Citation Nr: 21028975 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 09-45 570 DATE: May 12, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for lumbar strain is denied. Entitlement to a disability rating in excess of 20 percent for degenerative disc disease, C5-C7 is denied. Service connection for a bowel/bladder disability, as secondary to a service-connected cervical spine disability, is denied. FINDINGS OF FACT 1. For the period on appeal, the Veteran's lumbar strain did not manifest as limitation of forward flexion to 30 degrees or less, ankylosis, or incapacitating episodes of intervertebral disc syndrome (IVDS). 2. For the period on appeal, the Veteran's degenerative disc disease, C5-C7 did not manifest as limitation of forward flexion to 15 degrees or less, ankylosis, or incapacitating episodes of intervertebral disc syndrome (IVDS). 3. A bowel or bladder disability is not shown to be etiologically related to service-connected degenerative disc disease, C5-C7. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5237 (2020). 2. The criteria for a disability rating in excess of 20 percent for degenerative disc disease, C5-C7 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5242 (2020). 3. A bowel/bladder disability was not caused or aggravated by service-connected degenerative disc disease, C5-C7. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 1973 to January 1993, including service in the Persian Gulf War. These matters are on appeal from a June 2008 rating decision. In a December 2014 decision, the Board remanded the claims to attempt to obtain additional treatment records and to afford the Veteran an additional VA medical opinion. The Agency of Original Jurisdiction (AOJ) has done so. In a March 2016 decision, the Board remanded the claims again to attempt to obtain additional treatment records and to afford the Veteran additional VA examinations. The AOJ has done so. In a January 2017 decision, the Board remanded the claims again to afford the Veteran additional VA examinations and an additional VA medical opinion. The AOJ has done so. In a July 2017 decision, the Board remanded the cervical spine claim for readjudication because the AOJ had considered entitlement to a rating in excess of 20 percent rather than in excess of 10 percent. The AOJ has done so. In a December 2017 decision, the Board remanded the cervical spine claim to attempt to obtain additional treatment records and to afford the Veteran an additional VA examination. The AOJ has done so. In its July 2017 decision, the Board also denied the bowel/bladder and lumbar spine claims. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a Joint Motion for Partial Remand (JMPR), the parties agreed, in pertinent part, to vacate the Board's decision with regard to the denial of an evaluation in excess of 20 percent for the lumbar spine disability and service connection for a bowel/bladder disability as secondary to a service-connected cervical spine disability and remand the case to the Board for additional development. The Veteran abandoned his claim to entitlement to service connection for a bowel/bladder disability on a direct basis and as secondary to his service-connected lumbar spine disability. The JMPR was incorporated by reference in a Court order dated in May 2018. In a February 2019 decision, the Board remanded the bowel/bladder, lumbar spine, and cervical spine claims to afford the Veteran additional VA examinations. The Veteran was afforded VA examinations of his low back, neck, intestines, and urinary tract in September 2019. The VA examinations are adequate with regard to the claims being decided below because they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they describe his low back, neck, intestinal, and urinary symptoms in detail sufficient to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). There was therefore substantial compliance with the remand directives with regard to the issues being decided below. See Stegall v. West, 11 Vet. App. 268 (1998). VA's duty to notify was satisfied by a February 2007 letter. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service medical treatment records, VA medical treatment records, and private medical treatment records have been obtained. The Veteran most recently underwent VA examinations relating to the claims on appeal in September 2019. As stated above, those examinations are adequate. 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 (2020). 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. "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). When entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed. Hart, at 509; see also 38 U.S.C. § 5110(b)(3) (2012); 38 C.F.R. § 3.400(o)(2) (2020). 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 determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. In this case, at least the minimum compensable rating has been in effect during the entire appeal period. Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). 1. Lumbar Strain The Veteran contends that his lumbar strain warrants a rating in excess of 20 percent. It is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, for lumbosacral strain, with a 20 percent rating on and after March 31, 1995. VA received the Veteran's claim for an increased rating on January 29, 2007. Diagnostic Code 5237 provides for rating under the General Rating Formula for Diseases and Injuries of the Spine (General Formula). The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area affected by residuals or injury or disease. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2020). With regard to the thoracolumbar spine, under the General Formula, a 20 percent rating is warranted for forward flexion of greater than 30 degrees but not greater than 60 degrees, a combined range of thoracolumbar motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. Id. A 40 percent rating is warranted for forward flexion of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. Id. at Note (5). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from zero to 90 degrees, extension is from zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are from zero to 30 degrees. Id. at Note (2). 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. Id. In addition, the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes allows for the assignment of rating criteria based on the frequency and extent of incapacitating episodes during the preceding 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). For VA rating purposes, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). During a February 2007 VA treatment appointment, the Veteran reported low back pain with radiating leg pain and that his leg pain was "off the charts." He added that his leg pain was always present but had episodes when it increased. He did not specify whether he was referring to one or both legs. The Veteran was afforded a VA spine examination in April 2007. He reported low back pain that radiated to both hips when intense. He reported that his pain was constant and therefore had no flare ups. He also reported that he had to rest after walking around the block due to pain in his hips. (Service connection has been denied for left and right hip strain and those issues are not before the Board.) He reported that he avoided lifting heavy objects or standing or walking for long periods. On examination, thoracolumbar motion was reported as 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation, with pain at the end of forward flexion. Repetitive forward flexion did not decrease range of motion or spine function. There was no guarding, spasm, or weakness but there was moderate tenderness over the midsection of the lumbar spine. Spine contour and gait were normal. Sensory, motor, and reflex examination were normal. The clinician diagnosed lumbosacral spine strain. During a May 2007 VA treatment appointment, the Veteran reported pain radiating down his left leg. During a July 2007 VA treatment appointment, the Veteran reported severe bilateral lower extremity pain for the past two weeks, radiating from both hips down to the back of his legs. During a December 2008 VA neurosurgery consultation, the Veteran reported occasional tingling down his left leg; neurological examination was normal. During a June 2010 hearing before a Decision Review Officer (DRO), the Veteran reported pain radiating from his back down to his lower extremities. He was unclear as to whether this meant one or both legs, but specifically referred to pain on his left side. The Veteran was afforded an additional VA spine examination in August 2010. The Veteran reported severe weekly flare ups lasting one to two days at a time and that his flare ups decreased his range of motion. However, the clinician made no attempt to quantify the limitation of range of motion that would occur during flare ups. The Court has held that there must be an adequate rationale for declining to provide an opinion with regard to the functional impact of repetitive use over time or flare ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board therefore finds that the August 2010 examination report is inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. However, the Board notes the clinician's observation that the Veteran was able to flex his lumbar spine to 25 degrees more than the range of motion found on examination in order to reach his boots. There were no incapacitating episodes of spine disease. With regard to radiculopathy, the Veteran reported radiating pain to his left hip. Reflexes were normal. Sensory examination was normal. Strength was normal and there was no muscle atrophy. The Veteran was afforded an additional VA examination for back conditions in November 2012. The Veteran reported flare ups and that his flare ups decreased his range of motion. However, the clinician made no attempt to quantify the limitation of range of motion that would occur during flare ups. For the reasons given above, the Board finds that the November 2012 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. However, the Board notes the clinician's observation that the Veteran's range of motion "varied at different times of exam" and that he was "able to flex forward to higher range when not aware." The Veteran did not have IVDS. With regard to radiculopathy, the Veteran reported radiating pain to both hips and intermittent numbness and tingling on the left side of his body lasting a few minutes. Strength was normal and there was no muscle atrophy. Knee reflexes were normal and ankle reflexes were absent bilaterally. Sensory examination was normal. The Veteran reported mild paresthesias and/or dysesthesias and numbness in his left lower extremity and no radicular symptoms in his right lower extremity. The clinician found radiculopathy affecting the left sciatic nerve and characterized it as mild. During an April 2013 VA treatment appointment, the Veteran reported back pain radiating down his legs at times. The Veteran was afforded an additional VA examination for back conditions in June 2016. The clinician expressed an inability to opine as to the impact of repetition over time or flare ups without speculation because the Veteran was not observed under those circumstances. This is an inadequate rationale. The Board therefore finds that the June 2016 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. With regard to radiculopathy, strength was normal and there was no muscle atrophy. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom due to radiculopathy. The Veteran did not have IVDS. In a July 2016 statement, the Veteran reported that his pain medications often "confined [him] to bed rest." However, he did not report that this bed rest was prescribed by a physician and he specifically attributed it to the effects of medication, not IVDS. The Veteran was afforded an additional VA examination for back conditions in March 2017. The Veteran reported that flare ups left him "laid up for three to four days" but did not report that this bed rest was prescribed by a physician. The clinician expressed an inability to opine as to the impact of repetition over time or flare ups without speculation because the Veteran was not observed under those circumstances. This is an inadequate rationale. The Board therefore finds that the March 2017 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. With regard to radiculopathy, strength was normal and there was no muscle atrophy. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom due to radiculopathy. The Veteran had IVDS but there were no incapacitating episodes as defined above within the past 12 months. During an October 2018 VA treatment appointment, the Veteran reported low back pain radiating down both legs. The Veteran was afforded an additional VA examination for back conditions in September 2019. The Veteran reported no active issues, including radiculopathy. He did not report flare ups or functional loss or impairment. On examination, thoracolumbar motion was reported as normal, with no pain noted. There was no objective evidence of localized tenderness or pain on palpation. There was no evidence of pain with weight bearing. Range of motion was the same on repetition. The clinician found that repetition over time or flare ups would not significantly limit functional ability. There was no guarding or muscle spasm. There were no additional factors contributing to disability. Strength was normal. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom of radiculopathy. There was no ankylosis. There were no other neurologic abnormalities. The Veteran did not have IVDS. The Veteran did not report using any assistive devices. The clinician found that the Veteran's low back disability would have no impact on his ability to work. There was no objective evidence of pain on non-weight bearing or on passive range of motion testing and passive range of motion was the same as active range of motion. The preponderance of the evidence described above does not show that the Veteran's lumbar strain warrants a rating in excess of 20 percent. Of the two VA examinations that were adequate with regard to range of motion during the period on appeal, both found normal forward flexion. Given the existence of a range of thoracolumbar motion, the preponderance of the evidence is against a finding that the Veteran has ankylosis of the thoracolumbar spine as defined above. "Ankylosis" is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 92 (33rd ed. 2020). In addition, no examiner or treatment provider has found ankylosis of the thoracolumbar spine and the Veteran's symptoms are not analogous to ankylosis of the thoracolumbar spine as defined above. The Board has additionally considered whether a higher rating is warranted under the formula for rating IVDS based on incapacitating episodes. There is no evidence of incapacitating episodes as defined above having a duration of at least four weeks in twelve months during the period on appeal. For this reason, a rating in excess of 20 percent based on incapacitating episodes caused by IVDS is not warranted. The Board therefore finds that there are no other potentially applicable Diagnostic Codes by which higher ratings can be assigned. The Board has considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his low back disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, nothing in the Veteran's lay statements provides a basis for assigning a higher rating because the Veteran does not report that the predominant state of his thoracolumbar motion is 30 degrees or less of forward flexion or ankylosis of the thoracolumbar spine. In addition, the Board notes that two VA examiners observed the Veteran's actual range of forward flexion when not being examined to be greater than that found on examination. During the most recent VA examination, the Veteran reported no symptoms or functional impairment. In addition, the Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. There is nothing to indicate that the Veteran's pain causes functional impairment equivalent to forward flexion limited to 30 degrees or less or ankylosis of the entire thoracolumbar spine. Any associated objective neurologic abnormalities caused by the Veteran's low back disability, including, but not limited to, bowel or bladder impairment are to be evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a at Note (1). The Board will discuss the Veteran's contentions with regard to bowel or bladder impairment below. The Veteran has frequently reported pain in one or both of his legs, but only one examiner or treatment provider in the 14 years on appeal found radiculopathy in the left lower extremity; that finding is therefore an outlier and it is more likely than not that the other findings more accurately reflect the functioning of the Veteran's left lower extremity. No examiner or treatment provider during the period on appeal has found right lower extremity radiculopathy. During the most recent VA examination, the Veteran reported no radicular symptoms at all. Particularly given multiple examiners' findings that the Veteran's reported symptoms are more severe than his actual functioning reflects, the Board finds that the examiners' and treatment providers' findings are of greater probative value with regard to radiculopathy than the Veteran's lay assertions. 2. Degenerative Disc Disease, C5-C7 The Veteran contends that his degenerative disc disease, C5-C7 warrants a rating in excess of 20 percent. It is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242, for degenerative arthritis of the spine, with a 10 percent rating from August 23, 2004 to January 28, 2007 and a 20 percent rating on and after January 29, 2007. VA received the Veteran's claim for an increased rating on January 29, 2007. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that are more favorable to the Veteran will be applied. Prior to the amendment, Diagnostic Code 5242 provided for rating under the General Formula or under 38 C.F.R. § 4.71a, Diagnostic Code 5003 for degenerative arthritis. After the amendment, Diagnostic Code 5242 provides for rating under the General Formula, Diagnostic Code 5003, or 38 C.F.R. § 4.71a, Diagnostic Code 5010 for traumatic arthritis. As Diagnostic Code 5003, before or after the amendment, provides for a compensable rating only if one is not available under the General Formula, it is not applicable to this case. Prior to the amendment, Diagnostic Code 5010 provided for rating as degenerative arthritis under Diagnostic Code 5003. After the amendment, Diagnostic Code 5010 provides for rating as limitation of motion, dislocation, or other specified instability under the affected joint. As the Veteran's cervical spine disability is already rated based on compensable limitation of motion throughout the period on appeal, further discussion of Diagnostic Code 5010 under the prior or amended criteria is not warranted. With regard to the cervical spine, under the General Formula, a 20 percent rating is warranted for forward flexion of greater than 15 degrees but not greater than 30 degrees, a combined range of cervical motion not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. Id. A 30 percent rating is warranted for forward flexion of 15 degrees or less or favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. Id. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. Id. at Note (5). For VA compensation purposes, normal forward flexion of the cervical spine is from zero to 45 degrees, extension is from zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are from zero to 80 degrees. Id. at Note (2). 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 cervical spine is 340 degrees. Id. During a February 2007 VA treatment appointment, the Veteran reported right arm numbness and weakness. The treatment provider noted moderate compromise of bilateral neural foramina. The Veteran was afforded a VA spine examination in April 2007. He reported neck pain that radiated to the left upper extremity, with numbness and wasting of muscle mass and strength as well as decreased strength of the right upper extremity. He reported that his pain was constant and therefore had no flare ups. He also reported that he had to rest after walking around the block due to pain in his left shoulder. (Service connection has been separately granted for left shoulder tendonitis and its rating is not before the Board.) He reported that he avoided lifting heavy objects or standing or walking for long periods. On examination, thoracolumbar motion was reported as 35 degrees of forward flexion, 35 degrees of extension, 10 degrees of left and right lateral flexion, and 45 degrees of left and right lateral rotation, with pain at the end of all ranges of motion. Repetitive head rotations did not decrease range of motion or spine function. There was weakness and guarding but no spasm. There was tenderness. There was mild cervical kyphosis. There was wasting of the muscles of the left arm, not the forearm or hand, but strength was good, equal, and symmetric on both upper extremities. Sensory, motor, and reflex examination were normal. The clinician diagnosed degenerative disc disease and degenerative joint disease of the cervical spine with spinal stenosis, both central and foraminal, with loss of muscle mass on the left arm. During an August 2008 VA treatment appointment, the Veteran reported numbness in both hands. During a December 2008 VA neurosurgery consultation, the Veteran reported occasional tingling in the middle fingers of his left hand; neurological examination was normal. During a June 2010 hearing before a DRO, the Veteran reported pain radiating into his left arm and that he had "no strength there," that he didn't "have an arm anymore" and had "lost everything on [his] left side." He added that the pain "will carry" over into his right side "and work to these three fingers," which would tingle. The Veteran was afforded an additional VA spine examination in August 2010. The Veteran reported severe weekly flare ups lasting one to two days at a time and that his flare ups decreased his range of motion. However, the clinician made no attempt to quantify the limitation of range of motion that would occur during flare ups. The Court has held that there must be an adequate rationale for declining to provide an opinion with regard to the functional impact of repetitive use over time or flare ups. Sharp, 29 Vet. App. 26. The Board therefore finds that the August 2010 examination report is inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. There were no incapacitating episodes of spine disease. With regard to radiculopathy, the Veteran reported tingling in his left hand and radiating pain in his left arm. Reflexes were normal. Sensory examination was normal. Strength was normal and there was no muscle atrophy. The Veteran was afforded an additional VA examination for neck conditions in November 2012. The Veteran reported flare ups and that his flare ups decreased his range of motion. However, the clinician made no attempt to quantify the limitation of range of motion that would occur during flare ups. For the reasons given above, the Board finds that the November 2012 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. The Veteran did not have IVDS. With regard to radiculopathy, the Veteran reported pain radiating toward his left shoulder and occasional numbness and tingling in his left upper extremity. Strength was normal and there was no muscle atrophy. Reflexes were normal. Sensory examination was normal. The Veteran reported mild paresthesias and/or dysesthesias and numbness in his left upper extremity and no radicular symptoms in his right upper extremity. The clinician found radiculopathy affecting the left middle and lower radicular groups and characterized it as mild. The Veteran was afforded an additional VA examination for neck conditions in June 2016. The clinician expressed an inability to opine as to the impact of repetition over time or flare ups without speculation because the Veteran was not observed under those circumstances. This is an inadequate rationale. The Board therefore finds that the June 2016 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. With regard to radiculopathy, strength was normal and there was no muscle atrophy. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom due to radiculopathy. The Veteran did not have IVDS. He is right-handed. In a July 2016 statement, the Veteran reported that his pain medications often "confined [him] to bed rest." However, he did not report that this bed rest was prescribed by a physician and he specifically attributed it to the effects of medication, not IVDS. The Veteran was afforded an additional VA examination for neck conditions in March 2017. The Veteran reported flare ups approximately every day. The clinician expressed an inability to opine as to the impact of repetition over time or flare ups without speculation because the Veteran was not observed under those circumstances. This is an inadequate rationale. The Board therefore finds that the March 2017 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. With regard to radiculopathy, strength was normal and there was no muscle atrophy. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom due to radiculopathy. The Veteran had IVDS but there were no incapacitating episodes as defined above within the past 12 months. The Veteran was afforded an additional VA examination for neck conditions in January 2018. The Veteran reported flare ups that meant he "cannot function well" and that, during his most recent flare up, he could not move his neck. The clinician expressed an inability to opine as to the impact of repetition over time or flare ups without speculation because there is "no conceptual or empirical basis for making such a determination without directly observing function under these conditions." This is the specific rationale the Court rejected as inadequate in Sharp. The Board therefore finds that the January 2018 examination report is also inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. With regard to radiculopathy, the Veteran reported intermittent pressure pain with numbness and tingling radiating to both shoulders depending on position. Strength was normal and there was no muscle atrophy. Bicep and tricep reflexes were decreased bilaterally and brachioradialis reflexes were normal. Sensory examination was normal. The Veteran reported mild constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness bilaterally. The clinician found radiculopathy affecting both middle radicular groups and characterized it as mild. The Veteran did not have IVDS. During an October 2018 VA treatment appointment, the Veteran reported pain radiating down his left arm. The Veteran was afforded an additional VA examination for neck conditions in September 2019. The Veteran denied any cervical radiculopathy symptoms. He did not report flare ups or functional loss or impairment. On examination, cervical motion was reported as normal, with no pain noted. There was no objective evidence of localized tenderness or pain on palpation. There was no evidence of pain with weight bearing. Range of motion was the same on repetition. The clinician found that repetition over time would significantly limit functional ability but, given the other examination findings and the fact that the clinician marked "N/A" for the factors causing this loss and the reason for not describing it in terms of range of motion, the Board finds that this is likely a typographical error. The clinician found that flare ups would not significantly limit functional ability. There was no guarding or muscle spasm. There were no additional factors contributing to disability. Strength was normal. Reflexes were normal. Sensory examination was normal. There was no radicular pain or any other sign or symptom of radiculopathy. There was no ankylosis. There were no other neurologic abnormalities. The Veteran did not have IVDS. The Veteran did not report using any assistive devices. The clinician found that the Veteran's cervical spine disability would have no impact on his ability to work. There was no objective evidence of pain on non-weight bearing or on passive range of motion testing and passive range of motion was the same as active range of motion. The preponderance of the evidence described above does not show that the Veteran's degenerative disc disease, C5-C7 warrants a rating in excess of 20 percent. Of the two VA examinations that were adequate with regard to range of motion during the period on appeal, neither found forward flexion of less than 35 degrees; the most recent found normal forward flexion. A 30 percent rating requires forward flexion to be limited to 15 degrees or less. Given the existence of a range of thoracolumbar motion, the preponderance of the evidence is against a finding that the Veteran has ankylosis of the thoracolumbar spine as defined above. "Ankylosis" is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 92 (33rd ed. 2020). In addition, no examiner or treatment provider has found ankylosis of the cervical spine and the Veteran's symptoms are not analogous to ankylosis of the cervical spine as defined above. The Board has additionally considered whether a higher rating is warranted under the formula for rating IVDS based on incapacitating episodes. There is no evidence of incapacitating episodes as defined above having a duration of at least four weeks in twelve months during the period on appeal. For this reason, a rating in excess of 20 percent based on incapacitating episodes caused by IVDS is not warranted. The Board therefore finds that there are no other potentially applicable Diagnostic Codes by which higher ratings can be assigned. The Board has considered the Veteran's lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his cervical spine disability. See Jandreau, 492 F.3d at 1376-77. However, nothing in the Veteran's lay statements provides a basis for assigning a higher rating because the Veteran does not report that the predominant state of his cervical motion is 15 degrees or less of forward flexion or ankylosis of the cervical spine. In addition, the Board notes that two VA examiners observed with regard to the Veteran's thoracolumbar spine that the Veteran's actual range of forward flexion when not being examined was greater than that found on examination. During the most recent VA examination, the Veteran reported no symptoms or functional impairment. In addition, the Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. There is nothing to indicate that the Veteran's pain causes functional impairment equivalent to forward flexion limited to 15 degrees or less or ankylosis of the entire cervical spine. Any associated objective neurologic abnormalities caused by the Veteran's low back disability, including, but not limited to, bowel or bladder impairment are to be evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a at Note (1). The Board will discuss the Veteran's contentions with regard to bowel or bladder impairment below. The Veteran already has separate ratings for radiculopathy of the left upper extremity, rated 20 percent disabling on and after January 29, 2007, and for radiculopathy of the right upper extremity, rated 20 percent disabling on and after January 29, 2018. These ratings are under 38 C.F.R. § 4.124a, Diagnostic Code 8511. A 20 percent rating under Diagnostic Code 8511 contemplates mild incomplete paralysis of the middle radicular group. The Veteran submitted a Notice of Disagreement (NOD) with regard to each rating and the AOJ issued a Statement of the Case (SOC) with regard to each. The Veteran did not submit a substantive appeal with regard to either rating and the time for appeal has now expired. However, the Board retains jurisdiction to address the ratings for radiculopathy as part of the cervical spine appeal. Chavis v. McDonough, 2021 U.S. App. Vet Claims LEXIS 660 (Apr. 16, 2021). The Veteran has frequently reported symptoms in one or both of his upper extremities, but only two examiners or treatment providers in the 14 years on appeal found radiculopathy. The August 2010 VA examiner found mild radiculopathy in the left upper extremity and the January 2018 VA examiner found mild radiculopathy in both upper extremities. These findings are reflected in the current ratings and effective dates. No examiner or treatment provider during the period on appeal has found upper extremity radiculopathy that is of more than mild severity. The Board notes the April 2007 VA examiner's finding of left upper extremity muscle wasting, but all other examiners have found no muscle atrophy. That finding from the very beginning of the period on appeal is therefore an outlier and it is more likely than not that the other findings more accurately reflect the functioning of the Veteran's left upper extremity. The Board also notes the Veteran's June 2010 statements to the effect that he had effectively lost all function in his left arm but, particularly given multiple examiners' findings with regard to other disabilities that the Veteran's reported symptoms are more severe than his actual functioning reflects, the Board finds that the examiners' and treatment providers' findings are of greater probative value with regard to radiculopathy than the Veteran's lay assertions. During the most recent VA examination, the Veteran reported no radicular symptoms at all. The Veteran is service-connected for left upper extremity radiculopathy throughout the period on appeal and for right upper extremity radiculopathy on and after the date of the January 2018 VA examination. There is nothing in the findings of the examiners or treatment providers to warrant characterizing the Veteran's radiculopathy as of more than mild severity and, for the reasons stated above, the Board finds that the examiners' and treatment providers' findings are of greater probative value than the Veteran's lay assertions. Those findings do not include right upper extremity radiculopathy prior to the January 2018 VA examination. January 29, 2018 is the earliest date that there was evidence of right upper extremity radiculopathy, and there is no information contained in the examination report to provide a different effective date. No revision to either rating is warranted at this time. The January 2018 examiner described the overall severity of the radiculopathy as mild, the reported manifestations were mild, strength and sensory examinations were normal, and some reflexes were decreased. The November 2012 examiner described the overall severity of the radiculopathy as mild, the reported manifestations were mild, and strength, reflexes, and sensory examination were normal. This disability picture is best characterized as mild. There is no other probative evidence of additional neurologic abnormalities caused by the Veteran's cervical spine disability. 3. Bowel/Bladder As stated above, in the May 2018 JMPR to the Court, the Veteran agreed to abandon his claim to entitlement to service connection on a direct basis and as secondary to his service-connected lumbar spine disability. The Board will therefore not address those theories of service connection and will focus its analysis on the Veteran's remaining contention, that his bowel/bladder disability is secondary to his service-connected cervical spine disability. Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). During an October 2006 VA treatment appointment, the Veteran reported waking three to five times a night to urinate. During an April 2007 VA examination for spine conditions, the Veteran reported waking to urinate four to five times a night for the past couple of years. During a June 2010 hearing before a DRO, the Veteran reported bowel symptoms, but was referring to hernias and hemorrhoids. Service connection has been granted for hemorrhoids and denied for a right hernia; those claims are not currently before the Board. During an August 2010 VA examination for spine conditions, the only bowel or bladder symptom the Veteran reported was waking four times per night to urinate. During an April 2013 VA treatment appointment, the Veteran denied any loss of bowel or bladder control. The Veteran was afforded a VA medical opinion in April 2015. The clinician opined that it was less likely than not that the Veteran's urinary frequency was proximately due to or the result of his service-connected spinal condition but did not provide an opinion with regard to whether it had been aggravated by the service-connected spinal condition. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). This opinion is therefore inadequate and of no probative value; it will play no role in the Board's analysis. In a May 2015 statement, the Veteran contended that he had taken "over 40 years of medications" and that "something was bound to happen." He did not specify which of these medications were for service-connected conditions, let alone for his service-connected cervical spine disability, and did not identify any specific medication or even type of medication as a possible cause or aggravating factor for his nocturnal urination. "[...i]n the absence of any medical evidence, [the Veteran's] own conclusory statements regarding causation were insufficient to establish the necessary nexus between his in-service [disability] and his present ailments." Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). Conclusory, generalized statements are not enough to entitle a veteran to an examination under 38 U.S.C. § 5103A(d)(1)(B), "...[s]ince all veterans could make such a statement, this theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran's disability case. If Congress had intended that requirement, presumably it would have explicitly so provided." Id. Although no VA examiner has addressed this theory of service connection, the Board finds that the Veteran's contention regarding medication is too vague and speculative to entitle him to a medical opinion regarding it. The Veteran was afforded a VA examination for male reproductive system conditions in June 2016. The Veteran reported awakening to urinate three to five times a night and denied incontinence of urine or bowels. The clinician diagnosed benign prostatic hypertrophy (BPH). The clinician opined that it was less likely than not that the Veteran's urinary tract condition had been caused by a cervical spine disability because what he had was BPH, not a urinary tract condition. The clinician also opined that aggravation was less likely than not because the Veteran's BPH had "followed the usual, typical course of such a condition" and there was therefore no aggravation. The Veteran was afforded an addendum opinion by the June 2016 VA examiner in February 2017. The clinician opined that it was less likely than not that the Veteran's BPH had been caused by any of his service-connected conditions but did not provide an opinion with regard to aggravation. This opinion is therefore also inadequate and of no probative value; it will play no role in the Board's analysis. The Veteran was afforded a VA examination for intestinal conditions in September 2019. The Veteran reported occasional issues with constipation alternating with rare diarrhea. There was no diagnosis. He was also afforded a VA examination by the same examiner on the same day for urinary tract conditions. The Veteran reported nocturia three to five times a night since 2005 and that he had never been diagnosed with BPH. He denied any urinary incontinence. There was no diagnosis. The clinician opined that it was less likely than not that the Veteran's service-connected cervical spine disability had caused his bowel or bladder symptoms because he did not have an established bowel or bladder condition. The clinician further opined that it was less likely than not that the Veteran's service-connected cervical spine disability had aggravated his bowel or bladder symptoms because "cervical disc disease rarely causes bowel or bladder condition since it would have to be severe enough to cause other neurological deficits, including death." The Veteran is competent to report on matters observed or within his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in this case he is not competent to provide an etiology opinion for his urinary or bowel symptoms. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not shown to possess any pertinent medical training or expertise that would make him competent to render an opinion on the etiology of any current nocturia, constipation, or diarrhea or to express an opinion about when his symptoms first warranted any medical diagnosis. Jandreau, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide a medical diagnosis). Thus, the Veteran's opinion that his current nocturia is etiologically related to his cervical spine disability is not a competent medical opinion and it cannot be assigned any probative weight. Rather, the medical findings and opinions of trained medical professionals warrant greater probative weight than the Veteran's lay contentions. The Veteran has also never contended that his bowel symptoms are caused or aggravated by his service-connected cervical spine disability. The September 2019 VA examiner's opinion contains a highly persuasive rationale, that cervical disc disease sufficient to cause or aggravate a bowel or bladder condition would be fatal, and is unfavorable to the Veteran's claim. The record contains no evidence to the contrary other than the Veteran's contentions, discussed above. Because the preponderance of the evidence is thus against finding that the Veteran's bowel or bladder disability are etiologically related to his service-connected cervical spine disability, entitlement to service connection for a bowel or bladder disability is denied. Lastly, the Board notes that the Veteran has been in receipt of a total rating based upon individual unemployability (TDIU) due to service-connected disability since July 11, 2013, which is the date that he reported last working full time. Prior to that date, he worked as a mechanic and earned an income in excess of the poverty threshold for one person. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ryan Frank, 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.