Citation Nr: 21029035 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-19 494 DATE: May 12, 2021 ORDER Entitlement to service connection for chronic residuals of a traumatic brain injury (TBI) is denied. Entitlement to an initial rating in excess of 40 percent for service-connected lumbar spine disability is denied. Entitlement to an initial rating in excess of 10 percent for service-connected cervical spine disability prior to October 15, 2019 is denied. Entitlement to a rating in excess of 20 percent for service-connected cervical spine disability since October 15, 2019 is denied. REMAND Entitlement to service connection for a headache disability as secondary to service-connected disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has chronic residuals from an in-service TBI. 2. At no time during the appeal period, has the Veteran's lumbar spine disability been manifested by unfavorable ankylosis of the entire thoracolumbar spine. 3. Prior to October 15, 2019, the Veteran's cervical spine disability was not manifested by limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees; the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 4. Since October 15, 2019, the Veteran's cervical spine disability since October 15, 2019, the Veteran's cervical spine disability has not been manifested by limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine CONCLUSIONS OF LAW 1. The criteria for service connection for chronic residuals of a TBI are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 40 percent for service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 3. Prior to October 15, 2019, the criteria for a rating in excess of 10 percent for service-connected cervical spine disability was not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 4. Since October 15, 2019, the criteria for a rating in excess of 20 percent for service-connected cervical spine disability has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from August 1975 to August 1978. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in April 2018. In July 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing. A transcript of that hearing is of record. Service Connection 1. Entitlement to service connection for residual disability from a TBI The Veteran contends that he has residual disability due to a head trauma during service. Specifically, in a statement received in November 2008, he noted that during his tour of duty at Camp Lejeune, he was temporarily assigned to the boxing team (SMOKERS) and received multiple blows to his head and was knocked unconscious several times. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's service treatment records are negative for any complaints or findings of a head injury or headaches. VA treatment records indicate that the Veteran was hospitalized from September 27, 1993 to October 8, 1993, for psychiatric issues. The Veteran reported that after graduating high school, he joined the Marine Corps where he was employed in the warehousing area until he joined the boxing team. His remaining service was spent boxing; he denied ever having a head injury and being knocked out or losing consciousness. At that time, the Veteran had no medical problems to report. Private treatment records indicate the Veteran was seen at the emergency room in January 2004 for psychiatric complaints at which time he denied any somatic complaints, specifically he denied any headache. The Veteran underwent VA examination in November 2011 at which time he reported that he played football and participated in boxing during his military service and that he was treated for significant neck and head injury while playing football and was treated at the local hospital. The Veteran stated that he had many head injuries related to his in-service boxing. The Veteran also stated that he did not remember if he lost consciousness but indicated that multiple times during his boxing career, he became disoriented for approximately 10 seconds. The Veteran also noted that he developed headaches after these incidents, that he had severe head pain at one point in the early 1980s, and that apparently had a CAT scan done. The Veteran reported that he his current headaches occurred on a monthly basis and were sometimes tension-type headaches and at other times seemed more throbbing, severe, and migrainous in nature. He denied ever being evaluated for the headaches. After examination of the Veteran, the examiner found that the Veteran had headaches attributable to a traumatic brain injury (TBI). A VA September 2012 admission history and physician examination indicates that the Veteran denied a history of physical trauma/head injury. A Discharge Summary for a psychiatric hospitalization in April 2014 indicates that the Veteran denied a history of head trauma. At his July 2017 Board hearing, the Veteran testified that he fell off of a truck at Camp Lejeune, that he slipped in the rain and fell and hit his head on the loading dock. The Veteran also testified that he was on the boxing team, that he had eight fights, and that he got knocked out maybe three times. The Veteran underwent VA examination in October 2019 at which time he reported that he had been knocked out twice (for seconds each time) during a match, was out and on the ropes, and the fight was stopped. The Veteran reported that he was out for seconds each time, had knee weakness, and experienced alteration of consciousness each time like a numbness/fogginess. The Veteran stated that he could still hear, but it was surreal. The Veteran reported that the sensation lasted a day or two after each time and that his headaches started around this time (1977-1978). The Veteran denied being evaluated for headaches in service; and he noted that he treated with Excedrin approximately twice a month. The examiner found that the Veteran had never had a TBI and noted that service treatment records were silent for complaints of headaches or TBI. The examiner noted that the November 2011 VA examination did show a diagnosis of TBI, that the Veteran played football and was a boxer during his military career, that he reported one significant neck and head injury while playing football, that he reported that during boxing matches he would lose orientation for approximately 10 secondary on multiple occasions but could not recall being knocked out, and that he reported that he developed headaches in the early 1980s. The examiner reported that on examination that day, the Veteran reported two instances while boxing in which he was knocked out for approximately 10 to 20 seconds which could be consistent with a mild TBI and that the typical pattern of symptoms is gradual improvement to resolution over a period of a few days to weeks. The examiner noted, however, that the Veteran's reported worsening of his headaches and memory problems were not typical for a mild head injury, that the service treatment records did not contain any mention of treatment for boxing-related head injuries, that there was no objective evidence in the treatment records of a headache disorder, and that there was no consistency in the treatment records with regard to a TBI as some mental health notes reported no head injury while others reported boxing injuries. The examiner noted that without some objective evidence in the service treatment records, it was difficult to establish that there was a mild TBI. The examiner concluded that regardless, his complaints of worsening of memory were not consistent with a mild TBI. The examiner found that it was more likely than not that his memory complaints and neuropsychological complaints were due to concurrent substance abuse and psychiatric disorder and that it was less likely than not that he incurred a TBI with residual headaches that was incurred in service. Assuming that the Veteran did suffer head injuries in service, the Board finds his statements as to experiencing headaches during and continuing since service to lack credibility. The Veteran's service treatment records, as well as his post-service treatment records dated for many years following service, contain no complaints or findings of headaches. The Veteran sought treatment for numerous conditions both in service and after service, but made no mention of headaches. Of note, in giving his medical history for the purpose of VA hospitalization in September 1993, he reported prostatitis but not a headache condition. It strains credibility that the Veteran would seek treatment for numerous conditions during service and for many years thereafter, but not report headaches, to include when providing his medical history for the purpose of treatment. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference, and the courts have provided guidance for weighing medical evidence. They have held, for example, that an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Further, a post-service reference to injuries sustained in service, without a review of service treatment records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The November 2011 VA examiner specifically noted that the Veteran's claims file was not available. In addition, the examiner did not have access to the Veteran's VA treatment records except for those between October 2004 and October 2007, none of which noted headaches. As such, it appears that the VA examiner based the opinion on the Veteran's reports. As such, the Board cannot find the November 2011 VA examiner's opinion probative. In contrast, the October 2019 VA examiner's opinion was rendered after a review of the claims file, the Veteran's VA treatment records, and the Veteran's statements. As such, the Board finds the October 2019 VA examiner's opinion probative with respect to the issue as to whether the Veteran had a TBI during service with subsequent residuals because the opinion was based on an accurate medical history and provided an explanation that contained clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board gives more probative weight to the October 2019 VA examiner's opinion. The Board notes that there is conflicting evidence concerning an in-service head injury. In the May 2021 informal hearing presentation, the Veteran's representative questioned the validity of the October 2019 VA examiner's opinion on the basis that the examiner "was under the misapprehension that anything approaching the modern concussion protocol existed at the time as well as not recognizing that not all concussions involve unconsciousness." The representative referenced an article in support of his assertion. However, the October 2019 VA examiner, while noting that inconsistencies and a lack of objective evidence in the service treatment records made it difficult to establish that there was TBI, stated that regardless, the Veteran's reported worsening of his headaches and memory problems were not typical for a mild head injury. Thus, for the purpose of providing the opinion to examiner conceded an in-service head injury, but found that the Veteran's reports of worsening headaches and memory problems were not consistent with residuals of a TBI. The examiner concluded that it was more likely than not that the Veteran's memory complaints and neuropsychological complaints were due to concurrent substance abuse and psychiatric disorder and that it was less likely than not that he incurred a TBI with residual headaches that was incurred in service. Although the Veteran believes he has residual disability related to a TBI during service, in this case, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex as it requires specialized medical knowledge. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the October 2019 VA examiner's opinion. Accordingly, the Board concludes that the preponderance of the evidence is against finding that the Veteran has chronic residuals of a TBI that began during active service, or is otherwise related to an in-service injury, event, or disease. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignments of disability ratings following awards of service connection for the Veteran's lumbar spine and cervical spine disabilities. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's cervical and lumbar spine disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 for cervical and lumbosacral strain. The Board notes that 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. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Diagnostic Code 5237 was not amended; therefore, the rating criteria prior to February 7, 2021 remains. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). 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."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 2. Entitlement to an initial rating in excess of 40 percent for service-connected low back (lumbar spine) disability The Veteran contends that he is entitled to a higher rating for his service-connected lumbar spine disability. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. [Include any other relevant Note(s).] The Veteran underwent VA examination in November 2011 at which time he reported constant pain exacerbated by trunk range of motion, standing, walking, lifting/carrying, and prolonged sitting. Physical examination demonstrated flexion to 25 degrees, extension, lateral flexion, and lateral rotation all to 30 degrees; and there was no additional loss of motion on repetitive testing. The examiner noted that that there was less movement than normal, weakened movement, pain on movement, disturbance of locomotion, and interference with sitting, standing and/or weightbearing. Muscle spasm resulted in abnormal gait and abnormal spinal contour. Muscle strength testing was normal except for left knee extension which was slightly diminished. There was no muscle atrophy. Reflex and sensory examinations were normal, and straight leg raising was negative. The examiner noted that the Veteran did not have radicular pain, any signs or symptoms due to radiculopathy, or intervertebral disc syndrome (IVDS). X-rays revealed minimal degenerative disc disease. The Veteran was diagnosed as having lumbar strain. The Veteran underwent VA examination in June 2015 at which time he reported every two weeks he experienced episodes of increased low back pain lasting for an hour. Physical examination demonstrated flexion to 90 degrees with pain, extension, lateral flexion, and lateral rotation all to 30 degrees; and there was no additional loss of motion on repetitive testing. There was evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the back. The examiner was unable to say without mere speculation whether pain weakness, fatigability, or incoordination significantly limited functional ability repeated use over a period of time or with flare-ups because there was insufficient evidence or objective examination findings that would provide a reliable prediction of decreased functional ability with repeated use over a period of time or during flare-ups. There was no guarding or muscle spasm of the back. Muscle strength testing was normal, and there was no muscle atrophy. Reflex and sensory examinations were normal, and straight leg raising was negative. There was no ankylosis. The examiner noted that the Veteran did not have radicular pain, any signs or symptoms due to radiculopathy. There was evidence of IVDS that required no bed rest prescribed by a physician and treatment by a physician in the prior twelve months. X-rays revealed mild L5-S1 degenerative disc disease. The Veteran was diagnosed as having degenerative arthritis of the spine and IVDS. The examiner noted that the Veteran's back condition impacted his ability to work and noted that activities involving trunk range of motion (bending, twisting) and weight bearing (standing, walking) causes low back pain; flareups of approximately one hour duration every two weeks require bedrest until resolved. The Veteran underwent VA examination in October 2019 at which time he reported sharp, shooting midline lower back pain with stiffness worse at the end of the day with no radicular symptoms. He reported occasional flare-ups described as increased pain on movement occurring approximately once to twice a month and lasting a day or so. The Veteran reported difficulty getting in and out of the car, picking up laundry, bending over to pick up items, and lifting heavy loads as well as increased pain after sitting for long periods of time and walking long distances. Physical examination demonstrated flexion to 70 degrees, extension to 10 degrees, lateral flexion to 20 degrees, and lateral rotation to 15 degrees with pain on all motion and with weight bearing; and there was no additional loss of motion on repetitive testing. The examiner noted that it was not medically appropriate to test for evidence of pain on passive range of motion or when the joint was used in non-weight bearing. There was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the back. The examiner stated that functional ability was not significantly limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time or with flare-ups. There was no guarding or muscle spasm of the back. Muscle strength testing was normal, and there was no muscle atrophy. Reflex and sensory examinations were normal, and straight leg raising was negative. There was no ankylosis. The examiner noted that the Veteran did not have radicular pain or any signs or symptoms due to radiculopathy. There was evidence of IVDS that required no bed rest prescribed by a physician and treatment by a physician in the prior twelve months. X-rays revealed mild L5-S1 degenerative disc disease. The Veteran was diagnosed as having degenerative arthritis of the spine and IVDS. The examiner noted that the Veteran's back condition impacted his ability to work. The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for service-connected lumbar spine disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to less movement than normal, weakened movement, pain on movement, disturbance of locomotion, and interference with sitting, standing and/or weightbearing. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. He has not reported experiencing any symptoms approaching unfavorable ankylosis of the entire thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board notes that the new regulation assigns this diagnostic code only where there is disc herniation with compression and/or irritation of the adjacent nerve root. See 85 Fed. Reg. 76453 (November. 30, 2020). In this case, there are no VA treatment records after February 7, 2021; regardless, there were no VA treatment records prior to February 7, 2021, that demonstrated disc herniation with compression and/or irritation of the adjacent nerve root. At the October 2019 VA examination, the Veteran specifically denied having any radicular symptoms. In addition, at all three VA examinations, straight leg raising was negative; a positive test would have suggested radiculopathy often due to disc herniation. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 40 percent for service-connected lumbar spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial rating in excess of 10 percent for cervical spine disability prior to October 15, 2019 4. Entitlement to a rating in excess of 20 percent for cervical spine disability since October 15, 2019 The Veteran contends that he is entitled to a higher rating for his service-connected cervical spine disability. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. VA treatment records from 2009 to 2019 show normal range of motion for the Veteran's cervical spine. At the November 2011VA examination, the Veteran reported having headaches but no other cervical spine symptoms. Physical examination demonstrated flexion to 45 degrees with pain at 30 degrees, extension to 45 degrees with pain at 20 degrees, lateral flexion and lateral rotation to 80 degrees with no objective evidence of pain; and there was no additional loss of motion on repetitive testing. The examiner noted that that there was no functional loss or functional impairment of the cervical spine. There was no localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, no guarding, and no muscle spasms. Muscle, reflex, and sensory examinations were normal. The examiner noted that the Veteran did not have radicular pain, any signs or symptoms due to radiculopathy, any other neurologic abnormalities, or intervertebral disc syndrome (IVDS). The Veteran was diagnosed as having cervical strain. At the June 2015VA examination, the Veteran reported having neck pain with head and neck motion. Physical examination demonstrated flexion to 45 degrees, extension to 45 degrees, right lateral flexion to 30 degrees, left lateral flexion to 45 degrees, right lateral rotation to 60 degrees, and left lateral rotation to 80 degrees with pain on extension, right lateral flexion, and right lateral rotation; and there was no additional loss of motion on repetitive testing. The examiner was unable to say without mere speculation whether functional ability was significantly limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time. There was no localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, no guarding, and no muscle spasms. Muscle, reflex, and sensory examinations were normal. The examiner noted that the Veteran did not have radicular pain, any signs or symptoms due to radiculopathy, ankylosis, any other neurologic abnormalities, or IVDS. The Veteran was diagnosed as having cervical strain. At the October 15, 2019, VA examination, the Veteran reported having minor bilateral neck pain more midline (stiffness/achiness, nagging feeling in his neck) which is worse at the end of the day. The Veteran denied having radicular symptoms, numbness or tingling in his hands/arms, and flare-ups. The Veteran reported having difficulty driving long distances due to stiffness and increased neck pain; specifically, he reported trouble looking to reverse his vehicle, trouble looking up and down, and trouble checking his blind spot. The Veteran noted that the neck pain was made worse by repetitive motion over time. Physical examination demonstrated flexion to 45 degrees, extension to 20 degrees with pain, lateral flexion to 20 degrees, and lateral rotation to 25 degrees with pain on extension, right lateral flexion, and right lateral rotation; and there was no additional loss of motion on repetitive testing. There was no evidence of pain with weight bearing, with non-weight bearing, or on passive motion. There was no localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, no guarding, and no muscle spasms. The examiner stated that functional ability was not significantly limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time. Muscle, reflex, and sensory examinations were normal. The examiner noted that the Veteran did not have radicular pain, any signs or symptoms due to radiculopathy, ankylosis, any other neurologic abnormalities, or IVDS. The Veteran was diagnosed as having cervical strain. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to October 15, 2019, for service-connected cervical spine disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain; however, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. At both VA examinations prior to October 15, 2019, forward flexion was to 45 degrees and combined range of motion was 410 degrees in November 2011 and 305 degrees in June 2015; and there was no guarding and no muscle spasms. In addition, there was no additional loss of motion on repetitive testing; the November 2011 VA examiner noted that that there was no functional loss or functional impairment of the cervical spine; and the June 2015 VA examiner was unable to state without mere speculation whether functional ability was significantly limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time. The Board also finds that the preponderance of the evidence is against a rating in excess of 20 percent since October 15, 2019, for service-connected cervical spine disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to neck pain; however, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. At the October 2019 VA examination, forward flexion was to 45 degrees; and the examiner stated that functional ability was not significantly limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time; and there was no ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes; however, the Veteran does not have IVDS of the cervical spine. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent prior to October 15, 2019, and in excess of 20 percent since October 15, 2019, for service-connected cervical spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for a headache disability as secondary to service-connected disability As noted above, the October 2019 VA examiner noted that there was no objective evidence in the treatment records of a headache disorder and found that it was more likely than not that his memory complaints and neuropsychological complaints were due to concurrent substance abuse and psychiatric disorder and that it was less likely than not that he incurred a TBI with residual headaches that was incurred in service. Service connection has been established for schizoaffective disorder. As the October 2019 VA examiner's opinion raises the possibility that the Veteran's headache complaints are caused or aggravated by his service-connected schizoaffective disorder, the Board finds that an addendum opinion is needed which addresses whether the Veteran has a headache disability which is related to a service-connected disability. The matters are REMANDED for the following action: (Continued on the next page) Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has a current, chronic headache disability that is at least as likely as not proximately due to or aggravated beyond its natural progression by service-connected schizoaffective disorder and/or cervical spine condition. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.