Citation Nr: 21028200 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-29 956 DATE: May 10, 2021 ORDER Service connection for inactive tuberculosis is granted. Service connection for a low back disorder, to include degenerative joint disease, is denied. Service connection for a neck disorder, to include degenerative joint disease, is denied. An initial compensable rating for a traumatic brain injury (TBI) is denied. An initial rating of 30 percent, but no higher, for headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, his inactive tuberculosis is etiologically related to his active service. 2. A low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and degenerative joint disease did not manifest to a compensable degree within one year of separation from active duty. 3. A neck disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and degenerative joint disease did not manifest to a compensable degree within one year of separation from active duty. 4. The Veteran's TBI has resolved; and the Veteran's current symptomatology is related to his service-connected dementia, not his TBI. 5. Throughout the pendency of the appeal, the Veteran's headaches were manifested by characteristic prostrating attacks occurring on average once a month; the Veteran did not exhibit very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for service connection for inactive tuberculosis have been met. 38 U.S.C. §§ 1101, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.88C. 2. The criteria for service connection for low back disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for service connection for neck disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for an initial compensable rating for a TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124A, Diagnostic Code (DC) 8045. 5. The criteria for an initial 30 percent rating, but no higher, for headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.20, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1952 to October 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in June 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2017, the Board remanded the case for additional development. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for tuberculosis. In the documents of record, the Veteran contends that he is entitled to service connection for tuberculosis. As an initial matter, the Board finds that evidence of record reflects that the Veteran has current diagnoses of inactive tuberculosis. In a December 2018 VA examination, the examiner found that the Veteran had a diagnosis of tuberculosis, and in the related medical opinion, the VA examiner stated that the Veteran has inactive tuberculosis. The Board notes that chronic inactive tuberculosis is a ratable disability under VA regulations. 38 C.F.R. § 4.88C. In the Veteran's service treatment records (STRs), an undated treatment record notes that PPD in the first strength was positive. A June 1, 1954, treatment record notes intermediate PPD that was positive. A June 14, 1954, treatment record reports that a PPD tuberculin skin test was positive in the first strength, and the examiner diagnosed the Veteran with pneumonia. In an April 2003 Radiology Report for the chest, the examiner noted that there was no plain film evidence of tuberculosis. In a September 23, 2011, Radiology Report, the examiner noted that there was no evidence for active tuberculosis. In a September 29, 2011, Addendum, the examiner noted that the Veteran had a new positive PPD, and he would need to be treated for latent tuberculosis. In a Pharmacy E&M Note from the next day, the examiner noted that the Veteran had been diagnosed with latent tuberculosis. At the December 2018 VA examination, the Veteran stated that his tuberculosis had its onset around 1955 with a positive PPD found during active service. He was coughing up blood, and he was hospitalized and treated. The Veteran stated that the condition resolved. The December 2018 VA examiner determined that the Veteran's current inactive tuberculosis was at least as likely than not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that records showed the Veteran had a positive PPD test while on active duty. The VA examiner stated that the current diagnosis of tuberculosis is at least as likely as not a progression of the same condition diagnosed while the Veteran was in active service. Consequently, based on the evidence as described above, the Board finds the evidence is at least in equipoise as to whether the Veteran's tuberculosis is caused by or related to his active service. Therefore, the Board resolves all doubt in his favor and finds that service connection for tuberculosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to service connection for low back disorder, to include degenerative joint disease. 3. Entitlement to service connection for neck disorder, to include degenerative joint disease. In the documents of record, the Veteran contends that he is entitled to service connection for degenerative joint disease (DJD) of the lower back and service connection for DJD of the neck. As an initial matter, the Board finds that evidence of record reflects that the Veteran has current diagnoses of degenerative arthritis in the lower back and the neck. A December 2018 VA examination for the back and a December 2018 VA examination for the neck both found that the Veteran had degenerative arthritis of the spine. The Veteran's STRs are silent for any complaint, diagnosis, or treatment referable to the neck. Concerning the lower back, in a June 1957 treatment note, the Veteran complained of a backache for two weeks, as well as stiffness with resting a while. An examination of the Veteran's back revealed nothing but a slight tenseness of the lumbar musculature, and bending was not limited to a significant degree. X-rays of the lumbosacral spine were considered normal. The Veteran was given hot packs and released back to duty. There is no other complaint, diagnosis, or treatment of any back problems in the evidence of record from the Veteran's active service. Reports of Medical Examination from March 1952, July 1954, and October 1957 showed the Veteran's spine and other musculoskeletal conditions to be normal. In the Report of Medical History from an October 1957 examination, the Veteran reported that he had not experienced swollen or painful joints, arthritis, rheumatism, or any bone, joint, or other deformity. Looking at post-service treatment records for the lower back, in an April 1962 VA Report of Medical Examination for Disability Evaluation, the Veteran reported pain or an ache in the lower back for about a month. The VA examiner found that the back looked normal, and the Veteran had normal back motion, though the back motions pulled his low back at the extremes. A radiographic report from a couple days later showed no evidence of bony disease or injury in the lumbar spine. In an October 2007 VA Neurology Note, the Veteran complained of some lower back pain, and he stated it occurred only when he did not drink enough water. In a VA Primary Care Note from April 2010, the Veteran's wife stated that the Veteran had been having lumbosacral back pain. In a Primary Care E&M Note from the same day, the Veteran reported that he had lower back pain increasingly in the last few months. In an April 2010 Cardiology Consult, the Veteran complained of back pain, and he stated that he was told that tests have shown degenerative changes. In a June 2010 VA Neurology Note, the examiner reported that a May 2010 lumbar spine MRI showed multilevel lumbar spondylosis, central canal stenosis L4/L5, and facet arthropathy. In a November 2010 Primary Care Note, the Veteran's wife stated that the Veteran had lumbosacral back pain; and the Veteran stated that it does not really bother him. The examiner noted that the Veteran's last lumbosacral X-Ray in 1995 showed osteoarthritis of the spine. In an October 2016 VA Neurology Note, the examiner stated that the Veteran had multiple problems with pain, including in his lower back, and the examiner stated that the back pain could have numerous etiologies. At the December 2018 VA examination, the Veteran stated that his back condition had its onset in 1954, and it began with pain during long hours of lifting heavy military equipment. The Veteran reported functional impairments including pain, stiffness, and limited range of motion, as well as difficulty with heavy lifting, bending, climbing stairs, and prolonged standing or walking. The VA examiner determined that the claimed back condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted the June 1957 STR that showed a single complaint of a backache with stiffness after resting a while. The VA examiner also observed that the Veteran's October 1957 separation examination was silent for any complaints of back pain, and determined such meant that the backache was an acute condition that was resolved at the time of separation. The VA examiner found that there is no evidence of complaints of back pain within one year of separation; therefore, there is no evidence to establish a nexus between the single complaint in 1957 and the current back conditions. No other evidence of record from the period on appeal shows a direct causal relationship between the Veteran's DJD of the lower back and his active service. Concerning the Veteran's DJD of the neck, in a May 1961 treatment note, the Veteran presented with tightness and pain in the back of the neck, which he reported had its onset in the middle of April 1961, four years after separation from active service. Examination of the neck revealed full range of motion without any tenderness. The examiner diagnosed the Veteran with posterior neck pain that was probably functional. In an April 1962 VA Report of Medical Examination for Disability Evaluation, the Veteran complained of severe pressure in the back of the head into the neck, as well as pain and numbness in the right arm and leg. In a July 1971 Medical Certificate and History, the Veteran complained of pressure and burning in the back of the neck, and he reported that he had made similar complaints on a number of occasions since 1966. A December 1996 Radiology Report for the cervical spine showed moderate to marked degenerative spondylosis. In a March 2002 VA Physician Emergency Department E&M Note, the Veteran reported that his neck was stiff. The examiner observed that the Veteran was able to touch his chin to his chest, but he had difficulty with lateral flexion. In a May 2003 VA Mental Health Note, the Veteran reported that he had intermittent neck pain. In a November 2010 VA Neurology Note, the examiner found that the Veteran's neck had full range of motion. In an October 2011 treatment note, the Veteran denied any neck pain or stiffness. In a March 2015 VA Neurology Follow-Up Note, the Veteran reported neck pain that occurred upon movement. In a December 2017 Neurology Note, the Veteran reported that he had recently been experiencing neck pain and headaches that had been associated with increased blood pressure. At the December 2018 VA examination, the Veteran stated that his neck condition had its onset in 1954, and it began with pain during long hours of lifting heavy military equipment. The Veteran reported functional impairments including pain, stiffness, limited range of motion, and difficulty with heavy lifting and prolonged bending. The VA examiner determined that the claimed neck condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner observed that there are no medical records from the Veteran's active service showing diagnosis or treatment for a neck condition or any related cervical strain condition or injury while the Veteran was in active service. The Veteran's statements that his neck condition began in 1954 are inconsistent with the other evidence of record, including the treatment records described above where the Veteran reported his neck problem began in the 1960s. Also, as noted earlier, the Veteran's STRs do not indicate that he had complaints or treatment for neck problems during active service. In weighing credibility, the VA may consider inconsistent statements and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498 (1995). Therefore, because the Veteran's statements concerning the onset of his neck condition are not credible, they are not entitled to significant probative weight. No other evidence of record from the period on appeal shows a direct causal relationship between the Veteran's DJD of the neck and his active service. Based on the foregoing, the Board finds the evidence does not show a low back disorder or a neck disorder is causally or etiologically related to any disease, injury, or incident in service. Here, the Board affords great probative weight to the December 2018 VA examiner's opinions with respect to direct service connection. In particular, the examiner contemplated all pertinent evidence of record, to include the statements of the Veteran, his relevant medical history, and pertinent medical literature, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the physician offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Further, the VA physician clearly considered the Veteran's specific case. Thus, service connection for such disorders on a direct basis is not warranted. With regard to presumptive service connection, the record does not show DJD of the back or DJD of the neck manifested to a compensable degree within a year of separation from active service. There is no complaint, diagnosis, or treatment of arthritis in the back or the neck from the year immediately following the Veteran's period of active service. The first evidence of record concerning arthritis of the back is an X-Ray of the spine from July 1995, 38 years after separation from active service, that showed evidence of left sacroiliac joint osteoarthritis. Therefore, presumptive service connection for DJD of the lower back or DJD of the neck is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board has also considered service connection on a secondary basis. Specifically, the Board has considered whether the Veteran's DJD of the lower back and/or DJD of the neck are secondary to his service-connected TBI. In November 2017, the Board observed that, in May 1961, the Veteran was noted to have posterior neck pain, probably functional, and on a VA examination in April 1962, the Veteran reported severe pressure in the back of his head into the neck, as well as bilateral pain and numbness of the right arm and leg. Also, degenerative spondylosis of the cervical spine was noted in December 1996. The Board determined that a VA examination was necessary to determine the current nature of any lumbar and cervical spine disabilities and their relationship to active service or a service-connected disability. At the December 2018 VA examination for the back, the VA examiner determined that the claimed back condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected TBI. The VA examiner also found that the back condition was less likely than not aggravated beyond its natural progression by the Veteran's TBI. The VA examiner stated that there is no pathophysiological relationship between the conditions or any medical records showing such relationship. There is no direct correlation between the Veteran's back condition and having a TBI, as there is no medical physiology to explain such a relationship. At the December 2018 VA examination for the neck, the VA examiner also determined that the claimed neck condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected TBI. The VA examiner also found that the neck condition was less likely than not aggravated beyond its natural progression by the Veteran's TBI. The VA examiner stated that there is no pathophysiological relationship between the conditions or any medical records showing such relationship. There is no direct correlation between the Veteran's neck condition and having a TBI, as there is no medical physiology to explain such a relationship. The Board affords great probative weight to the December 2018 VA examiner's opinions as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez, supra; Stefl, supra. Notably, there is no medical opinion to the contrary. The Board has considered the Veteran's statements that his DJD of the lower back and DJD of the neck are caused by or related to his active service and/or service-connected TBI. However, the Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter as the etiology or cause of his back condition or his neck condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Board finds that the Veteran's assertions as to the etiology of his back condition or his neck condition are not competent evidence and, consequently, are afforded no probative weight. Thus, service connection for a low back disorder, to include DJD, is not warranted on a direct, presumptive, or secondary basis. Additionally, service connection for a neck disorder, to include DJD, is not warranted on a direct, presumptive, or secondary basis. In reaching these conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Ratings 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 veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. 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. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 4. Entitlement to an initial compensable rating for a TBI. The RO granted the Veteran service connection for a traumatic brain injury (TBI) in the June 2013 rating decision at issue with a noncompensable (0 percent) evaluation, effective February 28, 2011. The Veteran contends that he is entitled to a compensable rating for his service-connected TBI. The Veteran's TBI is rated under 38 C.F.R. § 4.124A, DC 8045. DC 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional / behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124A, DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions include goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table. VA is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. VA is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed in 38 C.F.R. § 4.124a, DC 8045, that are reported on an examination, VA is to evaluate under the most appropriate Diagnostic Code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The Board notes that, in this case, the Veteran is currently service-connected for right lower extremity neurological impairment, right upper extremity neurological impairment, left upper extremity neurological impairment, left lower extremity neurological impairment, visual defect, voiding dysfunction (to include recurrent urinary tract infections), chronic constipation, and seizure disorder. Each of these disabilities is associated with subarachnoid hemorrhage as secondary to the TBI. These issues are not presently before the Board in regard to his claim for a higher initial rating for his TBI. The Veteran is also service-connected for headaches associated with subarachnoid hemorrhage as secondary to the TBI, which will be discussed in the next section. The table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" addresses 10 facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." A 100 percent evaluation is assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. The current version of DC 8045 contains the following notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under DC 8045. Turning to the evidence of record in this case, in a February 2003 Mental Health Resident Note, the Veteran presented with a personality change secondary to a TBI. The examiner observed that the Veteran continued to have difficulties with short term memory and paranoia. In a November 2004 VA Mental Health Attending Note, the Veteran was diagnosed with cognitive disorder and status post brain hemorrhage and psychosis due to brain injury. The Veteran's wife noted that he had been doing reasonably well in general, but lately he became paranoid at times. One night, he went out on his own and got lost; and he thought that someone was listening in on his phone calls, and a government agency was involved. In a March 2007 Neurology Consult, the Veteran complained of a cognition problem. The Veteran's wife reported that he had short term memory difficulty. He is unable to find directions or remember new people. He forgets current dates, and he does not remember appointments. He cannot do billing. In a June 2013 VA examination, the Veteran was diagnosed with a TBI. The Veteran reported being in an altercation with a worker he was supervising as part of his active service duties in Korea on July 3, 1955. The Korean worker butted him in the forehead, and the Veteran recalled feeling dazed for a few minutes. He reported that he was seen for this incident by a physician immediately after the event. The Veteran's STRs show he was seen the day after the incident. He indicated that he developed migraine headaches immediately after this event. He later became incapacitated by a headache when he went to a nearby town on leave, but he did not lose consciousness. The June 2013 VA examiner noted that the Veteran was seen at a sub-port at Sondrestrom Air Force Base in Greenland on July 4, 1955, not in Korea. The treatment record from July 4, 1955 indicates a bite by a human on the right side of the face. It notes that the Veteran was bitten while engaging in a fist fight, and he was not performing assigned duties at the time. The VA examiner stated that he found no documented residuals following the July 1955 incident; and there was no evidence of record that he complained at the time of any residual symptoms, including headache, following the altercation. At the June 2013 VA examination, the Veteran stated that he believed the TBI was followed by the onset of headaches. He showed the examiner a healed scar on his forehead that corresponded to his report of where he was butted on the head. The VA examiner reported that the results of a recent neuropsychological evaluation indicated significant impairment of memory, attention, auditory comprehension, and executive functions, including judgment and the ability to establish and maintain cognitive set (i.e., stay on task). There was milder difficulty with expressive language, and memory and cognition were noted to have declined since his last neuropsychological evaluation in March 2007. The June 2013 VA examiner opined that it is unlikely that there is a diagnosis related to the July 1955 in-service incident, and there was no evidence for residual effects of a TBI that in fact occurred following that incident that could be attributed to a TBI. At a June 2013 VA examination for the central nervous system and neuromuscular diseases, the VA examiner reported that the Veteran had a diagnosis of a subarachnoid hemorrhage. The Veteran recounted the incident when he was headbutted in service. He reported that, after that incident, he began to suffer from headaches; and he was eventually sent to a rehabilitation hospital for four months. He continued to have symptoms from his head injury. In 1960, he was diagnosed with a subarachnoid hemorrhage due to an aneurysm as a result of the head injury. He had seizures, and throughout the years, he has had multiple small TIAs. The Veteran had an attention deficit, poor concentration, dementia, impaired short-term memory loss, as well as almost daily headaches, vertigo, or dizziness. He is legally blind. The VA examiner opined that the Veteran's subarachnoid hemorrhage was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that it is evident that his TBI symptoms and their consequential complications and residual effects began at the time of the head injury while on active duty. Thus, it was the examiner's opinion that the subarachnoid hemorrhage was due to the in-service TBI and should be service connected. In the November 2017 Board decision, the Board found that the June 2013 VA examiner did not fully complete the examination form, and medical findings relevant to the rating of the TBI disability were not made. Thus, the Board found that the Veteran must be provided with current examinations to assess the extent of his service-connected TBI. At a December 2018 VA examination for the TBI, the VA examiner reported that the Veteran had a diagnosis of a TBI but found that the TBI had resolved. The Veteran again recounted the incident when he was headbutted during service, and he stated that he has had headaches since then. The Veteran reported that he had a subarachnoid hemorrhage in 1960, and he had a headache for several weeks before that. The Veteran also reported that, in October 2012, he was diagnosed with dementia secondary to head trauma. The December 2018 VA examiner found that the Veteran's TBI symptoms included objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions. The Veteran also included severely impaired judgment. For even routine and familiar decisions, he was usually unable to identify, understand, and weigh alternatives, understand the consequences of choices, and make reasonable decisions. The Veteran's social interaction was occasionally inappropriate. He was often disoriented to two of the four aspects (person, time, place, situation) of orientation. His motor activity was moderately decreased due to apraxia, and his visual spatial orientation was moderately impaired. He usually got lost in unfamiliar surroundings; and he had difficulty reading maps, following directions, and judging distance. He had difficulty using assistive devices such as GPS. The Veteran had an inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time; and he had an inability to comprehend spoken language, written language, or both, at least half of the time but not all of the time. He may rely on gestures or other alternative modes of communication. He was able to communicate basic needs. The Veteran had no subjective symptoms or neurobehavioral effects. His consciousness was normal. The VA examiner found that the Veteran did not have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to TBI. At the December 2018 VA examination and in a related medical opinion, the VA examiner determined that the Veteran's current symptoms are related to the dementia due to multiple etiologies, including the subarachnoid hemorrhage in 1960 and multiple subsequent vascular events (strokes) over the years. The VA examiner stated that, at the time of this examination, the Veteran's TBI had resolved, and there were no symptoms due to the head butt during service. The VA examiner found that the head butt in the 1950s did not cause any TBI, and the dementia symptoms were never related to the headbutt in service. The VA examiner found that all of the Veteran's current symptomatology was related to the Veteran's dementia. The Board notes that the Veteran is service-connected for post-traumatic stress disorder (PTSD) with delusional disorder and dementia with a 100 percent rating, effective February 28, 2011. Based on the foregoing, the Board finds that a compensable rating for the Veteran's TBI is not warranted at any time during the pendency of the appeal. The June 2013 VA examiner found that there was no evidence for residual effects of a TBI that occurred following the reported in-service July 1955 incident that could be attributed to a TBI. As determined by the December 2018 VA examiner, the Veteran's TBI has resolved, and all of the Veteran's current symptomatology is related to his service-connected dementia, not his TBI. There is no additional symptomatology for which to compensate the Veteran related to a TBI. The Veteran's symptomatology is adequately compensated by the currently assigned 100 percent rating for PTSD with delusional disorder and dementia. To assign the Veteran an increased rating for a TBI based on the symptomatology described above would be assigning him additional ratings for the same symptoms for which he is rated for PTSD with delusional disorder and dementia, and this would constitute impermissible pyramiding. Therefore, the Board finds that an initial compensable rating for the Veteran's TBI is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an initial compensable rating for headaches. The RO granted the Veteran service connection for headaches in the June 2013 rating decision at issue with a noncompensable (0 percent) evaluation, effective February 28, 2011. The Veteran contends that he is entitled to a compensable rating for his service-connected headaches. The Veteran's headaches have been rated by analogy to migraines under 38 C.F.R. § 4.124A, DC 8100. See 38 C.F.R. § 4.20. Under DC 8100, a 50 percent disability evaluation is warranted for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent evaluation is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over last several months. A 10 percent evaluation is warranted for headaches with characteristic prostrating attacks averaging one in two months over the last several months. A noncompensable (0 percent) evaluation is warranted for headaches with less frequent attacks than the criteria for a 10 percent rating. See 38 C.F.R. § 4.124a, DC 8100. VA regulations do not define "prostrating," nor has the Court. See Fenderson, supra (in which the Court quotes DC 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, the Board notes that according to Webster's New World Dictionary of American English, Third College Edition (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in Dorland's Illustrated Medical Dictionary 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." Also, the term "productive of severe economic adaptability" has not been clearly defined by regulations. The Court has, however, explained that "productive of" for purposes of DC 8100 can either mean producing, or capable of producing. See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraine headaches need not actually produce severe economic inadaptability to warrant a 50 percent rating under DC 8100. Id. at 445-46. Similarly, "economic inadaptability" does not equate to unemployability, as such would undermine the purpose of regulations pertaining to a TDIU. Id. at 446; see also 38 C.F.R. § 4.16. The Board notes, however, that the migraine headaches must be, at a minimum, capable of producing severe economic inadaptability in order to meet the 50 percent criteria. In a January 2010 VA Nursing Emergency Department Triage Note, the Veteran complained of headaches. In a February 2010 VA Nursing Emergency Department Triage Note, the Veteran complained of pressure in the back of the head for the past two months; the pressure was located in the occipital region of the head. In a VA Physician Emergency Department E&M Note from the same day, the Veteran complained of headaches that were one day in duration with a posterior location; the pain was relieved with two Tylenol. In an October 2011 VA treatment note, the Veteran complained of a mild headache, but he denied any photophobia. In a February 2012 Primary Care Pact RN Telephone Note, the Veteran's wife stated that the Veteran had been complaining of headaches, but the headaches had stopped since she increased his medication dose. In a January 2013 VA PCP Message, the Veteran complained of headaches; the Veteran's wife restarted his medication for the past two weeks, and the headaches resolved. In a December 2017 VA Neurology Note, the Veteran reported that he had recently been experiencing headaches that have been associated with increased blood pressure. The examiner noted that the Veteran had recently developed occipital and cervical headaches that occurred almost every day and were somewhat alleviated by Tylenol. In a May 2018 VA Neurology Note, the examiner reported that the Veteran was previously experiencing frequent occipital headaches, and he was started on gabapentin for headaches. The examiner stated that the Veteran's headaches had now largely resolved. A May 2019 VA Neurology Note indicated that he had been started on gabapentin for headaches, and this led to an improvement in his headaches. He also took Tylenol about once a week for headaches. At a December 2018 VA examination, the VA examiner found that the Veteran experienced headache pain with pulsating or throbbing head pain on both sides of the head. Non-headache symptoms associated with headaches included nausea, sensitivity to light, and sensitivity to sound. The duration of typical head pain was one to two days. The Veteran had characteristic prostrating attacks of migraine or non-migraine headache pain, on average, once a month over the last several months. He did not have very prostrating or prolonged attacks of migraine or non-migraine pain productive of severe economic inadaptability. The Veteran's headache condition impacted his ability to work in that he had difficulty concentrating with intermittent headaches and sensitivity to light and sound. In a related medical opinion, the VA examiner stated that the Veteran had prostrating attacks about once a month lasting one or two days with moderately severe to severe attacks. The Board notes that the Veteran's symptomatology from his service-connected TBI and PTSD with delusional disorder and dementia mentioned in the previous section primarily concerned the mental and cognitive effects of the Veteran's disabilities, whereas the Veteran's headache disability is primarily a physical disability. The Board must ensure that the Veteran is compensated for all of the symptoms associated with his service-connected disabilities. Based on the foregoing, the Board finds that an initial rating of 30 percent, but no higher, is warranted for the Veteran's headaches. In this regard, at the December 2018 VA examination, the VA examiner found that the Veteran has experienced characteristic prostrating attacks occurring on average once a month over the last several months. His headaches have pulsating or throbbing head pain on both sides of the head and are accompanied by nausea and sensitivity to light and sound. Additionally, the December 2017 VA Neurology Note indicated that the Veteran was experiencing headaches almost every day. However, the evidence is against a finding that his headaches more nearly approximate the criteria for a 50 percent rating. Specifically, the rating criteria under DC 8100 look not only to frequency but also to the severity of the headaches. In this regard, even where the Veteran indicated that he was experiencing headaches almost every day, there was no indication of completely prostrating or prolonged attacks productive of severe economic inadaptability, as would be required for a rating in excess of 30 percent. The Board notes that there are no alternative diagnostic codes under which the Veteran's headaches may be analogously rated. See e.g., Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Board further finds that no staged ratings are warranted as the Veteran's disability has been consistent throughout the appeal period. Hart, supra. In reaching the foregoing conclusion, the Board has resolved all doubt in the Veteran's favor, which has resulted in an increased rating of 30 percent for headaches. However, to the extent that a higher rating is denied herein, the Board finds that the preponderance of the evidence is against such aspect of the Veteran's claim. Consequently, the benefit of the doubt doctrine is not applicable in such regard, and the Veteran's claim for a higher rating is otherwise denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3, 4.7. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.