Citation Nr: 21031445 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 15-31 898 DATE: May 21, 2021 ORDER A disability rating higher than 10 percent for lumbosacral degenerative arthritis with intervertebral disc syndrome (lumbar spine disability) prior to January 9, 2020 is denied. A disability rating of 20 percent for lumbar spine disability prior to November 9, 2020 is denied. A disability rating higher than 40 percent for lumbar spine disability is denied. A disability rating higher than 10 percent for cervicalgia (claimed as cervical condition, also reported as a cervical strain) (cervical spine disability) prior to January 9, 2020 is denied. A disability rating higher than 20 percent for cervical spine disability since January 9, 2020 is denied. A compensable disability rating for tension headaches prior to January 9, 2020 is denied. A disability rating higher than 30 percent for tension headaches since January 9, 2020 is denied. FINDINGS OF FACT 1. Prior to January 9, 2020, the Veteran's lumbar spine disability was manifested by painful, but noncompensable degree of limitation of motion; the disorder was not manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal, by ankylosis, or by incapacitating episodes of intervertebral disc syndrome (IDS) requiring bed rest as defined under VA law. 2. Prior to November 9, 2020, the Veteran's lumbar spine disability has been manifested by chronic pain resulting in forward flexion to 40 degrees when considering additional functional loss and/or impairment; the disorder is not manifested by ankylosis, or by incapacitating episodes of IDS requiring bed rest as defined under VA law. 3. Since November 9, 2020, the Veteran's lumbar spine disability is manifested by chronic pain resulting in forward flexion to 25 degrees when considering additional functional loss and/or impairment and is not shown to result in ankylosis of the spine, or incapacitating episodes of IDS requiring bed rest as defined under VA law. 4. Prior to January 9, 2020, the Veteran's cervical spine disability was manifested by chronic pain resulting in forward flexion to no worse than 40 degrees when considering additional functional loss and/or impairment; it is not manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. There is no evidence of ankylosis, additional neurologic disability manifestations, or incapacitating episodes of IDS requiring bed rest as defined under VA law. 5. Since January 9, 2020, the Veteran's cervical spine disability has been manifested by chronic pain resulting in forward flexion to no worse than 25 degrees when considering additional functional loss and/or impairment; it is not manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. There is no evidence of ankylosis, additional neurologic disability manifestations, or incapacitating episodes of IDS requiring bed rest as defined under VA law. 6. Prior to January 9, 2020, the Veteran's tension headaches are not productive of characteristic prostrating attacks averaging one in 2 months over last several months. 7. Since January 9, 2020, the Veteran's tension headaches do not manifest in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for lumbar spine disability prior to January 9, 2020 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DCs) 5242-5243. 2. The criteria for a disability rating higher than 20 percent for lumbar spine disability prior to November 9, 2020 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5242-5243. 3. The criteria for a disability rating higher than 40 percent for lumbar spine disability since November 9, 2020 are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5242-5243. 4. The criteria for a disability rating higher than 10 percent for cervical spine disability are not met prior to January 9, 2020. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5237-5243. 5. The criteria for a disability rating higher than 20 percent for cervical spine disability are not met since January 9, 2020. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.71a, DCs 5237-5243. 6. Prior to January 9, 2020, the criteria for a compensable disability rating for tension headaches are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8100. 7. Since January 9, 2020, the criteria for a disability rating higher than 30 percent for tension headaches are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 2007 to July 2010. In connection with this appeal, the Veteran and her husband testified at a hearing before the undersigned in November 2018. A transcript of that hearing is of record. In March 2019 the issues were remanded for additional development. INCREASED RATING The Veteran seeks increased evaluations for multiple service-connected disabilities. Disability ratings are determined by comparing a veteran's present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Spinal Disabilities The Veteran's lumbar spine disability is rated under DC 5242 and her cervical spine disability is rated under DC 5237. 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 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 will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version 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; Kuzma, 341 F.3d 1327. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable will be applied. The criteria for rating disabilities of the spine are listed under DCs 5235 to 5243. The code for intervertebral disc syndrome (DC 5243), permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Prior to the regulatory change lumbosacral or cervical strain was rated under DC 5237 and DC 5242 was applicable to degenerative arthritis of the spine. 38 C.F.R. § 4.71a. Any associated neurological abnormalities (e.g., bowel or bladder impairment) are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week, but less than two weeks in the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks in the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks in the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. The Board notes that the General Rating Formula for Diseases and Injuries of the Spine is unaffected by the February 7, 2021 regulatory changes. However, DC 5242 is expanded to include degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome. As of February 7, 2021, under the amended criteria, DC 5243 is only assignable when there is disc herniation with compression and/or irritation of the adjacent nerve root; DC 5242 is to be assigned for all other disc diagnoses. lumbar spine disability The Veteran's lumbar spine disability is currently rated as 40 percent disabling effective November 9, 2020. Prior to that date, her lumbar spine disability was rated as 20 percent from January 9, 2020, and as 10 percent disabling from July 17, 2010. In February 2021, separate 10 percent disability ratings were granted for associated radiculopathy involving the sciatic nerve of each lower extremity. The Veteran has not appealed; therefore, the issue of separate evaluations for the bilateral lower extremities is not on appeal and will not be considered. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, when the combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 225 degrees; or when there is 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 evaluation is appropriate where there is 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 is 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 evaluation for forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation 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. § 4.71. Normal forward flexion of the thoracolumbar segment of the spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See Note 2, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a, Plate V. prior to January 9, 2020 When examined by VA in June 2012, the Veteran reported constant pain to the entire spine with flareups that made daily tasks difficult. Range of motion testing showed forward flexion to 90 degrees, extension to 20 degrees, lateral flexion to 30 degrees bilaterally, and rotation to 30 degrees bilaterally with no objective evidence of painful motion. There was no additional limitation following repetitive testing but there was functional loss due to pain on movement as well as localized tenderness on palpation of the lumbar, thoracic and cervical paraspinals. There was no guarding or muscle spasm resulting in abnormal gait or spinal contour. Muscle strength was normal at 5/5 with no atrophy and deep tendon reflexes were 2+ bilaterally. Sensory examination was also normal and negative straight leg raising test. There were no signs or symptoms of radiculopathy, other neurologic abnormalities, or IDS. The Veteran did not require assistive devices to aid with walking. The functional impact of the back condition was difficulty with prolonged sitting or standing due to pain. Subsequently dated treatment records dated from 2011 to 2019 show that the Veteran continued to report chronic pain, treated conservatively over the years with medication, heat, ice, physical therapy, TENS unit, massage, and steroid injections. The clinical findings from these records are not materially different from those reported on the prior VA examination and show no indication of a worsening in range of motion or functional impairment. There are also no incapacitating episodes of IDS or findings to suggest bladder or bowel dysfunction. See clinical records from the Florida Spine Institute, Pivot Physical Therapy and VA clinical records from the Fayetteville VA Medical Center, the Palm Harbor VA Clinic, and the Denton VA Clinic. Based upon a review of the evidence of record, the Board concludes that the 10 percent rating is appropriate and fully contemplates the Veteran's lumbar spine disability. In fact, during the time period in question she has demonstrated normal or near normal ranges of motion with no additional loss of motion or function after repetitive use testing. There was also no evidence of spasms or guarding enough to result in an abnormal gait or abnormal spinal contour as required for a 20 percent rating. The preponderance of the evidence shows the Veteran's impairment due to lumbar spine disability prior to January 9, 2020 is most consistent with a 10 percent disability rating. prior to November 9, 2020 The 20 percent evaluation is based, in part, on findings from a January 2020 VA examination report. The Veteran reported lower back pain and associated right leg pain. She did not report flare-ups but did describe functional loss as difficulty with carrying, lifting, and bending. Range of motion testing showed forward flexion to 40 degrees, backward extension to 25 degrees, lateral flexion to 20 degrees bilaterally and rotation to 30 degrees bilaterally with no additional limitation following repetitive testing. There was no pain with weight bearing but there was mild tenderness in the lumbosacral area. There was no guarding or muscle spasm but there were additional factors contributing to disability included less movement than normal, weakened movement, disturbance of locomotion, and interference with sitting. Muscle strength was normal at 5/5 with no atrophy. Reflexes were normal at 2+ and sensation was normal. Straight leg raising test was negative but there was mild radiculopathy on the right. There was no ankylosis or other neurologic abnormalities or findings such as bowel or bladder problems/pathologic reflexes and the Veteran did not have incapacitating episodes of IDS that required prescribed bed rest in the past 12 months. The Veteran did not require assistive devices such as a back brace or cane to aid in walking. Imaging studies showed mild facet and disc degenerative changes at L5-S1 without evidence of acute fracture, dislocation or spondylolisthesis identified. The Board finds that while the foregoing evidence supports the grant of a 20 percent disability rating, a higher evaluation is not warranted. The most recent exam reflects forward flexion to at least 40 degrees. There are no specific findings of ankylosis, and the measurable range of lumbar spine motion indicates that the Veteran does not have ankylosis, much less unfavorable ankylosis, or a disability akin to an individual with ankylosis as required for a 40 percent, 50 percent, or 100 percent rating. The preponderance of the evidence shows the Veteran's impairment due to lumbar spine disability prior to November 9, 2020 is most consistent with a 20 percent rating. With regard to both timeframes, the Board has also considered the impact of functional loss on the Veteran's range of motion of the thoracolumbar spine but the clinical findings do not suggest that range of motion would change to the degree required for a higher rating (i.e. 30 degrees of forward flexion or less) due to pain, or after repetitive use, or with weight bearing, or during flare-ups. Also given that prior to January 2009, the Veteran's complaints did not prevent her from achieving normal and near-normal range of motion of the lumbar spine, they do not support a finding of significant functional loss for a higher rating at that time. Because the range of motion findings show that the Veteran has substantial range of back motion, even with consideration of these factors, there is no indication the lumbar spine disability suffers any significant or additional functional loss beyond that contemplated by the 10 and 20 percent ratings assigned. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Additionally, an increased evaluation is not warranted under the criteria for IDS, as the Veteran has not reported incapacitating episodes which required bed rest prescribed by a physician. The Board acknowledges the Veteran's account of chronic back pain, but what is lacking is objective documentation that any physician prescribed the bed rest or that the Veteran was treated by a physician for any period approaching a total duration of even one week during a 12-month period. Thus, an increased evaluation under this diagnostic code is not for assignment. See 38 C.F.R. § 4.71a, DC 5243. The preponderance of the evidence supports a 20 percent rating for the lumbar spine disability effective January 9, 2020 and prior to that date is most consistent with a 10 percent rating. 38 C.F.R. § 3.102. since November 9, 2020 The current 40 percent evaluation is assigned from November 2020, the date of the most recent VA examination. The Veteran reported pain and an inability to stand or walk for extended periods of time. She also reported moderate to severe flare-ups that occur monthly and last two days. Range of motion studies revealed forward flexion to 35 degrees, extension to 30 degrees, bilateral lateral flexion to 20 degrees, and bilateral rotation to 30 degrees. The Veteran was able to perform repetitive-use testing with additional loss of forward flexion to 25 degrees due to pain, extension limited to 20 degrees, left lateral flexion limited to 10 degrees and right lateral flexion to 20 degrees and rotation limited to 20 degrees bilaterally. There was evidence of pain with weight bearing but not when the spine is non-weight bearing. There was no muscle spasm or guarding that resulted in an abnormal gain or sinal contour. There were no additional factors contributing to disability. Muscle strength was normal except for slight weakness at ankle dorsiflexion and great toe extension. There was no muscle atrophy or ankylosis of the spine and reflexes were normal at 2+. Sensory examination showed decreased sensation to light touch in the thigh/knee, lower leg/ankle, and foot/toes and straight leg raising test was positive bilaterally. There were no other neurologic abnormalities or findings such as bowel or bladder problems/pathologic reflexes and the Veteran did not have incapacitating episodes of IDS that required prescribed bed rest in the past 12 months and did not require assistive devices such as a back brace or cane to aid in walking. The Veteran reported that she lost 2-4 weeks in the last 12 months in her job as a police officer and was unable to stand and walk for longer than 10 minutes without experiencing pain. Based upon a review of the evidence of record, the Board finds that the criteria for a rating greater than 40 percent for the Veteran's lumbar spine disability are not met as the examination findings would have to show ankylosis of the spine. The evidence of record including the most recent VA examination, contain no specific findings of ankylosis. So, while the Veteran may have very limited range of motion, there is no indication that she was unable to move her lumbar spine or that her spine was in a fixed position. 38 C.F.R. § 4.71a, General Formula, Note 5. Thus, the Board finds that the criteria for an evaluation greater than 40 percent are not met. VA must consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, incoordination, and other factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca supra; Mitchell supra, Correia supra, and Sharp supra. The Board notes that the Veteran is receiving the maximum schedular evaluation based on limitation of motion and that a higher rating requires ankylosis. However, the Veteran has not described or presented evidence of any specific functional loss or impairment consistent with that contemplated by ankylosis. See Chavis v. McDonough, No. 18-2928 (Vet. App April 16, 2021) (holding that the requirement of ankylosis in the context of a claim for an increased rating for the back can be demonstrated by evidence of the functional equivalent of ankylosis). Although the January 2020 VA examiner reported the Veteran suffered from "less movement than normal due to ankylosis" as well as other factors affecting her disability, it was ultimately determined the Veteran did not have ankylosis; a finding that was later confirmed in the November 2020 VA examination. At that time, the Veteran's measurable range of motion following repeated use over time and flare-up testing indicates the lumbar spine was not fixed in flexion or extension or in a neutral position (zero degrees). 38 C.F.R. § 4.71a, General Formula, Note 5. In addition, the Veteran has not required assistive devices to aid in walking and has not indicated that she is unable to take care of activities of daily living when the symptoms are most prevalent (i.e., flare-ups). So, while motion is significantly limited, neither the lay nor medical evidence reflects the functional equivalent of ankylosis warranting a rating higher than 40 percent. Additionally, an increased evaluation is not warranted under the criteria for IDS, as there is no evidence of incapacitating episodes which required bed rest prescribed by a physician. The Board acknowledges the Veteran's account of chronic back pain. However, what is lacking is objective documentation that any physician prescribed bed rest or that the Veteran was treated by a physician for any period approaching a total duration of even one week during a 12-month period. Thus, an increased evaluation under DC 5243 is not for assignment. See 38 C.F.R. § 4.71a. The preponderance of the evidence shows the Veteran's impairment due to her lumbar spine disability from November 9, 2020 is most consistent with a 40 percent rating. cervical spine disability The Veteran's cervical spine disability is currently rated as 20 percent disabling effective January 9, 2020. Prior to that date, her cervical spine disability was rated as 10 percent from July 17, 2010. In February 2021, separate 20 percent disability ratings were granted for associated radiculopathy involving the middle radicular nerve group of each upper extremity. The Veteran has not appealed; therefore, the issue of separate evaluations for the bilateral upper extremities is not on appeal and will not be considered. A 10 percent evaluation is awarded 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 evaluation is appropriate where there is 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 is 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 evaluation for forward flexion of the cervical spine of 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is appropriate for unfavorable ankylosis of the entire cervical spine. A 100 percent evaluation is appropriate for unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a. Normal forward flexion of the cervical segment of the spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. See Note 2, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a, Plate V. prior to January 9, 2020 When examined by VA in June 2012, the Veteran reported constant neck pain with flare-ups that made daily tasks difficult. Range of motion testing showed forward flexion to 40 degrees, extension to 40 degrees, right lateral flexion to 40 degrees, left lateral flexion to 30 degrees, and rotation to 50 degrees bilaterally with no additional limitation following repetitive testing. There was localized tenderness to palpation but no muscle spasm or guarding of the cervical spine. Muscle strength, sensation, and reflexes were all normal. There was no evidence of atrophy, ankylosis, or incapacitating episodes of IDS of the cervical spine. The major functional impact on the Veteran's ability to perform occupational tasks included difficulty sitting in front of a computer for long periods. Subsequently dated treatment records dated from 2011 to 2019 show that the Veteran continued to report chronic pain, treated conservatively over the years with medication, heat, ice, physical therapy, TENS unit, massage, and steroid injections. In general, the clinical findings from these records are not materially different from those reported on the prior VA examinations and show that while the Veteran continued to report neck pain, there were no specific findings from range-of-motion testing, in degrees, to permit meaningful comparison with the rating criteria. Based upon a review of the evidence of record, the Board concludes that the percent rating is appropriate and fully contemplates the Veteran's cervical spine disability. The evidence does not, however, indicate forward flexion of the cervical spine less than 30 degrees or combined range of motion of the cervical spine less than 170 degrees. There was also no evidence of spasms or guarding enough to result in an abnormal gait or abnormal spinal contour as required for a 20 percent rating. The preponderance of the evidence shows the Veteran's impairment due to cervical spine disability prior to January 9, 2020 is most consistent with a 10 percent rating. since January 9, 2020 The current 20 percent evaluation is assigned from January 9, 2020, the date of the VA examination. At that time the Veteran reported difficulty with lifting and turning her head but did not report flare-ups. Range of motion studies revealed forward flexion to 25 degrees, extension to 30 degrees, right lateral flexion to 20 degrees, left lateral flexion to 15 degrees, right rotation to 40 degrees and left rotation to 30 degrees with no additional limitation following repetitive testing. There was also no evidence of pain with weight bearing, but mild tenderness in the cervical paraspinals and upper trapezius. There was guarding that did not result in abnormal gain or abnormal spinal contour. There were no additional factors contributing to disability. Muscle strength testing was normal 5/5 in both upper extremities, with no muscle atrophy. Reflexes were normal at 2+ bilaterally at the biceps, triceps, and brachioradialis and sensation to light touch was normal in both upper extremities. There was no ankylosis or other neurological abnormalities noted and IDS of the cervical spine. When examined by VA in November 2020, range of motion studies revealed forward flexion to 35 degrees, extension to 30 degrees, lateral flexion to 20 degrees, bilaterally and rotation to 40 degrees bilaterally with no additional limitation following repetitive testing. There was mild tenderness on palpation of the neck. The Veteran was able to perform repetitive-use testing with additional loss of forward flexion to 25 degrees due to pain, extension limited to 20 degrees, lateral flexion limited to 10 degrees bilaterally, and rotation limited to 30 degrees bilaterally. There is objective evidence of pain when the spine is non-weight bearing. There were no additional factors contributing to disability. Muscle strength testing was normal 5/5 in both upper extremities, with no muscle atrophy. Reflexes were normal at 2+ bilaterally at the biceps, triceps, and brachioradialis and sensation to light touch was normal in both upper extremities. There was no ankylosis or IDS of the cervical spine. Imaging studies of the cervical spine were unremarkable. The functional impact of the Veteran's cervical spine disability was the inability to bear weight on neck for longer than 20 minutes without experiencing pain. The Board finds that while the foregoing evidence supports the grant of a 20 percent disability rating, a higher evaluation is not warranted. The VA examination reflects forward flexion to at least 25 degrees, with additional motion possible beyond the level of pain. There are also no specific findings of ankylosis, favorable or unfavorable, as required for a 30 percent, 40 percent, or 100 percent rating. The preponderance of the evidence shows the Veteran's impairment due to cervical spine disability since January 9, 2020 is most consistent with a 20 percent rating. With regard to both timeframes, the Board has also considered the impact of functional loss on the Veteran's range of motion of the cervical spine but the clinical findings do not suggest that range of motion would change to the degree required for a higher rating (i.e. 15 degrees of forward flexion or less) due to pain, or after repetitive use, or with weight bearing, or during flare-ups. Also given that prior to January 2009, her complaints did not prevent the Veteran from achieving near normal range of motion of the cervical spine, they do not support a finding of significant functional loss for a higher rating at that time. Because the range of motion findings show that the Veteran has substantial range of neck motion, even with consideration of these factors, there is no indication her cervical spine disability suffers any significant or additional functional loss beyond that contemplated by the 10 and 20 percent ratings assigned. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca supra; Mitchell supra, Correia supra, and Sharp supra. Additionally, an increased evaluation is not warranted under the criteria for IDS, as the Veteran has not reported incapacitating episodes which required bed rest prescribed by a physician. The Board acknowledges the Veteran's account of chronic neck pain, but what is lacking is objective documentation that any physician prescribed the bed rest or that the Veteran was treated by a physician for any period approaching a total duration of even one week during a 12-month period. Thus, an increased evaluation under this diagnostic code is not for assignment. See 38 C.F.R. § 4.71a, DC 5243. tension headaches The Veteran's headache disability is currently rated as 30 percent disabling under DC 8100, effective January 9, 2020. Prior to that date, it was rated as noncompensable (0) percent. Under DC 8100, headaches with less frequent attacks are rated noncompensable (0 percent). A 10 percent disability rating is warranted for characteristic prostrating attacks averaging one in 2 months over last several months. A 30 percent disability rating is warranted for characteristic prostrating attacks occurring on an average of once a month over the last several months. Very frequent, completely prostrating and prolonged attacks (of migraine headaches) productive of severe economic inadaptability warrant a 50 percent disability rating. 38 C.F.R. § 4.124a. Although the rating criteria do not define "prostrating," according to Dorland's Illustrated Medical Dictionary, 31st Edition (2007), p.1554, "prostration" is defined as "extreme exhaustion or powerlessness." A similar definition is found in Merriam-Webster's Collegiate Dictionary, Eleventh Edition (2003), p.999, "prostration" is defined as "complete mental or physical exhaustion or collapse." The rating criteria also do not define "severe economic inadaptability"; however, nothing in DC 8100 requires the claimant to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440 (2004). A review of the applicable rating criteria shows that, for the most part, ratings for headache disabilities are largely dependent on subjective reports of frequency and severity of headaches. The frequency and severity of the headaches is rarely observed by a clinician, and the determination of a disability rating turns on the reports by the Veteran as well as the supporting evidence he or she has submitted. prior to January 9, 2020 Here, the evidence includes a June 2012 VA examination report in which the examiner documented that the Veteran experienced constant headaches of pulsating/throbbing pain above the neck at the base of the skull, as well as sensitivity to light. The duration of typical headache pain lasting less than a day and the used Tylenol as needed to control symptoms. The examiner further indicated that the Veteran did not have characteristic or prostrating attacks of migraine or non-migraine headache pain and that she also did not have very frequent prostrating and prolonged attacks of migraine/non-migraine pain. The Veteran stated that it is difficult to concentrate when she has a headache but did not otherwise describe her headaches as a disability, which rendered her unable to work. A review of the remaining evidence of record between 2010 and 2019 show periodic evaluation of the Veteran's chronic headaches, and while the frequency of the headaches fluctuated, there were no reports that they were completely prostrating and no indication as to their duration or impact on functioning. The Board finds that the preceding evidence does not support the assignment of an initial compensable disability rating for tension headaches prior to January 9, 2020. The record prior to that date contains no complaints of prostrating attacks occurring with a frequency sufficient for a 10 percent evaluation. The VA examination noted that the duration of typical headache pain was less than one day, and that the Veteran did not have any characteristic prostrating attacks of migraine/non-migraine headache pain. Thus, based on the competent evidence, the Veteran's tension headaches did not occur with characteristic prostrating attacks averaging one in 2 months over the last several months. The preponderance of the evidence shows the Veteran's impairment due to tension headaches prior to January 9, 2020 is most consistent with a noncompensable disability rating. since January 9, 2020 The Board finds that the criteria for a rating in excess of 30 percent are not met at any point during the appeal period. During the January 2020 VA examination, the Veteran reported headaches occurring 4-7 times per month, lasting 1-2 days with pulsating/throbbing pain on both sides of the head, that worsens with physical activity. She also reported nausea, vomiting, sensitivity to light and sound, and changes in vision. The Veteran reported monthly prostrating headaches that were not very prostrating or prolonged attacks and were not productive of severe economic inadaptability. The examiner also noted that no treatment note showed economic inadaptability and while the Veteran confirmed headaches 4-7 per month, they do not interfere with gainful employment or causes economic inadaptability. See also VA Addendum Report, dated, January 13, 2021. There are no subsequently dated outpatient treatment records that show any further reference to headaches, either in the way of relevant subjective complaints or objective clinical findings. Based upon the preceding evidence, the Board finds no basis to grant a compensable disability for the Veteran's tension headache disability, prior to January 9, 2020. As noted above, the rating criteria for DC 8100 link the ratings for headaches to two elements: severity and frequency. It is not enough to demonstrate the existence of a particular frequency of headaches; the headaches must be of a specific prostrating character. So while the Veteran has reported headaches that sometimes occur up to several times a month associated with additional symptoms such as nausea, vomiting, and photophobia, the evidence does not establish that the intensity of the headaches rises to the level of "completely prostrating" such to warrant assignment of a 50 percent evaluation. In addition, the medical and lay evidence of record does not show that the tension headaches negatively impacted her job performance or that she has been in danger of losing her job because of them. Also, the VA examiner concluded the Veteran's headache condition did not impact her ability to work. (Continued on the next page) Therefore, the Board concludes that medical findings on examination, as well as the Veteran's own self-reported symptomatology, do not demonstrate headache symptomatology that more nearly approximates very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability as is required for a higher rating of 50 percent under DC 8100. The preponderance of the evidence shows the Veteran's impairment due to tension headaches since January 9, 2020 is most consistent with a 30 percent disability rating. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bryant, Jeana R 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.