medications are sedating and affect his ability to concentrate, focus and drive (Record 09/23/2016). An October 5, 2020, Physical Therapy Note reveals the Veteran’s complaint of low back pain. On examination of active range of motion, the spine was 75 percent limited and painful. Extension was neutral. Rotation was 50 percent limited and painful. An MRI showed multi-level degenerative changes, increased from the prior examination; mild spinal canal stenosis at L4-5; severe facet disease with facet fluid which may indicate hypermobility; severe bilateral neural foraminal narrowing at L4-5 and moderate-severe neural foraminal narrowing at L5-S1; and small left L5-S1 synovial cyst, not likely symptomatic (Record 12/08/2020 at 16). A November 2020 VA examination reveals diagnoses of degenerative arthritis and spinal stenosis. On examination, forward flexion was to 30 degrees; extension was to 10 degrees; and lateral flexion and rotation were to 15 degrees, bilaterally. After three repetitions, range of motion was unchanged. This range of motion did not constitute functional loss. Pain did not result in functional loss. There was evidence of pain with weight bearing. There was no guarding or muscle spasm. The Veteran’s symptoms resulted in disturbance of locomotion, interference with sitting, and interference with standing. Lower extremity muscle strength was full, with no atrophy. Reflexes were normal. Sensation was decreased. There were symptoms of moderate lower extremity radiculopathy, but no other objective associated neurological abnormalities. Regarding impact on employment, the Veteran would be unable to perform tasks involving ambulation or physical labor as he cannot stand or walk for long, and is unable to lift any heavy weight (Record 11/20/2020). The examiner opined that there would be no additional limitation of motion during flares or with repeated use over a period of time (Record 11/20/2020). After a review of all of the evidence, the Board finds that, for the service-connected low back disability, prior to April 9, 2013, the criteria for a rating higher than 10 percent were not met; from April 9, 2013, to October 14, 2014, the criteria for a rating of 20 percent, but not higher, were met; and, since October 14, 2014, the criteria for a rating higher than 40 percent are not met. The parties to the April 2020 Joint Motion identified deficiencies in the Board’s June 2019 decision. They agreed that the Board did not adequately address entitlement to higher ratings on an extraschedular basis. They agreed that the medical record contains evidence indicating that medications the Veteran takes for his service-connected low back disability have impacted him in ways that are not contemplated by the diagnostic code for back disorders. The parties cited the Veteran’s testimony that he took Percocet to treat his back symptoms, and a July 2016 private treatment record noting that this is sedating, and affects the Veteran’s ability to concentrate, focus, and drive. The parties also agreed that the Board must ensure all aspects of the Veteran’s functional loss are addressed, including limitations he experienced due to flareups. Citing English v. Wilkie, 30 Vet. App. 347, 355 (2018) for its holding that 38 C.F.R. §§ 4.40 and 4.45 permit consideration of a higher rating based on a greater limitation of motion due to pain on use, including during flareups, and based on weakened movement, excess fatigability, incoordination, and pain on movement, in addition to range of movement. The findings of the November 2020 VA examiner reveal no additional functional loss during flares or with repeated use over a period of time. It was estimated that range of motion would be unchanged during such periods. The demonstrated range of motion did not constitute functional loss. Accordingly, there is no basis for higher ratings under English, supra. The Board finds that the November 2020 examination report addresses directly the stipulation of the parties regarding this question. Prior to April 9, 2013, measurements of range of motion do not substantiate entitlement to any rating higher than 10 percent. Such a rating would require limitation of forward flexion of the thoracolumbar spine that is not greater than degrees. In other words, measured forward flexion from 31 degrees to 60 degrees. Alternatively, combined range of motion must be not greater than 120 degrees. The February 2010 VA examination shows that while motion was painful, the Veteran was able to attain 90 degrees of forward flexion even after repetitive use. Combined range of motion was 240 degrees. There were also no findings consistent with guarding or muscle spasm of the thoracolumbar spine. Gait and posture were normal. The March 2011 findings might be interpreted as showing greater impairment. However, that examiner discounted the reliability of those findings. The reliability of medical findings is inherently a medical question, and the Board is not competent to substitute its opinion for the opinion of the medical professional who directly examined the Veteran. While the written statements of the Veteran, his spouse, and friend, are competent evidence that the service-connected back disability resulted in functional impairment during the period prior to April, 9, 2013, this evidence does not establish that motion of the Veteran’s back was limited to the extent required for any higher rating than is currently assigned. As already discussed, such impairment is not demonstrated. Regarding the period from April 9, 2013, to October 14, 2014, the April 9, 2013, examination findings are consistent with a rating of 20 percent, based on forward flexion that is limited to 60-75 percent of normal. As normal is 90 degrees, this equates to forward flexion from 53 degrees to 68 degrees. The Board resolves reasonable doubt regarding this imprecise measurement in favor of the claim. As 53 degrees is not greater than 60 degrees, the criteria for a rating of 20 percent are more nearly approximated than are the criteria for a 10 percent rating. Also notable is the November 19, 2013, recommendation of permanent light duty restrictions, roughly corresponding to this examination. Prior to that, in August 2012, the Veteran’s back was described as being in stable condition. The range of motion findings in March 2011 did not substantiate any rating higher than 10 percent. Accordingly, the April 2013 findings appear to represent a recent worsening of the condition. Also reflective of a worsening of symptoms consistent with the April 2013 report is the Veteran’s statement to a physical therapist in October 2014 that his symptoms had worsened “at least a year ago.” Regarding the period since October 14, 2014, the Board acknowledges the October 14, 2014, Physical therapy Note, which reported 25 percent range of motion in all planes except extension. This equates to 22.5 degrees. Thus, it is 30 degrees or less. The October 14, 2014, Physical Therapy Note supports a rating of 40 percent and is the earliest date as of which it is factually ascertainable that such a rating is supported. The October 14, 2014, Physical Therapy Note does not suggest that there was unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. There are no such findings at any time. Accordingly, a rating higher than 40 percent is not warranted. Moreover, there is no earlier date that would support the award of a 40 percent. As discussed above, the findings of the March 2011 VA examiner are not probative of entitlement to any higher rating, as the examiner found the Veteran’s report of symptomatology to be of discounted reliability. Regarding extraschedular consideration of higher ratings, the parties agreed that the Veteran testified at the Board hearing that his pain medication caused stomach conditions. They also agreed that there was evidence of a sedating effect of his medications. The parties stipulated that the Board must address whether the claim should be referred for extraschedular consideration. In August 2020, the Board referred this matter to the Director of VA’s Compensation Service in August 2020. The Director found that there has been no factual demonstration of impairment to earning capacity based on exceptional or unusual factors for the lumbar spine condition. Thus, entitlement to an extra-schedular rating for the lumbar spine condition under provision 38 C.F.R. § 3.321(b)(1) was denied (Record 01/08/2021). The Board finds that the effects of pain medication are reasonably contemplated under the rating schedule. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made “with or without symptoms such as pain.” Even at the lowest compensable rating level, the effect of pain, such as guarding, and tenderness are explicitly listed. Moreover, painful motion is contemplated for all joint disabilities. 38 C.F.R. §§ 4.40, 4.45, 4.59. With pain and its effects so central to the rating schedule for the spine, the Board finds that there is not such an exceptional disability picture present here that the available schedular evaluations for the service-connected lumbar spine disability are rendered inadequate. In addition, the evidence does not demonstrate that the normal expected side-effects of the Veteran’s pain medication (sleepiness, tiredness, drowsiness, constipation, nausea, and stomach pain), see https://www.rxlist.com/oxycontin-side-effects-drug-center.htm, cause marked interference with employment or frequent periods of hospitalization. There is no assertion of hospitalization as a result of these medications. Moreover, the evidence does not substantiate any unusual occupational impact. The Veteran’s employment history is a cable technician. While his back disability certainly impacts that profession, it is unclear from his statements and testimony how his pain medication would markedly interfere with such employment. While it is presumed that any service-connected disability will cause some interference with employment, in this case, the evidence does not show that this interference is either unusual or marked. Indeed, these appear to be the usual expected side-effects of the medications in question, and they are prescribed for a disability whose rating schedule and supporting regulations explicitly contemplate pain as a component of disability. For the reasons discussed, the Board finds that an extraschedular rating is not warranted. The Board has considered the rating schedule for intervertebral disc syndrome; however, it was the finding of the November 2020 VA examiner that a diagnosis of intervertebral disc syndrome was not appropriate. The Board has also considered whether there are any objective associated neurological abnormalities for which separate ratings have not already been granted. Service connection has been granted for bilateral lower extremity neurological disabilities. There are no other identified neurological abnormalities associated with the service-connected low back disability. In sum, the Board finds that, prior to April 9, 2013, the service-connected low back disability was manifested by forward flexion greater than 60 degrees, but not greater than 85 degrees; from April 9, 2013, to October 14, 2014, the service-connected low back disability was manifested by forward flexion greater than 30 degrees, but not greater than 60 degrees; and, since October 14, 2014, the service-connected low back disability was manifested by range of motion approximating favorable ankylosis of the thoracolumbar spine, but not approximating unfavorable ankylosis. In light of these findings, the Board concludes from April 9, 2013, to October 14, 2014, an increased rating of 20 percent is warranted. However, no other increased ratings or separate ratings are warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (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). JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Cramp 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.