Citation Nr: 22017651 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-64 207 DATE: March 25, 2022 ORDER A rating in excess of 20 percent for a lumbar spine disability is denied. A 10 percent, but no higher, rating for right lower extremity radiculopathy, sciatic nerve, from April 9, 2015 to June 21, 2017 is granted, subject to the law and regulations governing the payment of monetary awards. A 20 percent, but no higher, rating for left lower extremity radiculopathy, sciatic nerve, from April 9, 2015 to June 21, 2017 is granted, subject to the law and regulations governing the payment of monetary awards. A rating in excess of 20 percent for right lower extremity radiculopathy, sciatic nerve, from June 22, 2017 is denied. A rating in excess of 40 percent for left lower extremity radiculopathy, sciatic nerve, from June 22, 2017 is denied. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy, femoral nerve, from September 23, 2020 is denied. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy, femoral nerve, from September 23, 2020 is denied. REMANDED Entitlement to service connection for a condition manifested by loss of concentration as secondary to service-connected disabilities, including medication taken for service-connected disabilities. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or housebound status is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine disability has not manifested with forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine, and a physician has not ordered bed rest for intervertebral disc syndrome (IVDS). 2. From April 9, 2015 to June 21, 2017, the Veteran had symptoms of pain in the right lower extremity that more nearly approximated mild incomplete paralysis of the sciatic nerve. 3. From April 9, 2015 to June 21, 2017, the Veteran had symptoms of pain and decreased sensation in the left lower extremity that more nearly approximated moderate incomplete paralysis of the sciatic nerve. 4. From June 22, 2017, the Veteran's right lower extremity radiculopathy, sciatic nerve, most nearly approximates moderate incomplete paralysis. 5. From June 22, 2017, the Veteran's left lower extremity radiculopathy, sciatic nerve, most nearly approximates moderately severe incomplete paralysis. 6. From September 23, 2020, the Veteran's left lower extremity radiculopathy, femoral nerve, more nearly approximates moderate incomplete paralysis. 7. From September 23, 2020, the Veteran's right lower extremity radiculopathy, femoral nerve, more nearly approximates moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5235. 2. From April 9, 2015 to June 21, 2017, the criteria for a 10 percent, but no higher, rating for right lower extremity radiculopathy, sciatic nerve, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 3. From April 9, 2015 to June 21, 2017, the criteria for a 20 percent, but no higher, rating for left lower extremity radiculopathy, sciatic nerve, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 4. From June 22, 2017, the criteria for a rating in excess of 40 percent for left lower extremity radiculopathy, sciatic nerve, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 5. From June 22, 2017, the criteria for a rating in excess of 20 percent for right lower extremity radiculopathy, sciatic nerve, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 6. From September 23, 2020, the criteria for a rating in excess of 20 percent for left lower extremity radiculopathy, femoral nerve, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8526. 7. From September 23, 2020, the criteria for a rating in excess of 20 percent for right lower extremity radiculopathy, femoral nerve, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1985 to March 1987. This matter is on appeal from an April 2015 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, a videoconference hearing was held before the undersigned. A transcript of the hearing is in the record. The case was previously before the Board in April 2020 when it was remanded for further development. In an October 2020 rating decision, the RO awarded service connection for radiculopathy, left lower extremity, femoral nerve, evaluated as 20 percent disabling, effective September 23, 2020, and service connection for radiculopathy, right lower extremity, femoral nerve, evaluated as 20 percent disabling, effective September 23, 2020. As service connection was awarded for these disabilities and ratings were assigned as part of the appeal before the Board seeking a higher rating for the lumbar spine disability, the Board finds that they are part and parcel of the appeal seeking an increased rating for the lumbar spine disability. See, e.g., Chavis v. McDonough, 34 Vet. App. 1, 15 (2021); 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). As such, the Board has included the bilateral lower extremity radiculopathy, femoral nerve, issues in the appeal. The Veteran was also separately evaluated during the appeal period for radiculopathy, left lower extremity, sciatic nerve, evaluated as 40 percent disabling, and radiculopathy, right lower extremity, sciatic nerve, evaluated as 20 percent disabling. Pursuant to Chavis, the Board also finds that these ratings are part of the increased rating for a lumbar spine disability that is before the Board. Additionally, as noted below, the Veteran has indicated that medications taken for his service-connected lumbar spine and radiculopathy disabilities affect his mental abilities. The Board finds that these statements logically relate to the claim seeking an increased rating for the lumbar spine and lower extremity radiculopathy claims before the Board and raise a claim of service connection for a psychiatric disability as secondary to the Veteran's service-connected disabilities. See Wilson v. McDonough, No. 19-3791, 2022 U.S. App. Vet. Claims LEXIS 85 (Vet. App. Jan. 26, 2022); Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). As such, the Board has included this issue for consideration and is remanding it for further development. 1. Increased Rating for Lumbar Spine Disability The Veteran contends that he is entitled to an increased rating for his service-connected lumbar spine disability, which is currently assigned a 20 percent evaluation. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243). Note (1) of the General Rating Formula for Diseases and Injuries of the Spine provides that associated objective neurologic abnormalities are evaluated under an appropriate diagnostic code. See also Chavis v. McDonough, 34 Vet. App. 1, 16 (2021). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excess fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). It is the intent of the Rating Schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 4-5. 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. Id., Note (5). In evaluating the severity of a particular disability, it is essential to consider its history.38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In both initial and increased rating claims, the Board must consider staged ratings for the entire period on appeal. A staged rating is appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings under the applicable diagnostic code. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The potential for staged ratings accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. Id. The Board has therefore considered the claim on appeal with the potential for a staged rating in mind. In this case, the Veteran was provided with a VA examination in November 2013 in which he reported daily sharp back pain increased with squatting, bending, and lifting. Initial range of motion testing showed forward flexion to 45 degrees. There was no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions with no additional loss in range of motion. The examiner indicated that there was functional loss after repetitive use as reflected by less movement than normal. Muscle strength testing was normal, and there was no muscle atrophy. Sensory testing was normal throughout the bilateral lower extremities. The examiner indicated the Veteran did not have radicular pain or any other signs or symptoms of radiculopathy and did not have any other neurologic abnormalities. The examiner noted intervertebral disc syndrome (IVDS) that did not result in incapacitating episodes over the past 12 months. The examiner noted that the Veteran did not use an assistive device as a normal mode of locomotion. The examiner noted that lifting tolerances are decreased. The examiner noted that the Veteran denied having significant flare-ups. The Veteran reported that pain, weakness, fatigability, or incoordination did not limit functional ability when the joint is used repeatedly over a period of time, and he did not describe additional range of motion loss due to pain or repeated use. On April 9, 2015, the Veteran was provided with an additional VA examination in which the Veteran reported flare-ups which consist of muscle spasms with pain. He indicated that when he has back pain it hurt to do anything. Initial range of motion testing showed forward flexion to 80 degrees with pain. The examiner noted that decreased back range of motion affects low back function when engaged in physical activity involving the back. There was no evidence of pain with weight bearing. The examiner noted tenderness to palpation in the bilateral lumbar areas. After repetitive use testing with at least three repetitions, there was additional loss of range of motion. The examiner described this as forward flexion to 55 degrees. The examiner noted that it was not practical or feasible to discuss functional limitation during flare-ups or with repeated use over a period of time without resorting to speculation. As the examiner did not provide an adequate rationale for this finding, the Board assigns no probative value to the notation regarding repeated use over time and flare ups. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). The examiner noted muscle spasm and localized tenderness that did not result in abnormal gait or abnormal spinal contour. The examiner noted that prolonged sitting, standing, and walking causes low back pain. Muscle strength was normal. There was no muscle atrophy and no ankylosis. Sensory testing revealed decreased sensation at the lower leg/ankle and foot/toes in the left lower extremity. The examiner indicated the Veteran had radicular pain described as mild intermittent pain in the right lower extremity and moderate intermittent pain in the left lower extremity. He did not report constant pain, paresthesias and/or dysesthesias, or numbness in either lower extremity. The examiner indicated that there were no other signs or symptoms of radiculopathy and indicated that the Veteran did not have radiculopathy. The examiner noted that imaging studies done in 2012 and during the examination did not reveal findings consistent with radiculopathy. Based on this objective evidence, the examiner concluded that the Veteran's radiculopathy symptoms were most likely due to referred symptomatology and not a true radiculopathy. The examiner stated the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine, such as bowel or bladder problems. The examiner noted no IVDS. The examiner noted occasional use of a cane and weight belt and brace. The examiner noted arthritis that results in functional limitation in the ability to lift. In August 2016, the Veteran was provided with an additional VA examination in which the Veteran reported that he lost his job due to back pain. He reported having back pain all of the time and that it may become worse with increased activity. He reported flare-ups during activities such as yardwork and lawnmowing that cause pain. Initial range of motion testing showed forward flexion to 40 degrees. There was no evidence of pain with weight bearing. The examiner noted localized tenderness or pain on palpation mildly along the paraspinals. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The examiner noted that pain, weakness, fatigability, and incoordination do not significantly limit functional ability during flare-ups or after repeated use over time. The examiner noted muscle spasms and localized tenderness not resulting in abnormal gait or abnormal spinal contour. The examiner noted additional contributing factors of disability of less movement than normal, disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing and sensory testing were normal. The examiner noted no muscle atrophy, no ankylosis, and no IVDS. The examiner noted the Veteran had radicular pain in the left lower extremity, manifested by mild intermittent pain and mild paresthesias and/or dysesthesias. The examiner further noted that no nerve root was affected and that the Veteran did not have radiculopathy. The examiner stated that the Veteran did not have any other neurologic abnormalities related to the spine disability, including bowel or bladder impairment. The examiner noted occasional use of a brace for his chronic low back pain. The examiner noted that the Veteran is unable to sit or stand for prolonged periods of time, especially with standing as this may cause pain and stiffness. She noted that lifting over 20 pounds or repetitive bending may also cause discomfort. In a December 2017 VA Form 9, Appeal to Board of Veterans' Appeals, the Veteran stated that his back had worsened and that he requires medication due to muscle spasms. He stated that his condition is so severe that he lost his job and that his range of motion has been severely reduced. During the February 2020 hearing, the Veteran reported worsening and stated that he experiences difficulty putting his socks and pants on. He reported daily flare-ups that range from mild to severe. He reported that his medication affects his mental ability. He reported that he has a device to pick up objects off the floor so that he does not have to bend over. He reported that if he's having a good morning then he can put his socks on but still needs his wife to help him put his pants on. He reported that he cannot tie his shoes and needs her to tie them. He discussed being put on light duty at work due to his disability and then having his position terminated. In September 2020, the Veteran was provided with an additional VA examination in which the Veteran reported flare-ups that "occur 20 to 30 times per day" and are mild to severe, lasting minutes to hours. The Veteran reported that he is not able to do much physically and cannot easily get into a comfortable position in order to sleep. He reported an unsteady gait and falling occasionally. He reported losing his job because he had to be given light duty allowing him to sit sometimes and because he has to take "mind altering medications in order to be comfortable enough to concentrate on work related tasks." Initial range of motion testing showed forward flexion to 90 degrees. The Veteran was unable to complete repetitive use testing, as after more than one attempt to move the back through the range of motion, the Veteran stiffened up and could no longer move his back at all. The examiner estimated range of motion after repeated use over time and during flare-ups as including forward flexion to 80 degrees. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). The examiner indicated that pain, fatigue, lack of endurance, and incoordination caused this functional loss. The examiner noted muscle spasms and guarding that resulted in abnormal gait or abnormal spine contour. The Veteran did not have any other neurologic abnormalities, including bowel or bladder impairment. The examiner noted occasional use of a cane and regular use of shoe inserts. The examiner noted the occupational impairment discussed above, including the Veteran reporting losing his job due to being given light duty and taking medication. Upon review of the record, the Board finds that the weight of the evidence is persuasively against a rating in excess of 20 percent throughout the entire appeal period. The evidence does not reflect forward flexion of the thoracolumbar spine limited to 30 degree or less, even when considering the additional functional limitation during flare-ups and after repeated use over time. Notably, the Veteran's forward flexion has at most been shown to be limited to 40 degrees, even when flare ups and additional contributing factors of disability of pain, fatigue, lack of endurance, disturbance of locomotion, interference with sitting, interference with standing, and incoordination have been considered. Further, the evidence reflects that the Veteran has not experienced ankylosis at any point during the period on appeal. Although the record notes a diagnosis of IVDS, the evidence does not reflect that bed rest has been ordered by a physician. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the evidence is persuasively against a finding that the Veteran has bowel or bladder impairment, as such has not been reported at any time during the appeal period. Regarding lower extremity radiculopathy, the Veteran has been evaluated for radiculopathy of the bilateral lower extremities, sciatic nerve, beginning June 22, 2017, and for radiculopathy of the bilateral lower extremities, femoral nerve, beginning September 23, 2020, and increased ratings for such radiculopathy are addressed below. However, the evidence raises questions as to whether the Veteran is entitled to separate ratings for radiculopathy for the sciatic nerve prior to June 22, 2017 and for the femoral nerve prior to September 23, 2020. For the following reasons, the Board concludes that the evidence is in approximate balance as to whether the Veteran is entitled to a 10 percent, but no higher, rating for right lower extremity radiculopathy, sciatic nerve, and a 20 percent, but no higher rating for left lower extremity radiculopathy, sciatic nerve, under Diagnostic Code 8520 from April 9, 2015 to June 21, 2017. 38 C.F.R. § 4.124a. On April 9, 2015 VA examination, the examiner noted that the Veteran had mild radicular pain in the right lower extremity and moderate radicular pain in the left lower extremity. Sensory testing in the left lower extremity also revealed decreased sensation at the lower leg/ankle and foot/toes. There was no constant pain, paresthesias and/or dysesthesias, or numbness in either lower extremity. The examiner noted that imaging studies done in 2012 and during the examination did not reveal findings consistent with radiculopathy. The examiner thus concluded that the Veteran's radiculopathy symptoms were most likely due to referred symptomatology and not a true radiculopathy. On August 2016 VA examination, there was mild intermittent pain and mild paresthesias and/or dysesthesias noted in the left lower extremity. Muscle strength testing and sensory testing of both lower extremities were normal, and the examiner indicated that the Veteran did not have radiculopathy. In examining the evidence in a light most favorable to the Veteran, and given that the evidence reflects the Veteran has since been diagnosed with radiculopathy, the Board finds that, although radiculopathy was not diagnosed at the time, these bilateral lower extremity manifestations most nearly approximated mild incomplete paralysis of the sciatic nerve in the right lower extremity and moderate incomplete paralysis of the sciatic nerve in the left lower extremity. Notably, symptoms in the left lower extremity were more severe than on the right side during this time, as there was decreased sensation on sensory testing in the left lower extremity on April 2015 VA examination and the Veteran reported moderate intermittent pain in the left lower extremity at that time. On the right side, the Veteran reported mild intermittent pain in April 2015 and sensory testing was normal in April 2015 and August 2016. Additionally, the Veteran did not report radicular pain on the right side on August 2016 VA examination. For both lower extremities, muscle strength testing was normal on April 2015 and August 2016 VA examinations. The Board finds that this evidence most nearly approximates mild incomplete paralysis of the sciatic nerve of the right lower extremity and moderate incomplete paralysis of the left lower extremity. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; see Miller v. Shulkin, 28 Vet. App. 376 (2017). Thus, a 10 percent, but no higher, rating is warranted for the right lower extremity radiculopathy, sciatic nerve, and a 20 percent, but no higher, rating is warranted for the left lower extremity radiculopathy, sciatic nerve, from April 9, 2015 to June 21, 2017. The Board finds that separate compensable ratings are not warranted for lower extremity radiculopathy, sciatic nerve, prior to April 9, 2015, as symptoms showing manifestations of radiculopathy were not factually ascertainable prior to that date. For example, on November 2013 VA examination, there was no radicular pain noted and muscle strength and sensory testing were normal. As such, the weight of the evidence is persuasively against a finding that the Veteran is entitled to separate ratings for radiculopathy of the lower extremities, sciatic nerve, prior to April 9, 2015. Additionally, the evidence weighs persuasively against a finding that there was involvement of the femoral nerve in either lower extremity prior to September 23, 2020, as the VA examinations and treatment records do not indicate such involvement prior to this date. In summary, the evidence weighs persuasively against a finding that a rating in excess of 20 percent for the lumbar spine disability is warranted, and that aspect of the claim is denied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5235. The evidence is in approximate balance that the Veteran is entitled to separate 10 percent, but no higher, ratings for left and right lower extremity radiculopathy, sciatic nerve, from April 9, 2015 to June 21, 2017, and the appeal is granted to that extent. 2. Increased Ratings for Bilateral Lower Extremity Radiculopathy From June 22, 2017, the Veteran is service connected for left lower extremity radiculopathy, sciatic nerve, rated at 40 percent, and right lower extremity radiculopathy, sciatic nerve, rated at 20 percent under Diagnostic Code 8520. From September 23, 2020, the Veteran is service connected for left and right lower extremity radiculopathy, femoral nerve, with separate 20 percent ratings under Diagnostic Code 8526. Note (1) of the General Rating Formula for Diseases and Injuries of the Spine provides that associated objective neurologic abnormalities are evaluated under an appropriate diagnostic code. See also Chavis v. McDonough, 34 Vet. App. 1, 16 (2021). Under DC 8520, a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, a 40 percent rating for moderately severe incomplete paralysis, and a 60 percent rating for severe incomplete paralysis. An 80 percent rating is assigned where there is complete paralysis of the sciatic nerve, characterized as dangle and drop of the foot, with no active movement of the muscles below the knee possible, and weakened or (very rarely) lost flexion of knee. 38 C.F.R. § 4.124a. Under Diagnostic Code 8526, a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is assigned for moderate incomplete paralysis, and a 30 percent rating is assigned for severe incomplete paralysis. A 40 percent rating is assigned where there is complete paralysis of the femoral nerve, characterized as paralysis of the quadriceps extensor muscles. The rating code 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 of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; see Miller v. Shulkin, 28 Vet. App. 376 (2017) (finding that the plain language of the note to § 4.124a contains no mention of non-sensory manifestations and declining to read into the regulation a corresponding minimum disability rating for non-sensory manifestations). The words "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the degree that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. In this case, on June 22, 2017, VA received a VA Form 21-526EZ, Application for Disability Compensation, in which the Veteran reported bilateral peripheral neuropathy of the lower extremities. In September 2017, the Veteran was provided with a VA examination in which the examiner diagnosed bilateral lower extremity radiculopathy. The Veteran reported severe pain with walking during flare-ups and difficulty with activities of daily living such as dressing. He reported severe residual pain after increased use where he has had to stay home and miss work. He reported that this has caused loss of his job and financial difficulties. The examiner noted moderate constant pain in the right lower extremity and severe constant pain in the left lower extremity; no intermittent pain; paresthesias and/or dysesthesias as moderate in the right lower extremity and severe in the left lower extremity; and numbness as moderate in the right lower extremity and severe in the left lower extremity. Muscle strength testing showed active movement against some resistance (4/5) in the left lower extremity, ankle plantar flexion, and ankle dorsiflexion. Muscle strength testing was normal in the right lower extremity. There was no muscle atrophy. Reflex testing showed hypoactive (1+) reflexes in both knees and ankles. There was decreased sensation to light touch in both lower legs, ankles, feet, and toes. Sensation was normal in both upper anterior thighs, thighs, and knees. There were no trophic changes. The Veteran's gait was abnormal due to guarding and abnormal weight bearing on the right leg. The examiner noted moderate incomplete paralysis in the right lower extremity and moderately severe incomplete paralysis in the left lower extremity for the sciatic nerve. The examiner noted mild incomplete paralysis in the right lower extremity and moderate incomplete paralysis in the left lower extremity for the posterior tibial nerve. The examiner noted regular use of braces, a cane, and a weight belt. The examiner noted that the Veteran cannot stand or walk due to severe pain associated with neuropathy that causes him to constantly move and change positions. The Veteran reported that he was fired from his job as a consequence of being placed on light duty. In a March 2019 VA Form 21-4138, Statement in Support of Claim, the Veteran described feeling pins and needles in his right lower extremity. In September 2020, the Veteran was provided with an additional VA examination in which the Veteran reported having severe constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness in both lower extremities. Muscle strength testing on the right and left lower extremities revealed hip flexion of active movement against gravity (3/5), knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension of active movement against some resistance (4/5). There was no muscle atrophy. Deep tendon reflexes were hypoactive (1+) in the right knee and ankle and in the left ankle. They were normal (2+) in the left knee. Sensory testing was normal in both lower extremities. The examiner noted severe radiculopathy of both lower extremities. The examiner noted bilateral femoral and sciatic nerve involvement. The Veteran reported occasional use of a cane. The examiner remarked that the radiculopathy "could be a progression of his currently established diagnosis or a referred constellation of symptomatology." Upon review of the record, the Board finds that manifestations of radiculopathy under Diagnostic Code 8520, for sciatic nerve impairment, more nearly approximate moderate incomplete paralysis in the right lower extremity and moderately severe incomplete paralysis in the left lower extremity, while manifestations of radiculopathy under Diagnostic Code 8526 for femoral nerve impairment, more nearly approximate moderate incomplete paralysis in the right and left lower extremities. Specifically, upon examining the Veteran, the September 2017 VA examiner found no more than mild incomplete paralysis of the sciatic nerve on the right side and no more than moderate incomplete paralysis of the sciatic nerve on the left side. This evidence indicates a degree of lost or impaired function substantially less than the type of picture for sciatic nerve severe incomplete paralysis on the left and moderately severe incomplete paralysis on the right. The Board acknowledges the severe pain, paresthesias and/or dysesthesias, and numbness reported in the left leg during the September 2017 VA examination and in both legs during the September 2020 VA examination. However, sensory testing showed decreased but not absent sensation to light touch in both lower legs, ankles, feet, and toes, but normal sensation in both upper anterior thighs, thighs, and knees. Muscle strength testing reflected nearly normal strength with 4/5 in both lower extremities, with active movement against some resistance on September 2017 examination. Additionally, there was no decreased sensation in either lower extremity on September 2020 examination and muscle strength testing on the right and left lower extremities revealed hip flexion of 3/5, and knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension of 4/5. The Veteran has been shown to be able to ambulate with a cane, brace, and weight belt for assistance. Moreover, the VA examinations of record have not revealed any muscle atrophy in either lower extremity; therefore, the evidence persuasively weighs against a finding that the Veteran has had severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. Thus, when examining this evidence in conjunction with the pertinent rating criteria, the Board concludes that it weighs persuasively against a finding that the Veteran's disability manifested by greater than moderate incomplete paralysis in the right lower extremity and moderately severe incomplete paralysis in the left lower extremity in the sciatic nerve or greater than moderate incomplete paralysis of the femoral nerve in the right and left lower extremities. The Board acknowledges that the September 2017 VA examiner indicated that there was also mild incomplete paralysis in the right lower extremity and moderate incomplete paralysis in the left lower extremity of the posterior tibial nerve. The Board has thus considered whether a separate rating under Diagnostic Code 8525, for neurological impairment of the posterior tibial nerve would be warranted. However, the Board finds that a separate evaluation under this Diagnostic Code would be pyramiding, as the posterior tibial nerve affects the same area of functioning of the lower extremity as the sciatic nerve does. Namely, they both affect function of the foot and lower leg. See M21-1, Adjudication Procedures Manual, pt. V, subpt. iii, ch. 12, A.2.e. Although the M21-1 manual is not binding on the Board, this section provides applicable guidance on the various nerve branches of the lower extremity and which ones would be entitled to separate ratings if symptoms arise from different nerve branches. This section explains that the posterior tibial nerve and sciatic nerve are both part of the sciatic nerve branch and affect foot and leg sensory and motor function of the buttock, leg, knee, muscles below the knee, lower leg, fibula, foot muscles, and toes. The relevant Diagnostic Codes also reflect that they address the same function, as Diagnostic Code 8525 indicates that complete paralysis of the posterior tibial nerve would occur when there was paralysis of the foot muscles and toes, while Diagnostic Code 8520 indicates that complete paralysis would include the foot and muscles below the knee. In contrast, the M21-1 manual indicates that impairment of the femoral nerve branch affects thigh and leg sensory and motor function of the quadriceps muscle, medial calf, and medial malleolus, which is separate from what is affected by the sciatic nerve branch. This is also shown by Diagnostic Code 8526 which indicates that complete paralysis of the femoral nerve would be manifested by paralysis of the quadriceps extensor muscles. Hence, separate ratings are appropriate for femoral nerve impairment, and have been assigned as described. Therefore, a separate rating under Diagnostic Code 8525 for posterior tibial nerve impairment is not warranted at any time during the appeal period as the symptoms of such impairment affect the same nerve branch as the already evaluated sciatic nerve and would result in pyramiding. 38 C.F.R. § 4.25. The Board further finds that evaluation under Diagnostic Code 8520 is more favorable to the Veteran, as incomplete moderate paralysis of the posterior tibial nerve only warrants a 10 percent rating, while incomplete severe paralysis only warrants a 20 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8525. As such, the Board finds that the weight of the evidence is persuasively against the Veteran's claim, the benefit-of-the-doubt rule is not for application, and the claims seeking higher ratings for radiculopathy of the bilateral lower extremities, sciatic nerve and femoral nerve, are denied. 38 U.S.C. § 5107(b); Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). REASONS FOR REMAND 1. Entitlement to service connection for a condition manifested by loss of concentration as secondary to service-connected disabilities, including medication taken for service-connected disabilities. As noted above, at the February 2020 hearing and at the September 2020 VA examination, the Veteran reported that the medications he takes for his back and radiculopathy of the bilateral lower extremities affect his mental ability and, in particular, cause him to have trouble concentrating. The Board has determined that these statements logically relate to the claims seeking an increased rating for the lumbar spine and lower extremity radiculopathy and raise a claim of service connection for a condition manifested by loss of concentration as secondary to the Veteran's service-connected disabilities. 38 C.F.R. § 3.155; see Wilson v. McDonough, No. 19-3791, 2022 U.S. App. Vet. Claims LEXIS 85 (Vet. App. Jan. 26, 2022); Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). As the RO has not completed development of or adjudicated such a claim, the Board finds that remand is warranted for such development and adjudication. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The Veteran contends that he is unable to secure and retain substantially gainful employment due to his service-connected disabilities. However, the Board finds that further development is necessary to ascertain the Veteran's full educational and occupational history. The established policy of VA reflects that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Factors such as employment history and educational and vocational attainments are to be considered. Id. The record reflects that the Veteran was provided with a TDIU claim form in August 2020 that elicited specific information about income, employment, and education (VA Form 21-8940) that is pertinent to adjudicating a TDIU claim. However, the record reflects that a VA Form 21-8940 has not yet been received from the Veteran. The Board notes that the duty to assist is a two-way street and that the Veteran cannot passively wait for assistance in those circumstances where he may or should have information that is essential in obtaining relevant evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In September 2021 written argument, the Veteran's representative indicated that the Veteran may not have been aware of the importance of submitting the Form 8940 for providing VA with pertinent employment and occupational information and that he should be given another opportunity to submit the form. As such, this matter must be returned to the RO to ensure that the Veteran is provided with another opportunity to submit this documentation. The Veteran is also notified that his claim for a TDIU will be considered abandoned if he does not submit the requested VA Form 21-8940 in a timely manner. 38 C.F.R. § 3.158(a); see also Jernigan v. Shinseki, 25 Vet. App. 220, 231 (2012) (finding that abandonment cannot be set aside or waived on grounds of alleged ignorance of regulatory requirements). The record also reflects the Veteran receives VA treatment; thus, updated VA treatment records should be associated with the claims file. 3. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or housebound status is remanded. As discussed above, the Veteran reported during the February 2020 hearing that he requires assistance from his wife to dress himself due to his disability. SMC is payable if, as the result of service-connected disability, the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Thus, the matter of entitlement to SMC based on the need for aid and attendance has been raised by the record, and the RO should decide the merits of this matter in the first instance. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from February 2021 to the present. 2. After completing the development in item 1, request that the Veteran file an Application for Increased Compensation Based on Unemployability (VA Form 21-8940) detailing his complete educational and occupational history. The letter should explain to the Veteran that this information is pertinent to determining his entitlement to TDIU. The Veteran is advised to complete the entire form. 3. Complete any necessary development for the matter of entitlement to SMC based on the need for regular aid and attendance. After completing development of the claim, adjudicate the claim. 4. Complete any necessary development of the claim seeking service connection for a condition manifested by loss of concentration as secondary to service-connected disabilities, including medication taken for service-connected disabilities. After completing development of the claim, adjudicate the claim. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. White, Associate 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.