Citation Nr: 22015291 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 06-37 317A DATE: March 17, 2022 ORDER Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for skin disability other than seborrheic dermatitis is denied. Entitlement to service connection for hematomas is denied. Entitlement to an initial 30 percent rating, but no higher, from October 3, 2008, for dysphagia is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 20 percent for cervical strain is denied. FINDINGS OF FACT 1. The evidence persuasively weighs against a finding that the Veteran has had hearing loss to an extent recognized as a disability for VA purposes at any time during or approximate to the pendency of her claim. 2. The evidence persuasively weighs against a finding that the Veteran has had any skin disability other than seborrheic dermatitis at any time during or approximate to the pendency of her claim. 3. The Veteran's hematomas did not have their onset in service, the disability is not otherwise related to an in-service injury or disease, and the disability is not an undiagnosed illness or a medically unexplained chronic multisymptom illness. 4. The evidence is at least evenly balanced as to whether, since the October 3, 2008 effective date of service connection, the Veteran's dysphagia has been manifested by moderate stricture of the esophagus; there has been no stricture of the esophagus such that only the passage of liquids is possible. 5. Since the October 3, 2008 effective date of service connection, the Veteran's cervical strain has been manifested by limitation of flexion of the cervical spine to at most 25 degrees during flare ups and with repeated use over time; there is no spinal ankylosis, functional equivalent of spinal ankylosis, or incapacitating episodes due to intervertebral disc syndrome (IVDS). CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for service connection for skin disability other than seborrheic dermatitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hematomas are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial 30 percent rating, but no higher, from October 3, 2008, for dysphagia, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.114, Diagnostic Code (DC) 7203. 5. The criteria for an initial rating higher than 20 percent for cervical strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1990 to May 1991 and from March 2003 to May 2004, which includes service in the Southwest Asia theater of operations. She had additional service with the Army Reserve. Her awards include the Army Commendation Medal. These matters initially came before the Board of Veterans' Appeals (Board) from March 2009, July 2009, and March 2014 rating decisions. In September 2014, the Board remanded the issues of entitlement to service connection for bilateral hearing loss and entitlement to a higher initial rating for cervical strain for further development. In July 2015, the agency of original jurisdiction (AOJ) awarded a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, from October 4, 2014 (the day after the Veteran's gainful employment ended). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a November 2016 hearing and a transcript of the hearing has been associated with her claims file. In April 2017, the Board granted an application to reopen a claim of service connection for skin disability and remanded the underlying claim of service connection for skin disability other than seborrheic dermatitis, as well as the claims of service connection for bilateral hearing loss and hematomas, and the issues of entitlement to higher initial ratings for dysphagia and cervical strain, for further development. In August 2020, the AOJ assigned a 20 percent disability rating for cervical strain, from January 7, 2013. In December 2020, the Board remanded the remaining matters on appeal for further development. In December 2021, a Decision Review Officer (DRO) assigned a 20 percent rating for cervical strain, from October 3, 2008. In the September 2014, April 2017, and December 2020 remands, the Board instructed the AOJ to, among other things, ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Mendez), obtain the Veteran's outstanding VA treatment records, obtain her outstanding relevant Social Security Administration (SSA) records, and afford her examinations to assess the nature of her claimed hematomas, to obtain an opinion as to whether her hematomas are related to service, and to assess the severity of her service-connected dysphagia and cervical strain. Pursuant to the Board's remands, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Mendez) by way of letters dated in October 2014, June 2015, June 2019, and December 2020. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letters. Moreover, all available outstanding VA treatment records were obtained and associated with the claims file, all relevant outstanding SSA records were obtained and associated with the claims file, VA hematoma, dysphagia, and cervical spine examinations were conducted in October 2019 and/or November 2021, and a VA medical opinion addressing whether the Veteran's hematomas are related to service was obtained in October 2019. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Lastly, the Board points out that the Veteran had also perfected an appeal with regard to the issues of entitlement to service connection for hypertension, bilateral eye disability, and bilateral hand/finger disability, and the Board remanded these issues in December 2020 for further development. A DRO awarded service connection for hypertension, bilateral dry eye syndrome, and bilateral hand strain with painful motion of the fingers in the December 2021 decision, and thereby resolved the appeal as to these issues. I. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first 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). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117 ; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317 (a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, an undiagnosed illness and a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317 (a)(2). A MUCMI is a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to, fatigue, signs or symptoms involving skin, headaches, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317 (b). 1. Entitlement to service connection for bilateral hearing loss disability Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The question for the Board is whether the Veteran has current hearing loss disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds, for the following reasons, that the Veteran does not experience hearing loss to an extent recognized as a disability for VA purposes, and has not experienced such disability at any time since her service connection claim was received in January 2013 or prior thereto. Cf. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran was afforded a VA audiological examination in February 2011. During that examination, her pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 10 15 LEFT 10 5 5 15 20 Speech audiometry revealed speech recognition ability of 100 percent in both ears. During an April 2012 VA audiological examination, the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 15 15 15 LEFT 15 10 15 15 15 Speech audiometry revealed speech recognition ability of 100 percent in both ears. A VA audiological examination was conducted in February 2013, but the Veteran's pure tone thresholds and speech recognition ability were unable to be tested. The examiner explained that the Veteran's pure tone average and speech recognition threshold were not in good agreement, even after resting and reinstruction. The Veteran revealed positive Stenger results. Due to these factors, the test was invalid and retesting at a later date was recommended. During an April 2015 VA audiological examination, the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 10 15 15 LEFT 25 15 15 20 20 Speech audiometry revealed speech recognition ability of 100 percent in both ears. During an October 2019 VA audiological examination, the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 20 20 LEFT 15 15 10 20 25 Speech audiometry revealed speech recognition ability of 100 percent in both ears. While the Veteran believes she has current bilateral hearing loss disability, and she is competent to report the symptoms of her claimed disability, VA has determined that for hearing loss to constitute disability, certain audiometric and speech recognition scores must be present. The Board is bound by the laws and regulations that apply to veterans' claims. 38 U.S.C. § 7104 (c) (2012); 38 C.F.R. §§ 19.5, 20.101(a). The above evidence does not establish bilateral hearing loss to the extent recognized as a disability for VA purposes at a time during or approximate to the claim period, and the Veteran has not alluded to the existence of any other evidence establishing a current bilateral hearing loss disability. Despite the Veteran's competent and credible reports of ear/hearing symptoms, the determination of whether hearing loss constitutes a disability for VA purposes is determined by a mechanical application of the definition found in 38 C.F.R. § 3.385 to audiometric (pure tone threshold and Maryland CNC) testing results. The provisions of 38 C.F.R. § 3.385 do not authorize a finding of hearing loss disability when pure tone thresholds and/or speech recognition scores fail to meet the requirements of the regulation. Hence, although the Veteran has reported complaints of hearing loss, the Board is bound by the testing results and has no discretion in this regard. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. Thus, where, as here, the evidence establishes that the Veteran does not have the hearing loss disability for which service connection is sought, pursuant to the applicable regulation that defines the disability in terms of audiometric and speech recognition scores, there can be no valid claim of service connection. See Gilpin, 155 F.3d at 1353; Brammer, 3 Vet. App. at 225. As such, service connection for bilateral hearing loss disability is not warranted because the first criterion for an award of service connection-evidence of current disability upon which to predicate such an award-has not been met. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for bilateral hearing loss disability is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 2. Entitlement to service connection for skin disease other than seborrheic dermatitis The question for the Board is whether the Veteran has any skin disability other than seborrheic dermatitis that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds, for the following reasons, that while the Veteran did experience skin problems in service, she does not experience any skin disability other than seborrheic dermatitis, and has not experienced any such disability at any time since her service connection claim was received in October 2008 or approximate thereto. Cf. Romanowsky, 26 Vet. App. at 293 (2013); McClain, 21 Vet. App. at 321. The Veteran contends that she experiences current skin disability which had its onset in service. Her service treatment records confirm that she reported and/or was treated for a skin rash, a facial lesion, and erythema in service, and her post-service medical records and lay statements indicate that her skin symptoms have continued in the years since service. Service connection has already been awarded for seborrheic dermatitis. However, the Veteran has not reported, and the evidence does not otherwise reflect, that she has experienced any skin disability other than seborrheic dermatitis or any skin symptoms not attributable to seborrheic dermatitis at any time during or approximate to the claim period. Overall, there is no evidence that the Veteran has experienced or been diagnosed as having any skin disability other than seborrheic dermatitis at any time during the pendency of her October 2008 claim or approximate thereto, and neither she nor her representative have alluded to the existence of any such evidence. Thus, where, as here, the evidence establishes that the Veteran does not have the disability for which service connection is sought, there can be no valid claim of service connection. See Gilpin, 155 F.3d at 1353; Brammer, 3 Vet. App. at 225. As such, service connection for skin disability other than seborrheic dermatitis is not warranted because the first criterion for an award of service connection-evidence of current disability upon which to predicate such an award-has not been met. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for skin disability other than seborrheic dermatitis is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch, 21 F.4th at 776. 3. Entitlement to service connection for hematomas The question for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds, for the following reasons, that, while there is evidence that the Veteran has current hematomas, the claimed disability is not shown to have had its onset in service, or to be otherwise related to a disease or injury in service. Medical records, including a January 2018 VA pulmonary note and the report of an October 2019 VA hematologic and lymphatic conditions examination, reveal that the Veteran has been diagnosed as having hematomas. Thus, current disability has been demonstrated. The Veteran does not contend, and the evidence does not otherwise reflect, that she has experienced a continuity of hematoma symptomatology in the years since service. In this regard, there is no evidence of any complaints of or treatment for hematomas documented in the Veteran's service treatment records and her April 1991 separation examination did not reveal any hematomas. There is no report of any separation examination for her period of service from March 2003 to May 2004. Also, the earliest evidence of hematomas following service is an August 2008 VA primary care note, which reveals that the Veteran experienced bilateral lower extremity hematomas with no history of trauma. The hematomas were in the resolving phase, there was no tenderness to palpation, and the Veteran's complete blood count was normal. There is no earlier evidence of any hematomas following service. In addition, the preponderance of the competent, probative opinions on whether there is a relationship between the Veteran's hematomas and service weigh against the claim. The examiner who conducted a May 2009 VA examination concluded that the hematomas in the Veteran's lower extremities had resolved and, therefore, it was not a chronic condition and was not caused by or a result of her Gulf War service. The examiner reasoned that the relevant VA regulation (38 C.F.R. § 3.317) states that chronic disabilities qualify for service connection, and the hematomas in the Veteran's lower extremities had resolved. The physician who conducted the October 2019 VA hematologic and lymphatic conditions examination opined that the Veteran's hematomas were not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. He reasoned that the most common cause of a hematoma is injury or trauma to blood vessels. This can happen as a result of any damage to blood vessels that can disrupt the integrity of the blood vessel wall. Occasionally, a hematoma may happen spontaneously without any identifiable cause or recollection of any specific injury or trauma. There are also certain medical conditions that may pose an additional risk for developing hematomas. In this case, the Veteran does not have any of the previously mentioned conditions, according to her medical history, and there is no diagnosis of any condition that could be the cause of the Veteran's hematomas. The May 2009 opinion is of little, if any, probative value because although no hematomas were present at the time of the examination, the examiner did not acknowledge the August 2008 VA primary care treatment note which reflects that the Veteran had lower extremity hematomas. Also, bruising was visible on her arms during the November 2016 Board hearing. In this regard, the requirement for current disability is satisfied if there is evidence of the disability at any time since approximately October 2008 when the Veteran's claim of service connection for hematomas was received, even if the disability goes into remission or completely resolves. McClain, 21 Vet. App. at 319. The October 2019 opinion, by contrast, is based upon an examination of the Veteran, a review of her treatment records, and consideration of her reported history, and it is accompanied by a specific rationale that is consistent with the evidence of record. Therefore, the October 2019 opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Additionally, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive question presented in this case (i.e., whether any relationship exists between the Veteran's hematomas and service) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). An opinion as to whether there is a link between the Veteran's claimed hematomas and service (where there is no evidence of any hematomas for years following service) is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that she has such experience. Her opinion on the question of nexus is therefore not competent evidence in this instance. Moreover, as the Veteran's claimed disability was specifically diagnosed as hematomas, it is not an undiagnosed illness. Also, the Veteran has not experienced any overlapping signs and symptoms associated with her claimed hematomas. Therefore, her claimed hematomas are also not a MUCMI. There is no other evidence of a relationship between the Veteran's current hematomas and service, and neither she nor her representative have alluded to the existence of any such evidence. Thus, for the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for hematomas is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch, 21 F.4th at 776. II. Higher Initial Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) (Rating Schedule) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). If two ratings are potentially applicable, 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. § 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. 1. Entitlement to an initial compensable rating for dysphagia The Veteran's dysphagia is rated under 38 C.F.R. § 4.114, DC 7203 as stricture of the esophagus. Under DC 7203, the following ratings apply: a 30 percent rating is warranted for moderate stricture; a 50 percent rating is warranted for severe stricture, permitting liquids only; and an 80 percent rating is warranted for stricture permitting passage of liquids only, with marked impairment of general health. 38 C.F.R. § 4.114, DC 7203. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "moderate" and "severe." The Board notes, for reference and illustrative purposes, that the definitions for moderate include of average or medium quantity, quality, or extent. See Webster's II New College Dictionary 704 (1995). Also, definitions of severe include extremely intense. Id. at 1012. The Board finds, for the following reasons, that the evidence is at least evenly balanced as to whether an initial 30 percent rating, but no higher, for dysphagia is warranted since the October 3, 2008 effective date of service connection. An April 2009 VA primary care follow up note, the May 2009 VA Gulf War examination report, a March 2016 VA gastroenterology consultation note, the Veteran's testimony during the November 2016 Board hearing, VA treatment records dated from August 2016 to October 2019, and the report of a November 2021 VA esophageal conditions examination indicate that the Veteran experienced occasional difficulty swallowing dry, solid foods (e.g., crackers, bread, meat). During episodes of dysphagia she experienced a "shocking sensation with cough" and shortness of breath. She did not experience any nausea, vomiting, chest pain, diarrhea, melena, hematochezia, or dysuria. She did not take any medications for her disability. There were no scars related to the Veteran's disability and she did not experience any other pertinent findings, complications, conditions, signs, or symptoms associated with her dysphagia. Examinations revealed that the Veteran was well developed, well nourished, and well groomed, and that her mouth, tongue, gums, uvula, and palate were all normal. The Veteran was diagnosed as having dysphagia secondary to lingual tonsil condition. This disability impacted her ability to work in that she needed a longer lunch time in order to swallow meals slowly. As a result of her dysphagia, it was recommended that the Veteran follow a special diet of mechanically altered/minced and moist food with some exposure to advance solids and regular liquids. Also, the examiner who conducted the November 2021 examination indicated that there was no increase in severity of the Veteran's symptoms during the claim period because there was no dysphagia to liquids. In light of the above symptoms and impairments associated with the Veteran's dysphagia (which include difficulty swallowing dry, solid foods, a cough, and the need to follow a special diet), the Board finds that the evidence is at least evenly balanced as to whether the symptoms of the Veteran's dysphagia have more closely approximated the criteria for a 30 percent rating under DC 7203 (which contemplates moderate stricture of the esophagus) during the entire claim period. As the reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran, an initial 30 percent rating for this disability is warranted, from the October 3, 2008 effective date of service connection. The Board also finds that a rating higher than 30 percent for dysphagia is not warranted at any time since the effective date of service connection. Specifically, although the Veteran experiences difficulty swallowing some solid foods, her dysphagia has not resulted in an inability to swallow all solids or limited her to only a liquid diet. Therefore, no higher rating is warranted under DC 7203. Moreover, the Board acknowledges that the Veteran has reported a cough/shortness of breath associated with her dysphagia. However, she has already been awarded service connection and a separate 60 percent disability rating for respiratory disability (asthma and sarcoidosis) during the entire claim period. Therefore, no separate/higher rating for dysphagia is warranted on the basis of the Veteran's reported respiratory symptoms. Overall, the Board finds that the service-connected dysphagia has not been shown to involve any other factor(s) warranting evaluation under any other provision(s) of VA's rating schedule. Therefore, an initial 30 percent rating, but no higher, from October 3, 2008, for dysphagia is warranted. 2. Entitlement to an initial rating higher than 20 percent for cervical strain The Veteran's cervical strain is rated under 38 C.F.R. § 4.71a, DC 5237. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021, and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. A cervical strain under DC 5237 is rated based on limitation of motion of the cervical spine under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula both prior to and since the regulatory change, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or, combined range of motion of the cervical spine not greater than 170 degrees; or, if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion, extension, and left and right lateral flexion of the cervical spine are zero to 45 degrees and left and right lateral rotation of the cervical spine are zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. The rating criteria provide that 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 for Diseases and Injuries of the Spine, Note (5). The Court has held that a veteran may be entitled to a rating under the General Rating Formula if she experiences the functional equivalent of ankylosis when considering the provisions of 38 C.F.R. §§ 4.40 and 4.45. Chavis v. McDonough, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660 (Vet. App. Apr. 16, 2021). Under DC 5243 both prior to and since the regulatory change, IVDS (preoperatively or postoperatively) is rated either under the General Rating Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, DC 5243. Under the criteria for rating IVDS, the following ratings apply: a 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during 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 during the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. For purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested cervical spine symptoms of the type and extent, frequency, and/or severity, as appropriate, to warrant no more than a 20 percent rating since the October 3, 2008 effective date of service connection. The reports of VA Gulf War and cervical spine examinations dated in May 2009 indicate that the Veteran experienced worsening cervical spine disability which did not properly respond to pain medications or physical therapy. She took medications on a daily basis for her disability, but the response was poor. The Veteran experienced fatigue, decreased motion, stiffness, weakness, spasms, and constant severe cervical/upper back pain. The pain occurred on a daily basis and did not radiate. The Veteran did not experience any flare ups of cervical spine symptoms and there was no history of any hospitalization or surgery, trauma to the spine, neoplasm, urinary or fecal symptoms, numbness, paresthesias, leg or foot weakness, falls, or unsteadiness. The Veteran had experienced 3 months of incapacitating episodes "for the thoracolumbar region" during the previous 12 months, but she not use any devices/aids and was able to walk 14 mile. Examination revealed that the Veteran's posture and head position were normal, that there was symmetry in appearance, that her gait was normal, that there were no abnormal spinal curvatures, and that there was no cervical spine ankylosis. There was bilateral spasm, pain with motion, and tenderness of the cervical sacrospinalis, but there was no muscle atrophy, guarding, or weakness. Upper extremity muscle strength was normal (5/5) bilaterally, upper extremity sensation was normal bilaterally, and upper extremity reflexes were all normal (2+) bilaterally. The ranges of motion of the cervical spine were recorded as being flexion to 30 degrees, extension to 25 degrees, left and right lateral flexion both to 30 degrees, left lateral rotation to 40 degrees, and right lateral rotation to 45 degrees. There was objective evidence of pain on active range of motion. Also, there was objective evidence of pain following repetitive motion, but there were no additional limitations after three repetitions of range of motion. The reduced ranges of spinal motion did not represent normal for the Veteran due to other factors not related to her service-connected cervical spine disability. Lasegue's sign was not positive and bilateral spurling test was negative. The Veteran was diagnosed as having cervical strain and degenerative cervical disc disease. She was employed on a full time basis as a post office clerk and had missed 12 weeks of work during the previous 12 months due to medical appointments, treatments, rest at home, and the use of pain medications. Her disability had significant effects on her occupation in that it resulted in increased tardiness and absenteeism, decreased concentration and mobility, problems with lifting and carrying, difficulty reaching, decreased strength, and pain. Also, the disability had mild to severe effects on other activities of daily living. A February 2013 VA examination report and addendum indicate that the Veteran experienced low back pain which traveled up to the neck and shoulders. The pain was severe, occurred spontaneously, and was relieved by rest and medications. Examination revealed that the Veteran's posture and gait were normal and steady, that her upper extremity motor function was normal, that upper extremity sensation was intact bilaterally, and that upper extremity reflexes were all normal. The ranges of motion of the cervical spine were flexion, extension, and right and left lateral flexion all to 45 degrees and right and left rotation both to 80 degrees, all without pain on movement. The Veteran was diagnosed as having a cervical strain. A February 2015 VA cervical spine examination report, a June 2015 private treatment record, and the Veteran's testimony during the November 2016 Board hearing indicate that she experienced a tense pressure-like pain in the neck that fluctuated from 4-7/10 in intensity and muscle spasms. She used medications to treat her symptoms and underwent physical therapy which provided only short-term relief. There were constant, daily flare ups of cervical spine symptoms which lasted for hours at a time, but the Veteran did not report any functional loss/impairment of the cervical spine. Examination revealed that the ranges of motion of the cervical spine were flexion to between 30 and 50 degrees, extension to between 25 degrees and 40 degrees, right and left lateral flexion both to between 30 degrees and 40 degrees, and left and right lateral rotation both to 40 degrees. The ranges of motion themselves contributed to a functional loss in that there was pain associated with all ranges of motion and the pain caused functional loss. There was no evidence of pain with weight bearing. There was tenderness to palpation of the joint or associated soft tissue of the cervical spine. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. She was not being examined immediately after repetitive use over time or during a flare up and the examination neither supported nor contradicted her statements describing functional loss with repetitive use over time and during flare ups. The examiner who conducted the examination was unable to determine without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare ups. The examiner explained that all musculoskeletal disorders present in an individual could potentially cause functional limitations during repetitive use over a period of time and during flare ups. However, to describe a functional limitation in terms of severity or significance based on a possible future event or classify the functional limitation of a flare up in the absence of the flare up would be mere speculation. Moreover, there were muscle spasms and localized tenderness, but they did not result in an abnormal gait or abnormal spinal contour. There was no guarding. There were additional contributing factors of disability in terms of less movement than normal. Upper extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, upper extremity reflexes were all normal (2+) bilaterally, and upper extremity sensation was normal bilaterally. There was no radicular pain or any other signs or symptoms due to radiculopathy, there was no ankylosis of the spine, and there were no other neurologic abnormalities related to a cervical spine disability. The Veteran had IVDS of the cervical spine, but had not experienced any episodes of acute signs and symptoms due to IVDS that required bedrest prescribed by a physician and treatment by a physician during the previous 12 months. She did not use any assistive devices and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's cervical spine disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. A diagnosis of cervical strain was provided. This disability did not impact the Veteran's ability to work. An October 2019 VA cervical spine examination report indicates that the Veteran experienced cervical spine stiffness and pain (5/10 in intensity). There was no radiation of symptoms to her upper extremities. Severe flare ups of cervical spine symptoms occurred on a weekly basis and lasted for days at a time. The examiner noted that the medical evidence, physical examination, and the Veteran's history were consistent with her lay statements regarding range of motion loss during flare ups and with repetitive use over time. There was functional loss/impairment of the cervical spine in terms of difficulty driving. Examination revealed that the ranges of motion of the cervical spine were flexion, extension, and right and left lateral flexion all to 35 degrees, and left and right lateral rotation both to 55 degrees. The ranges of motion themselves did not contribute to a functional loss. There was pain associated with all ranges of motion, but the pain did not result in/cause functional loss. There was evidence of pain with weight bearing and there was objective evidence of cervicodorsal spasm. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. She was not being examined immediately after repetitive use over time or during a flare up and the examination was medically consistent with her statements describing functional loss with repetitive use over time and during flare ups. Pain significantly limited functional ability with repeated use over a period of time and during flare ups. The examiner specified that the ranges of spinal motion with repeated use over time and during flare ups would be flexion, extension, and right and left lateral flexion all to 25 degrees, and right and left lateral rotation both to 30 degrees. Moreover, there were muscle spasms, but they did not result in an abnormal gait or abnormal spinal contour. There was no guarding. There were no additional contributing factors of disability. Upper extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, upper extremity reflexes were all normal (2+) bilaterally, and upper extremity sensation was normal bilaterally. There was no radicular pain or any other signs or symptoms due to radiculopathy, there was no ankylosis of the spine, and there were no other neurologic abnormalities related to a cervical spine disability. The Veteran did not have IVDS of the cervical spine, did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's cervical spine disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having cervical strain and mild spondylosis of the cervical spine. This disability did not impact the Veteran's ability to work. Also, the examiner noted that there was evidence of pain on passive range of motion testing and when the joint was used in non weight-bearing. In July 2020, a VA physician reviewed the Veteran's claims file and explained that mild spondylosis of the cervical spine (interchangeable term for degenerative arthritis of the cervical spine) was not a progression of the Veteran's service-connected cervical strain. The physician explained that medical evidence supports the fact that having cervical strain does not cause and does not progress to degenerative arthritis of the cervical spine. An April 2015 MRI revealed evidence of cervical spine degenerative disc changes and a March 2017 x-ray revealed cervical spondylosis or degenerative arthritis of the cervical spine. The MRI and x-ray were compatible with non-traumatic degenerative arthritis of the cervical spine, as seen in normal progression of the aging process. This is completely unrelated to the Veteran's service-connected cervical strain. Medical evidence does not support the fact that cervical strain could progress to cervical spine degenerative arthritis. Moreover, the physician explained that the IVDS of the cervical spine that was documented in 2015 was not a progression and was not related to the Veteran's service-connected cervical strain. Medical evidence supports the fact that cervical strain and cervical spondylosis (cervical degenerative arthritis) are not related. Also, medical evidence does not support the fact that having cervical strain could possibly cause or progress to IVDS. The above evidence reflects that since the effective date of service connection, forward flexion and extension of the cervical spine have been limited to at most 30 degrees and 25 degrees, respectively. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a 20 percent rating under the General Rating Formula. As for functional impairment, the Veteran has experienced neck pain and there has been pain with ranges of spinal motion, Nevertheless, the ranges of spinal motion remained the same following repetitive-use testing and there was no additional loss of function after three repetitions. The Veteran did not report any flare ups of cervical spine symptoms during the May 2009 or February 2013 examinations. Flare ups were reported during the February 2015 and October 2019 VA examinations, and the examiner who conducted the October 2019 examination specified that spinal flexion and extension would be limited to 25 degrees during flare ups and with repeated use over time. The Veteran is competent to report the symptoms associated with her service-connected cervical spine disability and the extent of her impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of her contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the evidence indicates that the Veteran's cervical spine symptoms have most closely approximated the criteria for at most a 20 percent rating for limitation of spinal motion under the General Rating Formula during the entire claim period since the October 3, 2008 effective date of service connection. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent rating at any time during the claim period. The most persuasive evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's neck symptoms have not shown to be so disabling to actually or effectively result in limitation of forward flexion of the cervical spine more nearly approximating 15 degrees or less, which is the requirement for a 30 percent rating based on limitation of spinal motion in the absence of ankylosis under the General Rating Formula. The Board also finds that a rating higher than 20 percent is not warranted on the basis of spinal ankylosis/functional equivalent of ankylosis or IVDS. Specifically, no spinal ankylosis was noted during any of the examinations conducted during the claim period. Also, despite the limited ranges of spinal motion during the claim period, the Board finds that even considering neck pain, flare ups, and other functional factors, the Veteran has not experienced the functional equivalent of spinal ankylosis (as defined above) at any time during the claim period. In other words, the most persuasive evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's neck symptoms have not been shown to be so disabling to actually or effectively result in fixation of the entire cervical spine in flexion or extension with any of the additional symptoms or limitations listed in Note (5) of the General Rating Formula. Therefore, a higher rating is not warranted on the basis of ankylosis/functional equivalent of ankylosis at any time during the claim period. Moreover, the Board acknowledges that the Veteran has been diagnosed as having IVDS during the claim period. However, the examiner who conducted the February 2015 examination specified that the Veteran did not experience any incapacitating episodes of IVDS as defined above (i.e., bed rest prescribed by a physician and treatment by a physician). The Board acknowledges that the May 2009 examination reports appear to suggest that the Veteran may have experienced 3 months of incapacitating episodes. It is unclear whether this is in reference to the cervical spine or the thoracolumbar spine. Nevertheless, even assuming that it was in reference to the cervical spine, the physician who reviewed the Veteran's claims file in July 2020 explained that the Veteran's IVDS was neither a progression of nor related to her service-connected cervical strain. Therefore, a higher rating is not warranted on the basis of IVDS at any time during the claim period. 3. Additional Considerations As a final point, in conjunction with the higher rating matters decided in this decision, no other related issues have been raised by the Veteran or her representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.