Citation Nr: 9825635 Decision Date: 08/26/98 Archive Date: 07/27/01 DOCKET NO. 96-20 154 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to an increased evaluation for right leg paralysis due to transverse myelitis, L1, currently evaluated as 60 percent disabling 2. Entitlement to an increased evaluation for left leg paralysis due to transverse myelitis, L1, currently evaluated as 60 percent disabling 3. Entitlement to an increased evaluation for intermittent bladder dysfunction due to transverse myelitis, currently evaluated as 40 percent disabling 4. Entitlement to an increased evaluation for intermittent bowel dysfunction due to transverse myelitis, currently evaluated as 30 percent disabling 5. Entitlement to special monthly compensation based on the loss of use of one or both feet 6. Entitlement to special monthly compensation based on being housebound or in need of regular aid and attendance of another person REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD C. Fetty, Associate Counsel INTRODUCTION The veteran had active military service from July 7, 1987, to July 30, 1987. The veteran submitted notice of disagreements to an August 1992 and an April 1994 rating decision; however, his substantive appeal was not received within applicable time limits for consideration of these rating decisions. This appeal arises from a June 1995 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that increased an evaluation for service connected intermittent bladder dysfunction from 20 percent to 40 percent, denied increased ratings for paralysis of the legs and intermittent bowel dysfunction, and denied a claim for special monthly compensation based on the loss of use of a lower extremity or extremities or on the basis of being housebound or in need of regular aid and attendance of another person. The veteran has appealed to the Board of Veterans' Appeals (Board) for favorable resolution of these issues. The veteran submitted a notice of disagreement in August 1995. The RO issued a statement of the case in September 1995. The veteran's substantive appeal was received in May 1996. A supplemental statement of the case was issued in September 1996. In June 1997 the Board remanded the case to the RO for consideration of additional evidence. In January 1998, the RO issued a supplemental statement of the case. The veteran's representative has requested consideration of an extraschedular evaluation for the loss of use of the feet. This issue is referred to the RO for appropriate action. The veteran's representative also argues that the RO has not considered the issue of special monthly compensation on account of the loss of use of both feet, or that the supplemental statement of the case on this issue is inadequate and that therefore the issue is not properly before the Board at this time; however, the Board finds that the issue has been considered by the RO both as a claim for aid and attendance or housebound benefits and as a claim for loss of use of one or both feet under 38 U.S.C.A. § 1114(k) and that the issues are properly before the Board. See supplemental statements of the case dated in September 1996 and January 1998. However, the special monthly compensation issues will be the subjects of a further REMAND, as will be explained. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that his service connected paralysis of the legs, bladder and bowel due to transverse myelitis have progressively worsened over time and cause greater impairment than currently rated. The veteran's representative points out that the veteran must use a catheter at least five times per day and must take medications for bladder and bowel incontinence. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against an increased rating for paralysis, right leg, due to transverse myelitis, L1; that the preponderance of the evidence is against the claim for an increased rating for paralysis of the left leg due to transverse myelitis, L1; that the evidence favors an increased rating for intermittent bladder dysfunction due to transverse myelitis; and that the preponderance of the evidence is against an increased rating for intermittent bowel dysfunction due to transverse myelitis. FINDINGS OF FACT 1. Clinical findings associated with right leg paralysis due to transverse myelitis, L1, include evidence of right leg weakness, hyperextension of the right knee, the use of cane and knee brace, poor vibration sensation and poor joint sense, positive Romberg's sign, ability to walk without a cane or knee brace for 10 feet, and partial foot-drop. The veteran cannot jog or squat. The disability is productive of no more than severe incomplete paralysis of the sciatic nerve. 2. Clinical findings associated with left leg paralysis due to transverse myelitis, L1, include evidence of left leg weakness (greater than on the right), hyperextension of the left knee, the use of cane and knee brace, poor vibration sensation and poor joint sense, positive Romberg's sign, ability to walk without a cane or knee brace for 10 feet, and partial foot-drop (greater than on the right). The veteran cannot jog or squat. The disability is productive of no more than severe incomplete paralysis of the sciatic nerve. 3. Clinical findings associated with intermittent bladder dysfunction (urine leakage) due to transverse myelitis, include the need for an appliance 5 times per day to drain the urinary bladder, the need for some absorbent material to control urinary leakage, and medication for urinary control and urinary tract infections. 4. Clinical findings associated with intermittent bowel dysfunction due to transverse myelitis, includes evidence of impacting requiring the use of stool softeners, constipation requiring the use of suppositories to induce bowel movement, and rare episodes of fecal leakage; extensive leakage and fairly frequent involuntary bowel movements are not shown. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 60 percent for right leg paralysis due to transverse myelitis, L1, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.124a, Codes 8010, 8520 (1997). 2. The criteria for an increased rating in excess of 60 percent for left leg paralysis due to transverse myelitis, L1, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.124a, Codes 8010, 8520 (1997). 3. The criteria for a 60 percent rating for intermittent bladder dysfunction due to transverse myelitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.115a, 4.115b, Code 7512 (1997). 4. A rating in excess of the currently assigned 30 percent rating for intermittent bowel dysfunction due to transverse myelitis is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.114, Code 7332 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran had active military service from July 7, 1987, to July 30, 1987. The record shows that shortly after beginning active service, the veteran complained of right knee pain and a nervous stomach. The veteran was separated from active service due to failure to adapt and no defects were noted upon separation. Private treatment reports indicate that the veteran was hospitalized in August 1987 for gastroenteritis and while there, he complained of neurologic symptoms in his lower extremity. A diagnosis of Guillain-Barre syndrome was made. Neurology symptoms developed in all extremities with paralysis in the legs. By October 1987 private medical reports note that the diagnosis was changed to transverse myelitis. Private therapy reports from February 1988 note that the veteran ambulated with a cane and continued to have mild rigidity in the left leg. He was reported to be independent in all active daily living requirements. In February 1990 the veteran underwent VA neurological examination. The examiner noted a history of paraparesis in 1987. The veteran had no problems above the waist; he walked with a cane and exhibited a spastic gait. With difficulty, he was able to stand on his toes and heels. Strength in the lower extremities was 3-4/5. Deep tendon reflexes in the lower extremities were brisk. There were bilateral Babinski's signs. He needed intermittent self- catheterization for urinary bladder control and had some neurologic deficits affecting bowel control as well. There was minimal decrease in pinprick and vibration sensation in both legs. The VA examiner was in agreement with the veteran's private physician that the condition was transverse myelitis, rather than Guillain-Barre syndrome. The disabilities of the lower extremities were not shown to be so severe as to permanently prevent all forms of gainful employment. By RO rating decision of April 1990, service connection was established for right leg paralysis due to transverse myelitis, L1 and a 40 percent rating was assigned under Code 8010-8520. Service connection was established for left leg paralysis due to transverse myelitis, L1, and a 40 percent rating was assigned under the same code. Service connection was established for intermittent bladder dysfunction due to transverse myelitis, and a 20 percent rating was assigned under Code 7512. Service connection was established for intermittent bowel dysfunction due to transverse myelitis, and a 10 percent rating was assigned under Code 7332. A July 1991 VA treatment report notes occasional knee buckling. Knee laxity was noted. The lateral collateral ligaments and anterior cruciate ligaments were noted as "OK." The veteran exhibited bilateral Trendelenburg's gait and he was slightly flexed at the hips and knees. There was no foot-drop. The assessment was transverse myelitis affecting muscle strength in the lower extremities, and functionally independent with occasional knee buckling. Bilateral knee braces with anterior stops to prevent recurvation were recommended. A July 1991 letter from Daniel Castellani, M.D., indicates that he had cared for the veteran since August 1987. Dr. Castellani noted that the veteran sustained mononucleosis while training in the Marine Corps and developed acute transverse myelitis as a complication. The myelitis produced a total paraplegia with complete paralysis of the bladder. The veteran made a good recovery; however, he continued to catheterize himself four times per day and there was marked residual spasticity in the lower extremities. His gait was abnormal with a scissors-like quality. He required the use of Lioresal. Dr. Castellani noted that the veteran had a permanent partial disability because of his gait disturbance. He could perform any sedentary-type occupation. In March and April 1992 the veteran underwent VA examination. The veteran complained of pain upon urination with occasional blood in the urine and fever and chills requiring antibiotics. He reported that he self-catheterized 4 to 5 times per day to overcome his dysfunctional bladder. Upon examination, the examiner noted occasional white blood cells and red blood cells in the urinalysis. The external genitalia were within normal limits. There was good sphincter tone in the rectal muscle. The prostate was small, soft and non-tender. The diagnosis was neurogenic bladder secondary to transverse myelitis. Recurrent urinary tract infections were also noted. Upon intestinal examination, the veteran reported an inability to defecate unless he used suppositories. He dis- impacted himself prior to stooling. There was no fecal incontinence reported. He reported that medication for his urinary bladder made the stools hard and worsened the problem. Upon examination, the examiner noted a spastic sphincter, but also noted that neither hemorrhoid disease nor stools were present. The veteran's current weight was 180 pounds and there was no anemia, malnutrition, or nausea. The diagnosis was transverse myelitis with bowel and bladder dysfunction as well as proximal and distal muscle weakness of both lower extremities, left greater than right. In an August 1992 notice of disagreement, the veteran indicated that he must use knee braces for both legs and a cane to walk. He reported that he used a catheter and gave himself suppositories for bowel movements. In September 1992 the RO received VA outpatient treatment records showing treatment at various times during 1991 and 1992. A July 1991 report notes self-catheterization with leaking between catheterizations and cloudy urine. Bowel movement was controlled with suppositories with "no accidents." Both knees tended to hyperextend. He had bilateral Trendelenburg gait with no foot drop. In July 1992 the veteran reported a urinary tract infection with nausea, abdominal pain, and dysuria. The veteran was treated with Amoxicillin for 10 days and symptoms improved. The veteran also reported a sweating episode with headaches. Self- catheterization was noted. In September 1992 the veteran underwent VA examination. The clinical assessment was spastic paresis secondary to longstanding transverse myelitis. Neither ankylosis nor shortening of an extremity nor complete foot-drop nor definite evidence for peroneal nerve palsy was found. The veteran wore knee braces, bilaterally, because his knees "popped out." He was markedly disabled in terms of gait and ambulation. Except for chronic constipation, the remainder of his general physical examination was normal. A rectal and anal (digestive) examination report notes a diagnosis of constipation due to spasticity of the rectal sphincter and to medications for myelitis. An examination for residuals of bladder injury noted catheterization five times per day, normal cystogram, and evaluation unchanged from previous study. In a February 1993 rating decision, the RO assigned a 60 percent evaluation for severe right leg paralysis due to transverse myelitis, L1. A 60 percent evaluation was also assigned for severe left leg paralysis due to transverse myelitis, L1. A 20 percent evaluation for intermittent bladder dysfunction and a 10 percent evaluation for intermittent bowel dysfunction were continued. The increased ratings for leg paralysis were considered a full grant of benefits sought on appeal. In April 1993 the veteran underwent VA examination. The examiner noted few changes from prior examination reports. There was occasional incontinence of stools. The veteran currently walked, but only with a cane. He had a wide gait and limited flexion of the knees, bilaterally. Additional VA outpatient treatment reports show that the veteran complained of low back pain in December 1992. In June 1993, he underwent a three-phase radiology bone imagining study. The study showed abnormalities in the ankles and multiple small bones of the feet, bilaterally, that might represent stress-induced changes. Diffuse abnormalities noted in the sacrum and hip joints might represent stress-inducted changes rather than degenerative changes. In January 1995 the RO received additional VA outpatient treatment records showing treatment at various times in 1993 and 1994. In September 1994, the veteran underwent cystoscopy. No obstructions or stones were found. A November 1994 reports notes that the veteran appeared to be unable to hold urine for long periods of time. In March 1995 the RO received private treatment reports showing treatment at various times in the 1980's and 1990's. An August 1987 report notes that the veteran was admitted on an emergency basis at Sisters of Charity Hospital. A discharge diagnosis of Guillain-Barre syndrome was given and he was immediately admitted to a rehabilitation unit and hospitalized until October 1987. In February 1995, the RO also received private treatment reports showing treatment at various times in the 1980's. In May 1995, the RO received additional treatment records showing private treatment during the 1980's. In April 1995 the RO received additional VA outpatient reports showing treatment at various times during 1994 and 1995 for continued symptoms. A September 1994 report notes that the veteran underwent cystoscopy for a neurogenic bladder and a urinary tract infection. The intraoperative findings included normal bladder mucosa, no evidence of bladder stones, tumors or diverticulum, slight erythema over the posterior wall and also the trigone with some edema. The left and right ureter orifices were in good anatomical position with good clear afflux of urine bilaterally. The veteran had +3 trilobar hypertrophy of the prostate with open bladder neck. The anterior and posterior urethras were within normal limits. In May 1995 the veteran underwent VA examination. A neuropsychiatry examination report notes that Romberg and finger-to-nose tests were negative. The veteran could use both hands. The cranial nerves II, III, IV, and XI were intact to all extraocular movements. Cranial nerves X and XII were intact to facial muscle strength testing. Facial senses were intact to light touch. Cranial nerves IX, X, XI and XII, and voice, gag, and swallow were within normal limits. Trapezii and sternocleidomastoid strength was within normal limits. Tone was midline without deviation. The motor system showed no asymmetry or involuntary movements. There was marked weakness of both lower extremities with left greater than right. There was no atrophy noted. Deep tendon reflexes were markedly increased in the lower extremities as compared to the upper extremities. There was decreased sensation to light touch and pinprick from the hips distally. The veteran was noted to be able to walk well wearing braces and using a cane, but he had difficulty with back pain. The diagnosis was transverse myelitis with features of Guillain- Barre with impairment of bowel and bladder. A May 1995 VA report of examination for regular aid and attendance/housebound status notes that the veteran had been retrained for work and was currently working. He continued to have difficulty with his lower extremities. He had weakness in both lower extremities, used braces on both knees, and had a tendency for hyperextension in both knees. He had decreased sensation in both lower extremities. He used a catheter to overcome loss of bladder control. At night, he occasionally wet the bed and used adult diapers constantly. He used suppositories to induce bowel movements and occasionally had bowel accidents and soiled himself. The veteran had foot-drop on the left and walked with a cane; however, he was able to drive a vehicle that had cruise control and automatic shifting. The examiner noted that when driving, the veteran could use his right foot to control the brake pedal, but he could not drive a vehicle with a clutch pedal. The examiner further noted that the veteran complained of muscle spasm in his lower extremities. He had stiffness and lack of coordination in his legs. He reported sexual impotence and 2 to 3 urinary tract infections per year. The VA-supplied diapers did not fit him very well and he preferred buying another brand for personal comfort. He had no known restrictions of his upper extremities. He could feed, shave, and clothe himself. He attended to the needs of nature himself. He had poor leg coordination and required knee braces to prevent hyperextension and for stability. He used a cane. He could not walk far, nor could he climb stairs or squat. He could not run or do any type of sports. He could not bend forward due to losing his balance; therefore, he was not absolutely knowledgeable as to the extent of the use of his lumbar and thoracic spine. There was no deformity of the thoracic spine that would prevent breathing. The examiner noted that the veteran had difficulty with his lower extremities and could not move quickly to get out of any danger. He had dizzy spells, poor balance and poor coordination of the lower extremities. His memory was good. The veteran was able to travel beyond his premises except when the weather was difficult and, at those times, the veteran could not leave his house. The veteran worked four days per week at Duke Power Company in an essentially seated position; otherwise, he remained at home most of the time. The veteran could walk without the assistance of another person for approximately a half block without resting. He was able to work on a daily basis and to go other places when not too tired. All of the veteran's disabilities were expected to be permanent. The diagnoses were: transverse myelitis with severe complications including sexual function, use of the lower extremities, feeling in the lower extremities, bladder and bowel control, foot-drop requiring braces on the knees, and muscle relaxer in order to prevent severe spasm; frequent use of antibiotics for urinary tract infection secondary to self-catheterization; and, use of adult diapers for urination and stooling accidents. The examiner also noted that a pulmonary function study might show a possibility of restricted breathing and X-ray reports might show other possibilities. Spirometry testing subsequently indicated normal pulmonary function. By RO rating decision of June 1995 (the subject of this appeal) all claims for increased ratings were denied except for intermittent bladder dysfunction which was increased from 20 percent to 40 percent disabling. In an August 1995 rating decision, the RO continued the 60 percent ratings for paralysis of the left and right leg, respectively, and a 40 percent rating for bladder dysfunction. In June 1996 the veteran testified before an RO hearing officer that he walked in an unbalanced fashion. He used braces on both legs and walked with a cane. He was currently obtaining a VA wheelchair because of fatigue and to prevent falling down. He had fallen occasionally. He reported that the braces helped with the instability of each leg. He reported that the left leg was the weaker leg. Without the braces, he could walk possibly 5 to 10 feet feeling very unbalanced. Because of foot-drop on the left, he used an AFO (ankle-foot orthosis) ankle brace connected to a knee brace. He testified that he had a slight foot-drop on the right also. With braces, he could walk approximately 50 yards but had to swing the legs to climb stairs. He could not walk on his toes or heels. He currently used a soft catheter for bladder control approximately five times per day. Without catheterization, the bladder would fill up and leak urine. Whenever he felt urinary urgency, he would immediately lose his urine. He took Di-tropan for bladder control. He had 2 to 3 urinary tract infections per year during which time he had increased bladder leakage at night. He used stool softeners for constipation and suppositories for bowel movement and took the stool softeners daily and suppositories every other day. Without these measures he would get constipation and impacted stools. The veteran also testified that he was scheduled for an orthopedic evaluation in October 1996 for reevaluation of the right leg. At the hearing, the veteran's representative requested a 60 percent rating for intermittent bladder dysfunction because of the use of an appliance. The representative also requested a rating reflecting complete loss of use of the bowel because the veteran was unable to control his bowels without outside aid. In July 1996 the RO received additional outpatient treatment reports showing treatment at various times during 1995 and 1996. These reports note continued symptoms of transverse myelitis. A March 1996 report notes that the veteran was doing well, walked frequently and followed a low cholesterol diet. Since beginning on Di-tropan, he had noticed less urinary leakage at night. He complained of swelling in the right knee and had fallen several times. Continued self- catheterization was noted in a November 1995 treatment report. In April 1997 an opinion from Dr. Craig Bash was submitted to the Board. Dr. Bash noted that the veteran was able to walk only with cane and/or braces and noted the veteran's reported current symptoms of transverse myelitis. Dr. Bash also noted the veteran's current bladder paralysis and symptoms required self-catheterization and adult diapers. Dr. Bash also noted the veteran's bowel paralysis secondary to transverse myelitis. As noted in the introduction, in June 1997, the Board remanded the case to the regional office for consideration of Dr. Bash's opinion. In July 1997 the veteran underwent VA examinations for multiple disorders. Upon spinal examination, the examiner noted that the veteran was able to walk awkwardly with a cane. Romberg's sign was positive. He could not jog or squat. There was mild to moderate weakness in the left quadriceps, anterior tibiales and hamstrings. Straight leg raising was adequate. He wore knee braces, bilaterally. Superficial sensation in the upper and lower extremities was good and traced figures were interpreted moderately. Vibration sensation was good in the upper extremities but poor in the lower extremities. Joint sense was poor in the lower extremities. The diagnosis was acute thoracic myelopathy, probably inflammatory, with rapid onset 10 years earlier, causing spastic reflexes in all extremities, most severe in the lower extremities and associated with severe clumsiness and splotchy sensory loss. The examiner suspected an unusual spinal cord inflammation without definite features of either Guillain-Barre or multiple sclerosis. The veteran's prognosis was "unpredictable" due to the unusualness of the disorder. Upon muscle examination, the VA examiner noted that the veteran had weakness of both legs, greater on the left. The veteran reported he could walk 10 feet or so without the use of appliances or a cane. He could walk approximately 200 feet with brace and cane. He had recently acquired a wheelchair and used it occasionally. The veteran was able to straighten both legs when he sat on the edge of a table. Examination of the knees revealed a slight tendency toward hyperextension. The examiner noted that recent right knee arthroscopic surgery gave some additional strength for a short period of time. There was no evidence of pain or muscle hernia. The diagnosis was status postoperative arthroscopic examination of the right knee with no significant physical findings. The examiner noted that the primary problems were neurologic. Upon cystitis and bladder examination, the veteran reported leakage at night with urinary tract infections one or twice per year. He self-catheterized 5 times per day with disposable plastic catheters. He wore an absorbable pad all the time and used an extra protector on his bed. The diagnosis was urinary tract dysfunction secondary to transverse myelitis with sexual impotence and the need for 5 daily catheterizations. Upon examination of the rectum and anus, the examiner noted that the veteran controlled his bowel movements with suppositories and disimpacted himself occasionally. He did not currently take stool softeners. He did have occasional slight diaper soiling after bowel movements. There was no rectal or anal bleeding, incontinence or diarrhea, tenesmus, dehydration, malnutrition, anemia, and only rare episodes of fecal leakage. The diagnosis was mild bowel dysfunction secondary to neurological problem. In January 1998 the RO continued current ratings for left and right leg paralysis, intermittent bladder and bowel dysfunction, and established service connection for impotency due to transverse myelitis and assigned a zero percent rating. Special monthly compensation, based on the loss of use of a creative organ, was granted. II. Legal Analysis The record shows that the veteran's claims are well grounded, meaning that they are plausible. The Board finds that all relevant evidence for equitable disposition of these claims has been obtained and that no further assistance to the veteran is required to comply with VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1997). Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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 (1997). 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 concern. The regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). A. Increased evaluation for right and left leg paralyses due to transverse myelitis, L1, currently evaluated 60 percent disabling for each lower extremity The term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. 38 C.F.R. § 4.124(a) (1997). Myelitis warrants a minimum 10 percent rating. This disorder and its residuals are part of a group of neurological disorders which may be evaluated from 10 percent to 100 percent disabling in proportion to the impairment of motor, sensory, or mental function which they produce. 38 C.F.R. §§ 4.124(a), Code 8010 (1997). A 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent evaluation requires moderate incomplete paralysis. A 40 percent evaluation requires moderately severe incomplete paralysis. A 60 percent evaluation requires severe incomplete paralysis with marked muscular atrophy. An 80 percent evaluation requires complete paralysis. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or very rarely lost. 38 C.F.R. § 4.124(a), Code 8520 (1997). In April 1990 service connection was established for right and left leg paralysis due to transverse myelitis and 40 percent ratings were assigned to each leg. At that time, the symptoms included minimal decreased pinprick and vibration sensation in the legs. Leg strength was diminished. The veteran walked with a cane, exhibited a spastic gait, and could stand on his heels and toes with difficulty. According to a September 1992 VA examination report, the veteran was wearing knee braces for instability and his gait and ambulation were markedly disabled. There was no ankylosis, shortening of an extremity, or complete foot drop. There was no definite evidence of peroneal nerve palsy. In February 1993 the RO assigned 60 percent ratings for each leg due to severe symptomatology. In a May 1995 VA examination report, left foot-drop was shown; however, the veteran could drive a car equipped with cruise control and an automatic transmission, and could brake with his right foot. In June 1996 the veteran testified that he currently wore knee braces for walking and an AFO ankle brace for left foot-drop. He experienced occasional right foot-drop also and had often fallen while walking. A July 1997 VA examination report notes that the veteran was currently using a wheelchair. He could walk about 10 feet without the use of leg braces or cane. He could walk 200 feet with braces and cane. There was weakness of the legs, with greater weakness on the left. The knees showed a slight tendency to hyperextend and he could straighten both legs when sitting on the edge of a table. Romberg's sign was positive, and the veteran could not jog or squat. Superficial sensation in the lower extremities was good but vibration sensation was poor and joint sense was poor. Severe clumsiness and splotchy sensory loss were found. The Board notes that under Code 8520, an 80 percent rating is available for complete paralysis of the leg, as shown by foot-drop with complete absence of active muscle movement below the knee and weakened or lost flexion of the knee. Evidence of bilateral foot-drop and weakness of both legs, greater on the left is noted. In July 1997 the examiner did not comment on the veteran's ability to flex the knees, but noted that the veteran could straighten (extend) them. The Board finds therefore, that even though there is some evidence of foot-drop and muscle weakness, neither loss of flexion nor complete paralysis of either leg has been shown. The veteran has some use of the legs and can walk, even without braces and cane, for 10 feet. He can use his right foot to operate an automobile. While his symptoms are severe, they do not approximate the criteria for complete paralysis of either leg. Because the preponderance of the evidence is against the claims for increased ratings for right and left leg paralysis due to transverse myelitis, L1, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Increased evaluation for intermittent bladder dysfunction due to transverse myelitis, currently evaluated as 40 percent disabling The veteran's service connected bladder dysfunction has been rated as a voiding dysfunction under Code 7512. For voiding dysfunction manifested by urine leakage, a 20 percent evaluation is warranted when there is a need for wearing absorbent materials which must be changed less than 2 times per day. A 40 percent evaluation is warranted when there is a need for wearing absorbent materials that must be changed 2 to 4 times per day. A 60 percent evaluation is appropriate when the use of an appliance is required or when there is a need for wearing absorbent materials which must be changed more than 4 times per day. 38 C.F.R. §§ 4.115a, 4.115b, Code 7512 (1997). In April 1990 the RO established service connection for intermittent bladder dysfunction and assigned a 20 percent rating under Code 7512. At that time, the medical evidence showed bladder dysfunction and a need for self- catheterization. A May 1995 VA examination report noted occasional urinary incontinence, bed-wetting, and a need for self-catheterization and the use of adult diapers. In June 1995 a 40 percent rating was assigned. The veteran testified in June 1996 that he performed self-catheterization for bladder control 5 times per day and took Di-tropan. He had 2 to 3 urinary tract infections per year and frequent leakage in bed at night. In July 1997 the veteran reported much the same symptoms and VA diagnosis of urinary tract dysfunction secondary to transverse myelitis with sexual impotence and the need for 5 daily catheterizations was made. Subsequently, service connection was established for sexual impotence; however, that disability is rated separately and will not be considered as part of the veteran's bladder dysfunction. The Board notes that the use of an "appliance" meets the criteria for a 60 percent evaluation as does the need to change absorbent material more than 4 times per day. In this case, the need to change absorbent material more that 4 times per day has not been shown; however, the use of disposable urinary catheters has been shown. The question is whether a urinary catheter is an "appliance." An "appliance" is a general term referring to various devices used to provide a function or therapeutic affect. A "prosthetic appliance" is a device affixed to or implanted in the body, designed to take the place, or perform the function of a missing body part. Dorland's Illustrated Medical Dictionary 110 (28th ed. 1994)). The Board finds that because the catheter is a device affixed to the body that provides a function or therapeutic effect upon the body by performing the function of a disabled bladder sphincter, it can be considered an "appliance" in this case. Obstructed voiding requiring intermittent or continuous catheterization warrants only a 30 percent rating. But here, the use of the catheter is not to relieve obstruction but to minimize leakage. Therefore, based on the use of an "appliance," the criteria for a 60 percent rating for intermittent bladder dysfunction due to transverse myelitis have been met. There is no higher schedular rating available for voiding dysfunction. C. Increased evaluation for intermittent bowel dysfunction due to transverse myelitis, currently evaluated as 30 percent disabling A noncompensable evaluation is warranted for healed or slight impairment of the rectal and anal sphincter without leakage. A 10 percent evaluation requires constant slight leakage or occasional moderate leakage. A 30 percent evaluation is appropriate if the impairment is manifested by occasional involuntary bowel movements that necessitate the wearing of a pad. A 60 percent evaluation is appropriate if there are extensive leakage and fairly frequent involuntary bowel movements. A 100 percent evaluation is appropriate if there is a complete loss of sphincter control. 38 C.F.R. § 4.114, Code 7332 (1997). In April 1990 the RO established service connection for intermittent bowel dysfunction and assigned a 10 percent rating under Code 7332. At that time, the medical evidence showed intermittent bowel difficulty. A September 1992 VA examination report notes constipation due to spasticity of the rectal sphincter and medication taken for myelitis. In April 1994 a 30 percent rating was assigned. A May 1995 VA examination report for aid and attendance and for housebound status notes that the veteran had a bowel control problem and used suppositories to induce bowel movements. The diagnoses included bowel control problems and the use of adult diapers for accidents relative to bladder and stooling. The veteran testified in June 1996 that he used stool softeners for constipation and suppositories for bowel movements. At a July 1997 VA examination, the veteran reported that he disimpacted himself occasionally. He had slight soiling of diapers after bowel movements. The examiner noted only rare episodes of fecal leakage with no rectal or anal bleeding incontinence or diarrhea, tenesmus, dehydration, malnutrition, or anemia. The Board notes that the evidence does not show impairment of sphincter control that would produce extensive leakage and fairly frequent involuntary bowel movements, although there is occasional minor soiling of the diapers. The Board finds that the veteran's symptoms do not approximate the criteria for the next higher rating for loss of sphincter control under Code 7332. Because the preponderance of the evidence is against the claim for an increased rating for intermittent bowel dysfunction due to transverse myelitis, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER 1. The claim for an increased evaluation for right leg paralysis due to transverse myelitis, L1, is denied. 2. The claim for an increased evaluation for left leg paralysis due to transverse myelitis, L1, is denied. 3. A 60 percent evaluation for intermittent bladder dysfunction due to transverse myelitis is granted, subject to regulations applicable to the payment of monetary benefits. 4. The claim for an increased evaluation for intermittent bowel dysfunction due to transverse myelitis is denied. REMAND In the recent case of Tucker v. West, No. 96-1493 (U.S. Vet. App. Aug. 13, 1998), the United States Court of Veterans Appeals (Court) ruled, in effect, that loss of use of a foot was a medical question, and that the effectiveness of balance and propulsion in ambulation could not be used by the Board (or other adjudicative personnel) to find that loss of use of a foot was not demonstrated. Such a finding, absent independent medical evidence, violates Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the issue of special monthly compensation based on loss of use of one or both feet will be REMANDED to the RO for further development. Consideration of the claim for special monthly compensation based on the need for aid and attendance or being housebound will be deferred pending this development, because a favorable outcome in the loss of use claim could, conceivably, affect the "A&A/housebound" claim. The case is REMANDED to the RO for the following action: The veteran should be afforded a VA examination to determine whether he has lost the use of one or both feet. With respect to each foot, the examiner should state whether it is at least as likely as not that there is complete paralysis of the external popliteal nerve (common peroneal) and consequent footdrop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve; or no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee, with use of a suitable prosthetic appliance. The determination should be made on the basis of the actually remaining function, whether the acts of balance, propulsion, etc., could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2), 4.63 (1997). The examiner should review the claims folder in making this determination. After review by the RO, if any decision remains adverse to the appellant, a supplemental statement of the case should be issued. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. J. E. Day Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board's decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1997).