Citation Nr: 21032680 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-15 689 DATE: May 27, 2021 ORDER Service connection for a genitourinary disorder is denied. Entitlement to a compensable rating for a laryngeal irritation is denied. Entitlement to a 40 percent rating for a lumbar spine disability, but no higher, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with secondary depression and somatic disorder is remanded. FINDINGS OF FACT 1. The preponderance of the evidence weighs against a finding that the Veteran has a genitourinary disorder which is secondary to his service-connected lumbar spine disability. 2. The preponderance of the evidence weighs against a finding that the Veteran's laryngeal condition has been manifested by hoarseness. 3. The preponderance of the evidence weighs in favor of a finding that the Veteran's lumbar spine disability has been manifested by unfavorable ankylosis; the preponderance of the evidence weighs against a finding that the Veteran's lumbar spine disability has been manifested favorable ankylosis, or intervertebral disc syndrome requiring physician prescribed bed rest. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a genitourinary disorder have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for a compensable rating for a laryngeal irritation condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.97, Diagnostic Code 6516. 3. The criteria for a 40 percent rating, but no higher, for a lumbar spine disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1982 to February 1992, to include verified service in the Southwest Asia Theater of Operations. These issues are before the Board on appeal from rating decisions of the Agency or Original Jurisdiction. Initially, the Board notes that at his most recent September 2020 lumbar spine examination, the Veteran first raised the theory that he believes he has a neurogenic bowel disorder that is secondary to his lumbar spine disorder. As the Agency of Original Jurisdiction (AOJ) has not adjudicated this issue in the first instance, it is referred to the AOJ. In November 2018, the Board remanded the Veteran's claims for service connection for a genitourinary disability, an increased rating for a laryngeal irritation condition, and an increased rating for a lumbar spine disability. Specifically, the Board directed the AOJ to afford the Veteran a new examination for his laryngeal condition to determine its current severity. The Board also directed that the Veteran be afforded a new lumbar spine examination which was consistent with the holdings in Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). The Board found the issue of service connection for genitourinary disorder was inextricably intertwined with the increased rating for a lumbar spine disorder and remanded that issue as well. Finally, the Board instructed the AOJ to obtain all outstanding VA treatment records and disability retirement records located with the Office of Personnel Management (OPM) and associate them with the evidence of record before the Board. The Veteran self-submitted OPM disability retirement records and these are also located in his Social Security Administration (SSA) disability records. These issues were again remanded by the Board in June 2020. Specifically, the Board directed the AOJ to obtain outstanding VA treatment records, afford the Veteran a new spine examination, and obtain opinions regarding his spine and any potential relationship to his claim for a genitourinary disorder. The foregoing has been accomplished and the Veteran's claims were readjudicated in a January 2021 Supplemental Statement of the Case. Accordingly, the Board finds its prior remand directives have been substantially complied with pertaining to the issues decided herein. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Although all the evidence of record has been thoroughly reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The analysis in this decision focuses on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Allday v. Brown, 7 Vet. App. 517, 527 (1995). Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, a disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Moreover, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Service connection for a genitourinary disorder The Veteran is claiming he has a genitourinary disorder which he believes is secondary to his service-connected lumbar spine disability. At January 2016 and December 2018 spine examinations, the Veteran denied any urinary or bladder complaints. At a March 2019 routine VA appointment, the Veteran indicated his back pain was stable with no changes; he denied dysuria or changes in urination. At a June 2020 gastroenterology appointment, the Veteran denied any problems with urination. At a September 2020 examination, the Veteran stated he had problems urinating when his back went out (flared-up), which occurred four to five times a year lasting up to a week each time. The examiner opined it was less likely than not (less than a 50 percent probability) that the Veteran's intermittent genitourinary condition was caused by his low back condition noting that other than during flare-ups, the Veteran reported he was alright, and had not been evaluated, diagnosed, or treated for this condition. The examiner further reasoned that control of bladder activity is located at S2-S4 levels of the lumbar spine and based on magnetic resonance imagining, there was no condition at those levels. Moreover, the examiner explained that when the bladder is affected by a spinal condition there is usually incontinence, yet the Veteran reported the opposite. The examiner also provided a separate opinion concluding it was less likely than not (less than a 50 percent probability) that the Veteran's intermittent genitourinary condition was aggravated by his lumbar spine condition given that there were no subjective complaints for treatment, the examiner was unable to find a baseline. Further, radiographic evidence did not show a condition at the proper level to say that a subjective genitourinary condition has originated in the spine, and therefore, aggravation was not established. Based on the foregoing, service connection for a genitourinary disorder must be denied. The September 2020 opinion provides a clear rationale for the conclusion reached and also contains separate opinions regarding causation and aggravation. The Board acknowledges that the Veteran believes his genitourinary disorder is secondary to his lumbar spine condition and that he is competent to report symptoms he experiences, such as urinary frequency. However, he does not demonstrate that he has the requisite medical experience, training, or education to make such a determination. Thus, the September 2020 opinion is more probative than his statements. Consideration has been given to the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). INCREASED RATING CLAIMS Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 1. Entitlement to a compensable rating for a laryngeal irritation The Veteran's claim for an increased rating for his laryngeal irritation condition was received on August 26, 2015. This condition is currently rated as noncompensable under Diagnostic Code 6516, which contemplates chronic laryngitis. See 38 C.F.R. § 4.97. Under Diagnostic Code 6516, a 10 percent rating is warranted when there is hoarseness with inflammation of the cords or mucous membrane. A maximum 30 percent rating is warranted for hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. At a January 2016 examination, the Veteran reported feeling the need to clear his throat frequently during the night. It was noted the Veteran had a laryngeal with mild inflammation of the mucous membrane; no hoarseness was noted. Vocal cords were not manifested by inflammation, thickening, nodules, polyps, or submucous infiltration. There was no evidence of incomplete or complete aphonia (the loss of the ability to speak due to a laryngeal condition). There was no vocal cord paralysis, injury to the pharynx, and no history of permanent tracheostomy or laryngectomy. At a December 2018 examination, the Veteran reported feeling the need to clear his throat frequently and that symptoms since onset had stayed the same. It was noted the Veteran had a laryngeal with mild inflammation of the mucous membrane; no hoarseness was noted. Vocal cords were not manifested by inflammation, thickening, nodules, polyps, or submucous infiltration. There was no evidence of incomplete or complete aphonia (the loss of the ability to speak due to a laryngeal condition). There was no vocal cord paralysis, injury to the pharynx, and no history of permanent tracheostomy or laryngectomy. Based on the foregoing, the Board finds a compensable rating for a laryngeal irritation (also described as chronic laryngitis) is not warranted. In order to warrant a 10 percent rating, the rating criteria require that the disability be manifested by hoarseness with inflammation of the cords or mucous membrane. See 38 C.F.R. § 4.97, Diagnostic Code 6516 (emphasis added). Although there was evidence of inflammation of the vocal cords at both the January 2016 and December 2018 examinations, the rating criteria specifically include the conjunctive "with," so that these symptoms must be demonstrated along with hoarseness. Id.; see also Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (holding that the use of the conjunctive in a statutory provision means that all the conditions in the provision must be met); cf. Johnson v. Brown, 7 Vet. App. 95, 97 (1994) (holding that "or" in the rating criteria shows that each is an independent basis for granting that rating). The Veteran has specifically indicated his sole symptom due to this condition is clearing his throat frequently; he has not claimed he experiences nor was hoarseness found on examinations. Thus, a 10 percent rating is not warranted. Similarly, the maximum 30 percent rating is not warranted as the preponderance of the evidence weighs against a finding that the Veteran experiences hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. See 38 C.F.R. § 4.97, Diagnostic Code 6516 (emphasis added). The Board has also considered whether rating the Veteran's laryngeal irritation under another diagnostic code would afford him a higher rating. However, his laryngitis is not due to tuberculosis, he has not undergone a laryngectomy, does not experience aphonia, does not have stenosis of the larynx, and does not have any injuries to the pharynx; therefore, there are no other applicable diagnostic codes. See 38 C.F.R. § 4.97, Diagnostic Codes 6515, 6518, 6519, 6520, 6521. The Board acknowledges that the Veteran is competent to report symptoms he experiences, such as frequently clearing his throat, as this requires only personal knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, even considering these statements, his functional impairment does not rise to the level such that a compensable rating is warranted. Consideration has been given to the benefit of the doubt doctrine; however, as the preponderance of the evidence is against a compensable rating for a laryngeal irritation, it does not apply. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. 2. Entitlement to a rating in excess of 20 percent for a lumbar spine disability The Veteran is claiming his service-connected lumbar spine disability is worse than the 20 percent rating reflects. His claim for an increased rating was received on August 26, 2015. Initially, the Board notes that service connection was originally granted for a chronic lumbar strain. The Veteran's condition has not progressed to include degenerative arthritis and degenerative disc disease. Although some examiners have found his arthritis and disc disease were not a progression of the original injury, and other have found they were a progression, none of the examiners were able to separate the symptoms and impairment due to each diagnosis. Therefore, the Board will attribute all symptoms relating to the Veteran's low back as due to his service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Legal Criteria All service-connected spine disabilities are rated pursuant to The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), unless the spinal disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based (IVDS) on Incapacitating Episodes (Incapacitating Episodes Rating Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. 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. No changes were made to the General Rating Formula under the recent rating criteria amendments. Under the General Rating Formula, a 20 percent rating is warranted for the thoracolumbar spine when forward flexion is greater than 30 degrees but not greater than 60 degrees. A 40 percent disability rating is warranted when forward flexion is to 30 degrees or less; or, there is evidence of favorable ankylosis of the entire thoracolumbar spine. The next highest 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. The maximum 100 percent evaluation is assigned if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. For VA compensation purposes, unfavorable ankylosis is 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. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Rating Formula, Note (5). Objective evidence of neurologic abnormalities of the spine are rated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula at Note (1). In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Incapacitating Episodes Rating Formula provides ratings for IVDS based the duration of incapacitating episodes in the previous twelve months. 38 C.F.R. § 4.71a, Incapacitating Episodes Rating Formula. VA regulation defines an "incapacitating episode" as a period of acute signs and symptoms due to IVDS that requires physician prescribed bed rest and treatment by a physician. Id. at Note (1) (emphasis added). Amendments were made to the rating criteria effective February 7, 2020, and now specifically indicate that a rating under IVDS may only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve; prior to then, this was not a requirement. 85 Fed. Reg. 230 (Nov. 30, 2020). However, the amendments are not relevant to the claim at hand; significantly, the Veteran has not claimed, and the evidence does not suggest that he has experienced incapacitating episodes which required physician prescribed bed rest; thus, these criteria are not applicable and will not be discussed herein. See id. Factual Background and Analysis At a January 2016 examination, the Veteran indicated his back pain was worse and when his back went out he had to go to the emergency room and missed work. He reported experiencing flare-ups and described functional impairment as tightening when sitting and that he had to change positions while sleeping. On examination, flexion was to 50 degrees and extension was to zero degrees. Repetitive use testing did not reveal any loss of range of motion and the examiner indicated it was not possible to describe functional impairment during repetitive use as it had not been observed. Similarly, although the examiner acknowledged flare-ups, he or she was unable to describe in terms of range of motion as a flare-up was not observed. At a December 2018 examination, the Veteran reported his back pain was worse and described symptoms of pinching pain and muscle pain. He described flare-ups as manifested by pinching pain and indicated he experienced difficulty bending and lifting due to his back condition. On examination, flexion was to 70 degrees and extension was to 20 degrees, and there was no objective evidence of pain. Repetitive use testing did not further limit range of motion and based on the examination and the Veteran's statements, the examiner estimated no additional loss of range of motion on repetitive use. The examiner noted the Veteran was not examined during a flare-up and that based on the record and verbal report it would be expected that the Veteran would experience increased pain leading to decrease in functional capacity; the examiner also indicated it was not possible to accurately estimate range of motion loss or limitation as they were affected by duration, repetition, and severity. The Veteran did not report any neurological abnormalities affecting the bowel or bladder. At a September 2020 examination, the Veteran reported constant back pain with flare-ups four to five times a year lasting approximately a week. He indicated that pain during flare-ups was brought on by increased intense activities and caused decreased strength and the inability to extend backwards. He indicated that when he back went out, he experienced difficulty defecating or urinating. On examination, flexion was to 60 degrees and extension was to 20 degrees. The examiner estimated that on repetitive use flexion would be decreased to 55 degrees and extension to 15 degrees. With flare-ups, the examiner estimated that flexion would be limited to 45 degrees and extension limited to 10 degrees. The examiner noted subjective reports that the Veteran indicated he had difficulty voiding or defecating during flare-ups. There was no evidence of IVDS. Based on the foregoing, the Board finds the evidence is evenly balanced as to whether a 20 percent or 40 percent rating is warranted, and, affording the Veteran the benefit of the doubt, finds a 40 percent rating is warranted. At his January 2016 examination, the Veteran's extension was to zero, representing favorable ankylosis. At his September 2020 examination, although the examiner estimated extension limited to 10 degrees during flare-ups, the Veteran reported the inability to extend backwards during flare-ups. The December 2018 examiner did not provide an opinion regarding additional functional limitation during flare-ups but did acknowledge that flare-ups would cause a decrease in functional impairment. Thus, the evidence demonstrates the Veteran's lumbar spine disability is more appropriately described as manifested by unfavorable ankylosis during flare-ups, and therefore, a 40 percent rating is warranted. A rating in excess of 40 percent is not warranted as the preponderance of the evidence weighs against a finding that the Veteran has experienced unfavorable ankylosis of the thoracolumbar spine or entire spine. Additionally, the preponderance of the evidence weighs against a finding that the Veteran has IVDS with physician prescribed bed rest. Finally, turning to neurological manifestations, service connection for bilateral lower extremity radiculopathy was granted in a January 2021 rating decision. In the instant decision, the Board has denied a claim for a genitourinary disorder secondary to the lumbar spine and has referred a claim for a neurogenic bowel disorder secondary to the lumbar spine. The preponderance of the evidence weighs against a finding the Veteran has claimed or experiences any other neurological manifestations associated with his lumbar spine. Accordingly, no additional separate ratings are for consideration. Additional Considerations The Board notes that entitlement to total disability rating based on individual unemployability (TDIU) has been granted effective March 31, 2016. See January 2017 rating decision. Prior that date, the Veteran was employed full time. See August 2016 TDIU Application. Thus, entitlement to TDIU prior to March 31, 2016, is not before the Board. REASONS FOR REMAND The Veteran is claiming a rating in excess of 50 percent is warranted for his PTSD with secondary depression and somatic disorder and that separate evaluations for tremors, dizziness, balance problems, and headaches are also warranted. See August 2015 Notice of Disagreement. Although the Board regrets the delay, an additional remand is required for further development and readjudication. This claim has a long and complicated procedural history. Service connection for PTSD was granted in a May 2007 rating decision, rated as 30 percent disabling, effective October 7, 2003. Additional records pertaining to this claim were submitted within the appeal period and in a February 2009 rating decision, the AOJ readjudicated the claim and increased the rating for the Veteran's PTSD with secondary depression to 50 percent effective May 2, 2002 (the date the Veteran first requested to reopen his claim). In June 2011, the Board remanded the Veteran's claim so that the AOJ could review additional evidence in the first instance. In October 2012, the Board found there was evidence the Veteran's condition may have worsened and ordered a more recent examination to determine the current severity of his mental health disorder. In November 2013, the Board denied a rating in excess of 50 percent for PTSD with secondary depression, and the Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). In a November 2014 Order, based on a Joint Motion for Remand (Joint Motion), the parties agreed that the Board failed to explain how the Veteran's complaints of other symptoms (tremors, dizziness, balance problems, headaches) were or were not related to the Veteran's psychiatric disorder and/or his service-connected neuronal brain damage. In April 2015, the Board remanded the Veteran's claim for additional examinations and opinions consistent with the instructions in the Joint Motion. Following a July 2015 mental health examination, in an August 2015 rating decision, the AOJ granted service connection for a somatic symptom disorder (to include headaches, tremors, dizziness, and balance problems) effective May 3, 2002. It was noted that this disorder was "evaluated along with the already service-connected disability of [PTSD] with secondary depression." Significantly, the July 2015 examiner found that the Veteran's subjective reports of impairment of cognitive function, balance problems, dizziness, headaches, and tremors were related to his somatic disorder. This claim was remanded by the Board in November 2018 to provide the Veteran an examination, obtain outstanding VA treatment records, and to obtain outstanding records from the Office of Personnel Management related to a March 2016 disability determination, all of which was accomplished. The claim was again remanded in June 2020 for consideration of whether separate ratings were warranted for manifestations of a somatic disorder, such as balance problems, dizziness, headaches, and tremors, which the AOJ did not consider in their January 2021 supplemental statement of the case. Although the Board regrets the delay, an additional remand is required. Here, it is reported that the Veteran experiences symptoms of balance problems, dizziness, headaches, and tremors, as manifestations of his somatic disorder; however, it is unclear whether there is functional impairment caused by these symptoms, with the July 2015 examiner indicating that the Veteran had a "subjective report of impairment" and the December 2018 examiner indicating that the Veteran had back and knee pain due to his somatic disorder without mention of the balance problems, dizziness, headaches or tremors. Therefore, a remand is required to afford the Veteran examinations to assess the conditions, so that VA can then evaluate whether his symptoms warrant separate compensable ratings. While this case is in remand status, all outstanding VA treatment records must be obtained and associated with the evidence of record before the Board. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The Veteran and his representative have the right to submit additional evidence and argument on this matter while it is in remand status. See Kutscherousky v. West, 12 Vet. App. 369 (1999). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the evidence of record. 2. Afford the Veteran the appropriate examination(s) to determine any physical symptomatology related to his service-connected somatic disorder, to specifically include consideration of the symptoms of balance problems, dizziness, headaches, and tremors. Following an examination of the Veteran and a review of the record, the examiner must provide the following information: Determine any and all physical symptomatology which manifests due to the Veteran's somatic disorder and specifically include consideration of balance problems, dizziness, headaches, and tremors. Explain how and to what extent the Veteran experiences physical manifestations/symptomatology related to his service connected somatic disorder. Be as specific as possible, consistent with DBQs required for any physical disabilities attributed to the Veteran's somatic disorder. (Continued on the next page) A complete rationale for any opinion rendered is required. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 3. Readjudicate the claims, with specific consideration of whether any separate ratings are warranted for manifestations of a somatic disorder, such as headaches, tremors, dizziness, or balance problems. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O'Connell, Jessica L. 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.