Citation Nr: 21022409 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 14-10 552 DATE: April 15, 2021 ORDER Entitlement to an initial rating of 50 percent for migraine headaches is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, the Veteran’s migraine headaches have been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability throughout the appeal period. 2. Resolving reasonable doubt in the Veteran’s favor, the evidence of record shows that the Veteran has been rendered unable to obtain or retain substantially gainful employment due to her service-connected disabilities throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent for migraine headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code (DC) 8100. 2. The criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1998 to September 1998 and from October 2003 to February 2004, with subsequent service in the Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision. The Board notes that in March 2016, the Board determined that the issue of entitlement to a TDIU had been raised under Rice v. Shinseki, 22Vet. App.447 (2009), and remanded the issue for development and adjudication at that time. By way of background, in a July 2018 Board decision, the Board granted entitlement to an initial increased rating of 30 percent for the Veteran’s migraine headaches disability and considered the Veteran’s TDIU claim abandoned since the Veteran nor her representative supplied a completed VA Form 21-8940 and/or a statement with comparable information. The Veteran appealed to the United States Court of Appeals for Veterans Claims (“CAVC” or “the Court”) the portion of the July 2018 decision that denied a disability rating in excess of 30 percent for migraines, and the portion that denied entitlement to compensation for TDIU. The Court issued a Memorandum Decision in December 2019 vacating the Board’s July 2018 decision as it pertained to these issues and remanded the case back to the Board for disposition consistent with the Court’s Order. Specifically, the December 2019 CAVC Memorandum Decision found that the Board failed to provide an adequate statement of reasons or bases for its decision to grant the Veteran a 30 percent disability rating instead of a 50 percent disability rating for her migraine headaches disability. The Court noted that the Board did not explain how it reached the subjective determination that the Veteran’s headaches were “prostrating” and not “completely prostrating.” Additionally, the Court noted that the Board offered no explanation for why it found that the Veteran’s headaches do not cause severe economic inadaptability. With respect to the issue of TDIU, the Court found that the Board failed to support its denial with an adequate statement of reasons or bases. It was specifically noted that although the Board explained that the Veteran did not complete, sign, and return VA Form 21-8940, the Board did not explain why it found other evidence of record inadequate to permit the Board to fully assess whether the Veteran should be awarded TDIU benefits. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In Johnson v. Wilkie, 30 Vet. App. 245 (2018), the United States Court of Appeals for Veterans Claims (Court) held that the criteria of DC 8100 are successive. Successive criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). Although 38 C.F.R. §§ 4.7 and 4.21 generally provide that symptoms need only more nearly approximate the criteria for a higher rating in order to warrant such a rating, those regulations do not apply where the rating schedule establishes successive criteria. In Pierce v. Principi, 18 Vet. App. 440, 446 (2004), the Court held that “nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 [percent] rating, and [i]f ‘economic inadaptability’ were read to import unemployability, the appellant, if he met the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating.” In addition, the Court in Pierce acknowledged the Secretary’s concession that the phrase productive of severe economic inadaptability in DC 8100 should be construed as either producing or capable of producing severe economic inadaptability. Id. at 445. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for any increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board notes that in deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of positive and negative 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. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to an initial rating of greater than 30 percent for migraine headaches. The Veteran through her attorney asserts that she is entitled to an initial 50 percent rating for migraine headaches. The Veteran asserts that she experiences two to four headaches per month that require her to lie down in a dark room and further states that she was often unable to work during the headaches because they impaired her thinking and concentration (See February 2016 VA treatment note; November 2015 Board hearing; July 2012 VA examination; January 2009 treatment record). The Veteran contends that her headaches lasted for up to a day at a time and a report from a vocational specialist contends that the Veteran’s migraines are capable of producing severe economic inadaptability. See Appellate Brief Received January 2021. The Veteran’s migraine headache disability is currently assigned an initial noncompensable rating of 30 percent under Diagnostic Code 8100, effective December 19, 2011. Diagnostic Code 8100 provides for a 10 percent rating for characteristic prostrating attacks occurring an average of once every two months over the last several months. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a Diagnostic Code 8100. The phrase “characteristic prostrating attacks” means migraine attacks that typically produce powerlessness or a lack of vitality. Johnson v. Wilkie, 30 Vet. App. 245 (2018). In other words, the term “prostrating” takes on its plain meaning of “lacking in vitality or will: powerless to rise: laid low.” Id. (citation omitted). For reference, the Board notes that “prostration” is defined as “extreme exhaustion or powerlessness.” See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d. ed. 2012). Also, the Board notes that "migraine" is commonly associated with irritability, nausea, vomiting, constipation or diarrhea, and often with photophobia. Also, attacks are preceded by constriction of the cranial arteries, often with resultant prodromal sensory (especially ocular) symptoms. Id. at 1166. Additionally, the term “productive of severe economic adaptability” has not been clearly defined by regulations or by case law. The Court has noted that “productive of” can either have the meaning of “producing” or “capable of producing.” 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 that would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability. Id. at 446; see also 38 C.F.R. § 4.16. The Board notes, however, that the migraines must be, at minimum capable of producing “severe” economic inadaptability. Again, turning to the plain meanings of these words, the Board notes that the term “severe economic inadaptability” refers to a great degree of inability in adjusting to the environment of an economic marketplace. See, Merriam-Webster definitions of “inadaptability;” “adaptation;” “severe;” and “economic.” The Veteran was afforded a VA examination in July 2012. The Veteran was diagnosed with migraines with migraine variants. The Veteran reported experiencing pain on both sides of the head with associated nausea and sensitivity to light. The typical head pain would last one to two days and be on the right side of the head. The examiner noted the Veteran had characteristic prostrating attacks occurring once in two months. A July 2013 treatment note indicates two to three headaches per month, but no mention of migraines or prostrating attacks. The record indicates the Veteran takes Aleve as needed. A February 2015 Boise VAMC treatment record notes slight headaches every week with full blown migraines twice per month. A September 2015 treatment record indicates nearly weekly migraine headaches. During her November 2015 hearing before the Board, the Veteran testified that the number of migraines she experienced in any given month varied, and that some months she experienced migraines approximately half of the days in each month. The Veteran testified that on occasion she has to lay down when she has headaches and it makes it difficult for her to function and drive. In December 2015, the Veteran reported four migraine headaches per month with two to three days of intense pain. The Veteran reported photosensitivity and nausea. A February 2016 treatment record notes nearly daily headache at the base of her skull. However, migraines are less frequent and resulting from too much sun or changes in the weather. Symptoms include blurry images and pain. In April 2016, the Veteran’s physicians noted she was having three migraine headaches per month. She was told she could not use triptans to treat her migraines. The Veteran was afforded a VA examination in October 2017. The Veteran was diagnosed with migraines with migraine variants. The Veteran reported migraine headaches twice a month. She had to stop gabapentin due to nausea. The Veteran reported experiencing pain on both sides of the head with associated changes in vision and sensitivity to light. The typical head pain would last more than two days and be on the right side of the head. The examiner did not indicate any characteristics of prostrating attacks nor that it was productive of severe economic inadaptability. The examiner noted that headaches impact her work by reducing the Veteran’s ability to focus on mental task. In an Addendum submitted in conjunction with the Veteran’s VA Form 21-8940, the Veteran noted that she struggled with her job as a bus driver because of her severe migraine headaches and the Veteran noted that the migraines interfered with her ability to concentrate on driving and caused her to run through red lights. The Veteran also noted that on the weekends, when working in an administrative capacity, sitting in front of the computer for an hour would cause headaches. The Veteran indicated that she ultimately had to leave her job as a bus driver and as an administrative assistant in part, because of her severe migraine headaches. The Veteran noted that she has a migraine episode four times per month which involves extreme sensitivity to sound and light and noted that these episodes last two to three days. Additionally, she noted that most of the time the migraine headaches are accompanied by nausea and vomiting. The Veteran also stated that she often feels sick during a migraine and cannot eat or drink and all she can do is lay down in the dark in a quiet room and allow it to run its course. The Veteran reported that the pounding in her head is too much for her to be able to fall asleep and further indicated that she takes Tylenol, but it does not mitigate the pain. The Veteran stated that she is completely unable to focus and concentrate during her migraines because of the severe pain they cause. See VA Form 21-8940 Received January 2021. The record contains an employability evaluation by vocational consultant PT which addresses the Veteran’s migraine headache condition. PT reviewed the Veteran’s relevant examinations of record and concluded that the Veteran’s migraines cause severe head pain and result in symptoms such as nausea, vomiting, sensitivity to light and sound and necessitate the need to lie down in a dark, quiet room, which more likely than not would distract the Veteran from work tasks. See Appellate Brief Received January 2021. Affording the Veteran the benefit of the doubt, the preponderance of the evidence described above shows that the Veteran’s migraine headaches warrant a rating of 50 percent during the period on appeal. First, taking into account the Veteran’s detailed statements concerning her migraine headaches as well as PT’s opinion that the Veteran’s headaches were frequent, prostrating, and productive of severe economic inadaptability are persuasive. The Board finds that the Veteran is competent to report observable symptoms to include her headache pain and symptoms thereof. See Layno v. Brown, 6 Vet. App. 465 (1994). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran reported that she has a migraine episode four times per month which last two to three days and most of the time is accompanied by nausea and vomiting. Moreover, the record supports that the Veteran had to ultimately quit her job in part because her migraine headaches interfered with her ability to perform work tasks. The Board emphasizes that the October 2017 examiner noted that the Veteran’s migraine headaches impact the Veteran’s work by reducing the Veteran’s ability to focus on mental task. The record overall demonstrates that the Veteran’s migraine headaches create a great inability to adapt to in the economic marketplace. Notably, the record includes several notations, including the opinion by PT the vocational specialist, which indicate that the Veteran’s migraines cause severe head pain and result in symptoms such as nausea, vomiting, sensitivity to light and sound and necessitate the need to lie down in a dark, quiet room, until the migraines run their course. The lay and medical evidence reflect that the Veteran’s symptoms more nearly approximate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. As such, a 50 percent rating, which is the maximum schedular rating for migraine headaches, is warranted for the Veteran’s migraine headaches for the period on appeal. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. The Veteran asserts that she left full time employment due to complications with her service-connected disabilities. The Veteran asserts that she completed high school and three years of college although she did not earn a degree. She further asserts that she possesses basic computer skills from her job as an administrative assistant. The Veteran noted that her 2012 VA kidney examination documented the need for continuous medication and 10 weeks of absenteeism due to fatigue within a 12 month period. Further, the Veteran noted that during her November 2015 Board hearing, she testified to missing two to three weeks of work due to her kidney condition. Additionally, the Veteran states that the October 2017 VA examiner who evaluated her back and knee disabilities documented pain with prolonged sitting and standing and found that these limitations along with lifting, bending, and twisting affect the Veteran’s ability to work. Additionally, the Veteran asserted that a vocational specialist opined that it is at least as likely as not that the Veteran’s migraine headaches, back, right knee, and kidney conditions preclude the Veteran from securing and following substantially gainful employment in any capacity including sedentary employment from December 2011 to present. See Appellate Brief Received January 2021. Total disability is considered to exist when there is any impairment that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). Total ratings are authorized for any disability or combination of disabilities for which the VA’s Schedule for Rating Disabilities, 38 C.F.R. Part 4, prescribes a 100 percent evaluation. 38 C.F.R. § 3.340 (a)(2). The law also provides that a total disability rating based on individual unemployability due to service-connected disability may be assigned where the veteran is rated at 60 percent or more for a single service-connected disability, or rated at 70 percent for two or more service-connected disabilities and at least one disability is rated at least at 40 percent, and when the disabled person is unable to secure or follow a substantially gainful occupation as a result of the service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). Factors to be considered are the veteran's education and employment history, and loss of work-related functions due to pain. Ferraro v. Derwinski, 1 Vet. App. 326, 330, 332 (1991). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the veteran's advancing age. 38 C.F.R. § 3.341 (a). See also 38 C.F.R. § 4.19 (age may not be a factor in evaluating service-connected disability or unemployability); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Id., at 363. In making its determination, the VA considers such factors as the extent of the service-connected disabilities, employment history, and educational background. 38 C.F.R. §§ 3.321 (b), 3.340, 3.341, 4.16(b), 4.19. The Veteran is currently service-connected for chronic kidney disease, rated 80 percent disabling from December 19, 2011; migraine headaches disorder, rated 50 percent disabling from December 19, 2011; degenerative arthritis and bursitis of the right knee, rated 10 percent disabling from December 19, 2011; mild degenerative disk disease at L5-S1, rated as 10 percent disabling from December 19, 2011; radiculopathy of the Sciatic nerve, right lower extremity, rated 10 percent disabling from April 7, 2016; and hypertension associated with chronic kidney disease, rated as noncompensable from December 19, 2011. The Veteran has been in receipt of a total combined disability rating of at least 90 percent from December 19, 2011. See September 2020 rating decision. Thus, she has satisfied the schedular requirements for a TDIU throughout the appeal period. In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence of record, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154 (a); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The record contains a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability in which the Veteran noted her chronic kidney disease, migraine headaches, degenerative arthritis and bursitis, right knee, radiculopathy, right leg, and hypertension disabilities prevent her from securing or following any substantially gainful occupation. The form states that the Veteran was employed as a bus driver where she worked 40 hours a week from 2006 to September 2011. Additionally, it was noted that the Veteran was employed by the Army Reserves as an administrative assistant from 2003 to 2012 where she worked approximately 20 hours a week. It is further noted that the Veteran completed high school and three years of college. See VA Form 21-8940 Veteran’s Application for Increased Compensation Based on Unemployability Received January 2021. An addendum was provided with the Veteran’s Application for Increased Compensation Based on Unemployability. In the addendum, the Veteran indicated that she has not worked in any capacity since early 2012 when she left her job as a part-time administrative assistant for the Army Reserves. The Veteran stated that the struggles that she endured with her service-connected conditions ultimately caused her to quit her job as an administrative assistant as well as her job as a bus driver which she had until September 2011. See VA Form 21-8940 Addendum. The Veteran stated that when she worked as a bus driver her migraine headaches caused her to have trouble concentrating on driving and resulted in her making errors like accidentally running through red lights. The Veteran noted that standing in formation aggravated her back condition and sitting at a computer all day triggered migraines. The Veteran also noted that she experienced pain and fatigue due to her kidney conditions which affected her jobs. The Veteran further stated that since she stopped working, her kidney condition has gotten much worse. The Veteran stated that she was in severe pain every day and she can’t do anything aside from waiting for it to pass. Moreover, the Veteran stated that when she gets flare ups of pain, she must lay down and use a heating pad on her sides to quell the ache. The Veteran reiterated that she is easily fatigued and exhausted by simple tasks. Additionally, the Veteran stated that the medications for her kidney conditions has worsened her health and had negative effects and as a result, she cannot take certain medications. The Veteran stated that her right knee condition makes it difficult for her to bend down, sit down, and go upstairs. Additionally, the Veteran stated that stooping down also hurts her lower back and so does prolonged sitting. The Veteran asserts that these difficulties are why she left her last place of employment and is unable to secure and follow substantially gainful employment. See VA Form 21-8940 Addendum. The record includes numerous records from the Social Security Administration (SSA). The Veteran’s SSA records describe in detail the symptoms the Veteran experiences as a result of her service-connected disabilities. These symptoms include chronic back pain, fatigue, difficulty with standing, lifting, carrying, handling objects or speaking or traveling. The Veteran reported that her conditions affect lifting, squatting, bending, standing, walking, sitting, kneeling, stair climbing, memory, completing tasks, concentration, getting along with others. The Veteran’s SSA records also indicate that the Veteran’s disabilities, including kidney disease, high blood pressure, and back pain cause limitations and difficulty in daily functioning. These records also note that the Veteran’s work history included employment as: a cashier at a restaurant from July 1996 to September 1996, Desk Help associate at a college from September 1997 to May 1998, Trainee in the US Army from May 1998 to September 1998, Truck stocker at UPS from September 1998 to October 1998, Cashier at Walmart from October 1998 to December 1998, Dog handler from December 1998 to May 1999, Food service worker at a school from April 2000 to May 2002, customer service car rental from November 2002 to September 2003. Other SSA records noted that the Veteran worked in animal care from 1998 to 1999, in the reserves from September 2003 to August 2009, as a stock clerk from 1998 to 1999, at a car rental from 2002 to 2003, and as a bus driver from August 2006 to September 2011. As part of a November 2012 favorable determination for SSA benefits, an administrative law judge determined the Veteran has not engaged in substantial gainful activity since September 1, 2011, and was unable to perform any past work as it exceeds her functional capacity. See SSA Disability Determination Received September 2017. The Veteran’s earnings were $4,818 and $1,181 in 2011 and 2012, respectively. See Social Security Statement of Earnings Received January 2021. With respect to the Veteran’s back and knee disabilities, the July 2012 VA examiner documented that the Veteran experiences less movement than normal on pain on movement. The examiner also documented increased pain with bending over, walking more than 30 minutes, standing for more than an hour. The Board also notes that a December 2012 VA treatment record documented persistent sharp pain, swelling, and bruising in the right knee, as well as swelling with prolonged walking. Additionally, the Board notes that the examiner stated that the Veteran’s knee did not impact her ability to work. The October 2017 VA examiner documented reports of functional loss/functional impairment of the right knee to include pain after prolonged standing. Additionally, the October 2017 examiner noted that the Veteran’s knee condition impacts her ability to work and results in painful prolonged weight bearing pain with direct pressure to the knee. The Veteran was afforded an examination to assess her kidney disorder in October 2017. The examiner stated that the Veteran’s kidney condition did not impact her ability to work. The examiner remarked that the Veteran is well developed, well-nourished and in no acute distress. Additionally, the examiner stated that there are no signs of malaise present and inspection of the chest and lungs was normal. The examiner stated that there was no evidence of tenderness on palpation and breath sounds were symmetric with no rhonchi, rales or wheezes. There examiner noted that there was no edema of the right lower extremity and no edema in the left lower extremity. The Veteran was afforded an examination to assess her migraine headaches condition in October 2017. The examiner noted that the Veteran’s migraine headache condition impacted her ability to work by reducing her ability to focus on mental tasks. Furthermore, as stated in the section above, the Veteran reported to the examiner that she had migraine headaches twice a month and had to stop gabapentin medication due to nausea. During the examination, the Veteran reported experiencing pain on both sides of the head with associated changes in vision and sensitivity to light and it was noted that typical head pain would last more than two days and be on the right side of the head. The record contains an employability evaluation by vocational consultant PT. The record reflects that PT’s credentials include a master’s degree in Industrial and Organizational Psychology and experience as a vocational expert for over 20 years. The record also reflects that PT has been recognized as a Certified Disability Management Specialist and Senior Diplomat of the American Board of Disability Analysts. PT opined that after reviewing the entirety of the Veteran’s claims file, it is at least as likely as not that the Veteran is unable to secure and follow substantially gainful employment from at least December 2011 to the present. PT provided a very thorough report with great specificity regarding how each of the Veteran’s service-connective disabilities directly impact the Veteran’s ability to work. PT highlighted the Veteran’s extensive medical history and the limitations of the Veteran’s service-connected disabilities. She noted that the Veteran’s service-connected degenerative arthritis and bursitis, right knee, and mild degenerative disk disease at L5-SL cause the Veteran to be unable to sit, stand, or walk for any prolonged period of time and further noted that this precludes her from performing the basic physical requirements of even sedentary employment. Further, she highlighted the fact that the Veteran’s chronic kidney disease results in severe pain and fatigue and precludes her ability to concentrate and focus during the day. Moreover, PT pointed out that the Veteran’s migraine headaches occur frequently and cause nausea, vomiting, sensitivity to light and sound, and the Veteran is not able to function until her symptoms subside. It was noted that the Veteran’s headaches preclude her concentration, focus, and ability to sleep. PT stated that these limitation which stem directly from the Veteran’s service-connected disabilities, all cause the Veteran to be unable to remain on task for extended periods and meet employer expectations of adequate pace and productivity on a consistent and reliable basis. The Board places significant weight on the employment evaluation provided by PT who specializes in assessing an individual’s ability to work. PT considered all of the Veteran’s service-connected medical encounters as well as the impact that they have had on the Veteran’s former employment and how the symptoms of each of these disabilities would greatly affect the Veteran’s ability to work going forward. The Board also assigns some probative value to the Veteran’s SSA records which document the severity of the Veteran’s service-connected disabilities and the limitations imposed by those disabilities to include causing difficulty with daily functioning. The Board acknowledges that some of the VA examinations of record give the impression that despite the Veteran’s disabilities, she is able to work; however, the Board finds that collectively these examinations, along with the private vocational assessment and SSA records, demonstrate that the Veteran’s service-connected disabilities prevent the Veteran from being able to obtain and maintain substantially gainful employment, even with respect to sedentary positions. Resolving all doubt in favor of the Veteran the evidence of record supports the Veteran’s contention that she is unemployable due the combined effects of her service-connected disabilities. Accordingly, entitlement to a TDIU is granted throughout the period on appeal. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dorsey-Kwansa, Associate 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.