Citation Nr: A21013196 Decision Date: 08/04/21 Archive Date: 08/04/21 DOCKET NO. 200810-102779 DATE: August 4, 2021 ORDER Entitlement to a higher initial rating, increased from 30 percent to 50 percent, but no higher, for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) is granted. Entitlement to an initial rating in excess of 70 percent for right (major) hand neuropathy due to trauma is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. The Veteran's PTSD with TBI is manifested by no more than occupational and social impairment with reduced reliability and productivity. 2. The Veteran's current combined rating for impairment of his right (major) hand due to trauma is at least as high as the rating that is available for amputation of the major arm below insertion of the pronator teres or for loss of use of the major hand. 3. The Veteran's service-connected disabilities have been shown to prevent him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a higher initial rating, increased from 30 percent to 50 percent, but no higher, for PTSD with TBI have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 4.130, Diagnostic Code 8045-9411. 2. The criteria for entitlement to an initial rating in excess of 70 percent for right (major) hand neuropathy due to trauma have not been met. 38 C.F.R. §§ 4.68, 4.71a, Diagnostic Codes 5124, 5125, 4.124a, Diagnostic Codes 8513 through 8516. 3. The criteria for entitlement to a total disability rating based on individual unemployability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2006 to October 2018. This matter (Docket No. 200810-102779) comes before the Board on appeal of an August 2019 Regional Office (RO) rating decision. The Veteran timely appealed this decision to the Board and requested the opportunity to testify at a Board hearing. (See August 2020 VA Form 10182.) In October 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Increased Ratings Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 1. Entitlement to a higher initial rating, increased from 30 percent to 50 percent, but no higher, for PTSD with TBI is granted. The Veteran's PTSD with TBI is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. In the case at hand, Diagnostic Code 8045 applies to residuals of TBI, and the hyphenated diagnostic code directs that the disability be rated as PTSD (Diagnostic Code 9411). Disabilities that are evaluated under 38 C.F.R. § 4.130 are to be rated pursuant to VA's General Rating Formula for Mental Disorders. A 0 percent (noncompensable) rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and the inability to establish and maintain effective relationships. A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held "that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In particular, the Federal Circuit has expressly rejected interpreting 38 C.F.R. § 4.130 in such a manner that would render specific symptomatology a secondary consideration at the 70 percent level. Id. By way of history, the Board notes that the Veteran underwent a VA initial PTSD examination in April 2018. The examiner determined that it is possible to differentiate which symptoms are attributable to TBI and which symptoms are attributable to PTSD. The examiner noted that the Veteran's headaches are attributable to his TBI, while poor sleep, nightmares, anxiety, irritability, startle, hypervigilance, intrusive memories, avoidance, isolation, depression, and poor concentration are attributable to his PTSD. The examiner determined that the Veteran's level of occupational and social impairment with regard to all mental diagnoses is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. It was noted that the Veteran got married in 2010 and that he and his wife have no children. In terms of education and occupation, it was noted that the Veteran finished high school and he has not finished any college courses. It was noted that the Veteran is not sure what kind of work he will be able to do due to the problems with his right hand. It was noted that the Veteran has had poor sleep every night for a couple of years. He has problems falling and staying asleep. He wakes up with nightmares about Afghanistan. He has anxiety during the day, and it is worse when he is around people. He has some irritability. He has startle and hypervigilance. He has avoidance and is more withdrawn that he used to be. He has depression, loss of energy, and loss of interest. He is not suicidal, manic, or psychotic. He has some forgetfulness and has to keep notes. Sometimes he will be driving and lose track of time and not know how he got somewhere. He was not working and is at the Wounded Warrior Battalion because of his right arm. He can get along with the public, coworkers, and supervisors. He can learn new procedures and follow complex instructions. He has some problems with work stress, anxiety, depression, poor sleep, chronic pain, and loss of functioning with the right arm. With respect to social impairment, hs is a little uncomfortable out in public. On mental status examination, he was neatly groomed and dressed and behaved normally. With respect to attitude, he was pleasant, cooperative, and polite. He was not hostile or belligerent. Speech was normal in rate and tone, with good grammar and vocabulary. He was spontaneous and logical, not inhibited or vague. There was no pressured speech, flight of ideas, or loose associations. He communicated well. He had no stuttering or word finishing problems. He did not lose his train of thought. With respect to thought content, there were no hallucinations, delusions, paranoia, or ideas of reference. He was not homicidal or suicidal. He was not a threat to himself or others. His self-confidence was good. With respect to affect, he had mild depression and mild to moderate anxiety. He has no panic attacks. He has mild irritability. Impulse control is good. He has poor sleep. On cognitive examination, he was fully oriented and alert. He knew his date of birth, social security number, and address. Concentration was good. Recent and remote memory were good. Fund of information was good, judgment was good, insight was fair, and intelligence was average. He is able to perform activities of daily living. He will occasionally get together with friends or go out to eat. He stays in touch with his mother, stepfather, and sisters. He gets along with his wife, in-laws, and friends. He is able to establish and maintain effective work and social relationships. With respect to the enumerated rating criteria, the following 30 percent symptoms were noted to apply to the Veteran's diagnosis: depressed mood; anxiety; chronic sleep impairment; and mild memory loss (such as forgetting names, directions, or recent events). With respect to the enumerated rating criteria, the following 50 percent symptom was noted to apply to the Veteran's diagnosis: difficulty in establishing and maintaining effective work and social relationships. None of the criteria for a 70 percent or 100 percent rating was selected. It was noted that the Veteran does not have any other symptoms that are not listed above that are attributable to his PTSD. Currently, an April 2019 VA medical record notes that the Veteran reported that his depressive and anxiety symptoms make it extremely difficult to do his work, take care of things at home, or get along with others. The Veteran reported symptoms that may be consistent with moderate to severe anxiety. On mental status examination, his grooming was appropriate to situation and he was attired appropriately. His attitude was cooperative, and eye contact was good. Motor activity was normal. His speech was normal in volume and tone. Mood was euthymic. Affect was midrange. Thought content and process were linear and logical. Cognition was alert, and he was fully oriented. A May 2019 VA psychiatric evaluation record notes that the Veteran reported not sleeping, nightmares, avoiding people, and avoiding the public due to anxiety in public. He denied feeling depression, noting that he feels anger before depression. Review of symptoms indicated the presence of depression, sleep disturbance, decreased energy, decreased concentration, indecisiveness, anxiety, anhedonia, detachment, restricted range of affect, and irritability/anger. He denied obsessions/compulsions, hallucinations, and delusions. On mental status examination, the Veteran was well-nourished with adequate hygiene and was appropriately dressed with good eye contact. He was fully oriented with appropriate behavior. Attention was within normal limits and focused. There were recent memory deficits. Thought processes were within normal limits/logical. Thought content was free from hallucinations, delusions, paranoia, ideas of reference, hypochondriasis, and obsessions. Mood was appropriate/stable. Affect was mood-congruent. There was no suicidal or homicidal ideation, plan, or intent. Judgment and insight were appropriate. Fundamental knowledge was within normal limits for age/education. The June 2019 VA PTSD examination report estimates that the Veteran's level of occupational and social impairment is best summarized as "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." The Veteran reported that he had been married for nine years with no children. He described his marital relationship as "good" with no marked problems. He has two good friends with whom he served. He maintains contact with one of these friends, who lives locally, approximately once every two to three weeks. He reported having a neutral relationship with his mother. He endorsed avoidance of large groups of people and endorsed irregular episodes of irritable behavior toward others. He has been attending college full time since February 2019, taking a mixture of seated and on-line courses. In the current semester, he was only taking one seated course, which he described as anxiety-provoking. He made the Dean's List last semester. It was noted that, from a psychological perspective, the Veteran is capable of performing activities of daily living without assistance. He enjoys spending time with his wife and going fishing. He helps manage his 7-acre property and care for his animals, which include horses, dogs, chickens, ducks, rabbits, and a tortoise. With respect to the enumerated rating criteria, the following 30 percent symptoms were noted to apply to the Veteran's diagnosis: anxiety and chronic sleep impairment. With respect to the enumerated rating criteria, the following 50 percent symptom was noted to apply to the Veteran's diagnosis: difficulty in establishing and maintaining effective work and social relationships. With respect to behavioral observations, the examiner noted that the Veteran was cooperative and had a notably blasé attitude toward the examination process. He was fully oriented. He presented with an "aggravated" mood and calm affect. He maintained good eye contact and speech was normal in rate, tone, and volume. Cognition, impulse-control, insight, and judgment were adequate/intact. There was no obvious impairment in thought process, thought content, or communication. He denied current suicidal or homicidal ideation, plan, or intent. He had no other symptoms attributable to PTSD. The Veteran testified at his October 2020 Board hearing that he was no longer being treated for PTSD and TBI, noting that he and the mental health provider he had been seeing were not on the same page. (See Board hearing transcript, page 7.) He reported that he has "almost panic-attack anxiety levels" when he is in crowded places. He reported that he does not sleep at night, which makes it difficult on him, his wife, and anyone who deals with him. He reported that he does not trust people. He reported that his "wife's a saint. We had a lot of hard times when she was attempting to figure out how to cope with this and help me, but not anymore." (See Board hearing transcript, page 6.) He reported that he and his wife talked and determined that the Veteran isolating himself is the best way for him to deal with his symptoms. He reported that he is irritable. The Veteran indicated that the report of his being in school full time and making the Dean's List are a misleading indication of his functioning. He described his problems as follows: [W]e tried to do the seated classes, and I had teachers that were very, very understanding because I had a we'll call it a meltdown per se in a class, and I had I got asked to leave, and when I walked out, one of the teachers followed me out and asked what was going on, and I was informing her where I got seated and having a bunch of people behind me wasn't working out, and I was having a panic attack, and I explained my situation, and after that, they made it to where I had the back corner of the class, and if at any point in time, I needed to leave, because it wasn't going good, I could walk out. Thankfully, I had those two teachers to work with me on that, and then after that, we just realized that it it wasn't working because I what happens when you get a teacher that's not going to be that understanding with you? So, I did the online schooling because I honestly would like to have a better education and have been working towards it. Based on the above, the Board finds that an increase from 30 percent to 50 percent, but no higher, is warranted for the Veteran's PTSD with TBI residuals. This increase is warranted based in part on the June 2019 VA examination report's finding of the enumerated rating criterion of difficulty in establishing and maintaining effective work and social relationships. However, it does not demonstrate a level of severity to result in an inability to establish and maintain effective relationships. As noted above, the Veteran has a good relationship with his wife. He also has relationships with family members and has at least one friend with whom he is in regular contact. Therefore, the Board finds that the Veteran's social functioning is most consistent with the criteria for a 50 percent rating. The Board also notes the Veteran's reports of inability to attend classes without special accommodations that allowed him to sit in the back corner and leave when needed, measures that were not allowed in most of his classes, due to his anxiety. The Board finds this symptom is more severe than the "anxiety" and "panic attacks (weekly or less often)" that are noted in the 30 percent rating and more comparable in severity, frequency, and duration to the "panic attacks more than once a week" that are contemplated by the 50 percent criteria. At the same time, these symptoms do not rise in severity, frequency, and duration to "near-continuous panic or depression affecting the ability to function independently, appropriately and effectively" as listed in the 70 percent rating criteria. Given these symptoms, as well as the overall effect they have on his level of functioning, the Board finds that entitlement to a 50 percent rating is warranted. As noted above, the Veteran does not demonstrate near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively or the inability to establish and maintain effective relationships, both of which are listed in the 70 percent rating criteria. Nor does he demonstrate suicidal ideation, and he is not considered to be at risk of harming himself or others. He has not exhibited obsessional rituals that interfere with routine activities. Nor has he demonstrated impairment of speech to such a degree as contemplated by the 70 percent rating. Rather, his speech has consistently been found to be within normal limits. While he has reported irritability, there is no indication that he has lost control of his emotions, resulting in violence. He has consistently been found to be fully oriented and properly groomed. While he has had trouble with stressful circumstances, he has been able to adapt to such circumstances, as is evident by his ability, at times, to attend in-person classes with the above-described accommodations and his ability to move his learning from in-person to on the computer. The difficulties in his ability to complete on-line classes appear to be related to his right hand disabilities rather than his PTSD with TBI. There are no additional symptoms that have been reported that are of a similar severity, frequency, and duration to the criteria for a rating of 70 percent or higher. The Board has considered whether a separate or increased rating is appropriate under 38 C.F.R. § 4.124a, Diagnostic Code 8045, for residuals of TBI. The April 2018 VA TBI examination report notes complaints of mild memory loss. It also notes subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. It was also noted that the Veteran has headaches. Otherwise, no impairment was noted. The July 2019 VA TBI residuals examination report notes that all of the categories under which TBIs are evaluated were normal. It also notes that he has migraine headaches. The Board notes that all of these symptoms are already compensated, either under his PTSD rating under Diagnostic Code 9411 or his headaches rating under Diagnostic Code 8100. Therefore, further consideration of whether to assign a separate or higher rating based on TBI need no longer be discussed. In short, the Board finds that entitlement to an increased rating, from 30 percent to 50 percent, but no higher, is warranted for his PTSD with TBI. To the extent that a rating in excess of 50 percent is sought, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, entitlement to a rating in excess of 50 percent must be denied. 2. Entitlement to an initial rating in excess of 70 percent for right (major) hand neuropathy due to trauma is denied. The Veteran is currently in receipt of a 70 percent rating based on severe, incomplete paralysis of all radicular groups of his right (major) hand under 38 C.F.R. § 4.124a, Diagnostic Code 8513. A 90 percent rating is assigned when there is complete paralysis. The Diseases of the Peripheral Nerves section of 38 C.F.R. § 4.124a provides that "The term 'incomplete paralysis,' with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration." The radicular groups consist of the upper, middle, and lower radicular groups. 38 C.F.R. § 4.124a, Diagnostic Codes 8510, 8511, and 8512. Diagnostic Code 8510 applies to the upper radicular group, which describes complete paralysis as "all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected." Diagnostic Code 8511 applies to the middle radicular group, which describes complete paralysis as "adduction, abduction, and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected." Diagnostic Code 8512 applies to the lower radicular group, which describes complete paralysis as "all intrinsic muscles of hand, and some or all of flexors or wrist and fingers, paralyzed (substantial loss of use of hand)." The Board notes, however, that both relevant VA examination reports of record clearly state that the Veteran had severe, incomplete paralysis of the right musculospiral (radial) nerve, medial nerve, and ulnar nerve. (See April 2018 and June 2019 VA peripheral nerves conditions examination reports.) These impairments fall under Diagnostic Codes 8514, 8515, and 8516. They do not indicate any impairment of the upper, middle, or lower radicular groups. For the musculospiral (radial) nerve, under Diagnostic Code 8514, complete paralysis involves: drop of hands and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movements of wrist; supination of hand, extension or flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of triceps occurs only as the greatest rarity. For the median nerve, under Diagnostic Code 8515, complete paralysis involves" the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. For the ulnar nerve, under Diagnostic Code 8516, complete paralysis involves the "'griffin claw' deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened." In short, the Veteran's disability consists entirely of impairment of his wrist and his hand rather than his entire arm. The Veteran corroborated this characterization at his June 2019 VA examination: He reports decreased sensation of the hand from the wrist to his fingers. Veteran states he has random pain with numbness and tingling to his hand and fingers that radiate from his [right] wrist. Veteran states his pain is intense at times, and he described the pain as a burning pain. He reports decreased grip strength to his right hand. Severe, incomplete paralysis of the major hand for each of these nerve groups is rated at less than 70 percent. (Diagnostic Code 8514 provides a 50 percent, rating, Diagnostic Code 8515 provides a 50 percent rating, and Diagnostic Code 8516 provides a 40 percent rating.) None of these diagnostic codes provides a rating in excess of 70 percent for complete paralysis. (Diagnostic Code 8514 provides a 70 percent rating, Diagnostic Code 8515 provides a 70 percent rating, and Diagnostic Code 8516 provides a 60 percent rating.) The Board finds no reason to change the Veteran's 70 percent rating under Diagnostic Code 8513. The "amputation rule" must be kept in mind when assigning multiple ratings for an extremity. The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. A 70 percent rating is provided for either amputation of the major arm below insertion of the pronator teres or for loss of use of the major hand. 38 C.F.R. § 4.71a, Diagnostic Codes 5124, 5125. In the case at hand, in addition to the 70 percent rating for his neurologic impairment of the right upper extremity, the Veteran is separately in receipt of a 30 percent rating for status post right (major) wrist compound fracture and dislocation and a 0 percent rating for surgical scars of the right wrist. When combined under 38 C.F.R. § 4.25, these rating result in an 80 percent rating for the Veteran's right hand and wrist. Thus, if the Board were to grant a rating in excess of 70 percent for the Veteran's right upper extremity neuropathy, it would violate the amputation rule. Therefore a rating in excess of 70 percent for right (major) hand neuropathy due to trauma is not warranted. 3. Entitlement to a TDIU is granted. A total disability rating based upon individual unemployability due to service-connected disabilities is assigned when service-connected disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. 38 C.F.R. § 4.16(a). A claim for a total compensation rating based upon individual unemployability, "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or to impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In the case at hand, service connection is now in effect for (1) right (major) hand neuropathy due to trauma (at 70 percent disabling); (2) PTSD with TBI (at 50 percent disabling); (3) status post right (major) wrist compound fracture and dislocation (at 30 percent disabling); (4) cervical strain (at 10 percent disabling); (5) thoracolumbar stain (at 10 percent disabling); (6) left knee strain (at 10 percent disabling); (7) tinnitus (at 10 percent disabling): (8) diplopia (at 0 percent disabling); (9) surgical scars of the right wrist (at 0 percent disabling); and (10) migraines (at 0 percent disabling). These disabilities combine under 38 C.F.R. § 4.25 to result in an overall disability rating of 90 percent. The Board will now consider whether these disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. Following review, of the record, the Board finds that the Veteran's service-connected disabilities result in such impairment of mind or body that he is precluded from following a substantially gainful occupation. First, the Board notes the Veteran's neurologic and musculoskeletal disabilities of his major hand and wrist render him unable to type, which results in significant impairment in his ability to engage in sedentary employment that requires typing. He testified at his Board hearing that he would have been unable to complete his online classes on his own. He reported that he has had to have his wife type for him because he is unable to type one-handed and talk-to-text software cannot understand his accent. (See Board hearing transcript, page 35.) He reported that he "can click multiple choice stuff with the mouse for myself, obviously, with my good hand, but it unless I can have someone there to type as dictating it, it's not going to be a whole lot of one-handed time." (See Board hearing transcript, page 35.) When asked at his Board hearing whether he has considered vocational rehabilitation or an apprenticeship, he stated that "I can't think of anything that would really fit (inaudible) an apprenticeship. Like I said, if I'm doing something in an office, (inaudible) someone to type for me or a some kind of software that all of a sudden understands southern mixed with Appalachian American." (See Board hearing transcript, pages 35-36.) Second, as discussed above, the Veteran has difficulty in crowds due to his PTSD symptoms, which would render it difficult for him to work around other people. A June 2019 VA individual unemployability statement from the psychologist who examined the Veteran checks the box stating that the "Individual has other mental health problems or symptoms, e.g., panic attacks, irritability, suspiciousness, etc., that interfere significantly with the ability to work." Third, the Board finds that the severity of the Veteran's headache complaints contributes to rendering him unemployable. The April 2018 VA examination report notes that the Veteran experiences constant head pain, pulsating or throbbing head pain, pain on both sides of the head, pain that worsens with physical activity, nausea, sensitivity to light, and sensitivity to sound. The examiner also noted that the head pain lasts less than one day. The examiner noted that the Veteran does not have characteristic prostrating attacks of migraine/non-migraine headache pain and that he does not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. There were no other pertinent physical finding, complications, conditions, signs, or symptoms related to the Veteran's headaches. The Veteran also underwent a VA headache examination in July 2019. The resulting examination report notes that the Veteran is "[g]etting 3-4 headaches a week [with] occasional aura. Pain bifronto temporal throbbing he gave it 8-10 on scale of 10 lasting 1/2 a day or longer with photophobia." The pain was described as pulsating or throbbing head pain with pain on both sides of the head with sensitivity to light. The typical duration is less than one day. It was noted that he does not have characteristic prostrating attacks of migraine/non-migraine headache pain and that he does not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to this condition. It was noted that his headache condition impacts his ability to work, with a notation that he has "[greater than] 5 weeks work time lost in last 12 months confirmed in medical record[.] He indicate[s] that during headaches he can not function all day. [H]e is having 4-5 a week." The Veteran has submitted an August 2019 private medical record and a September 2019 headache log that corroborate his reports of having frequent headaches. (These records were originally submitted outside of one of the evidentiary submission windows but were resubmitted within the 90-day evidentiary window following his October 2020 Board hearing.) The August 2019 private medical record notes that the Veteran is having headaches "4-5 times a day. Some of them he may see spots. The pain is bifrontotemporal, throbbing, with photophobia and phonophobia and occasional nausea. Severity ... at its highest remains for 35 to 45 minutes but the headache continues all day long." It describes his medication regimen and notes that he had Botox in the past, which did not help. It was noted that "Really the only thing left in the game as a viable option is the CGRP antagonists which I discussed with him in length and I am giving him a sample and a prescription for Aimovig 140 mg and arranged for f/u in 2 mos." The Veteran has also submitted a September 2019 migraine log. This log records 20 severe migraine headaches during that month. The Board finds that the impairment caused by the Veteran's right hand, psychiatric, and migraine headaches preclude him from following a substantially gainful occupation. While the Veteran has been able to learn how to perform some activities with his left hand rather than his right hand, many occupations, both sedentary and physical, require that an individual be able to use both hands. The Board finds that the impairment from his right hand and wrist, which essentially render him unable to use his dominant hand, precludes the performance of activities, such as lifting or the use of tools, that is required for much light, medium, and heavy physical employment. In addition, the Veteran is unable to type due to his service-connected right hand disabilities and is presumably unable to write due to these disabilities as well, which precludes many types of sedentary employment. To the extent that he is able to perform sedentary or light physical employment that does not involve typing or writing, the Veteran's frequent and severe headaches interfere with his ability to function for extended periods of time. In addition, his psychiatric disability has been found to interfere significantly with his ability to work, which potentially impacts all types of employment in which he has to interact with a supervisor, coworkers, and the public. In short, the Board finds that the Veteran's service-connected disabilities preclude him from following a substantially gainful occupation, and entitlement to a TDIU is granted. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.