Citation Nr: 0006603 Decision Date: 03/10/00 Archive Date: 03/17/00 DOCKET NO. 98-00 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES Entitlement to a disability evaluation in excess of 40 percent for low back disability from January 26, 1998. Entitlement to a disability evaluation in excess of 10 percent for low back disability from January 13, 1994, to January 26, 1998. Entitlement to a disability evaluation in excess of 30 percent for post-traumatic stress disorder. Entitlement to a disability evaluation in excess of 20 percent for cervical spine disability from May 27, 1997. Entitlement to a disability evaluation in excess of 10 percent for cervical spine disability from January 13, 1994, to May 27, 1997. REPRESENTATION Appellant represented by: John Stevens Berry, Attorney INTRODUCTION The veteran served on active duty from December 1986 to December 1992. When this matter was previously before the Board of Veterans' Appeals (Board) in August 1999, it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska, for additional development. Following the requested development, the RO in continued the evaluations previously assigned for the disabilities at issue on this appeal. The matter is now before the Board for final appellate consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. The service-connected low back disability is manifested by severe limitation of motion of the lumbar spine with pain and muscle spasm on motion in at least one plane of excursion and some mild radiculopathy on the left, but diagnostic imaging does not show degenerative changes in the lumbar spine. 3. From January 13, 1994, to January 26, 1998, the service- connected low back disability was productive of moderate limitation of motion of the lumbar spine, but neither severe lumbosacral strain nor severe intervertebral disc syndrome was demonstrated. 4. Post-traumatic stress disorder is manifested by intrusive recollections of his motor vehicle accident in service, disturbed sleep, an anxious and depressed mood, some memory loss affecting ability to learn new material, ideas of reference, fear of driving, massive social avoidance, impaired self-confidence and self-esteem, and a feeling of a foreshortened future; he has headaches instead of panic attacks. 5. The service-connected cervical spine disability is currently manifested by slight limitation of motion of the cervical spine with loss of normal cervical lordosis on X- rays, paraspinal muscle spasm, intermittent pain and numbness in the left upper extremity, but no more than moderate manifestations of intervertebral disc syndrome or lumbosacral strain are shown. 6. Between January 13, 1994, and May 27, 1997, the service- connected cervical spine disability was manifested by moderate limitation of motion, but severe lumbosacral strain or severe intervertebral disc syndrome has not been demonstrated with respect to the cervical segment of the spine. 7. The veteran has not shown good cause, such as the presence of a complex or controversial medical question, for seeking the opinion of an independent medical expert of the VA Under Secretary for Health regarding the severity of the disabilities at issue on this appeal. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 40 percent for low back disability from January 26, 1998, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.10, 4.40, 4.59, 4.71a, 18, Diagnostic Codes 5292, 5293 (1999). 2. The criteria for a 20 percent evaluation for low back disability from January 13, 1994, to January 26, 1998, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.10, 4.40, 4.59, 4.71a, Diagnostic Code 5292 (1999). 3. The criteria for a 50 percent evaluation for post- traumatic stress disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (1999). 4. The criteria for an evaluation in excess of 20 percent for cervical spine disability from May 27, 1997, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.20, 4.40, 4.59, 4.71a, 18, Diagnostic Codes 5290, 5293, 5295 (1999). 5. The criteria for a 20 percent evaluation for cervical spine disability from January 13, 1994, to May 27, 1997, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.20, 4.40, 4.59, 4.71a, Diagnostic Code 5290 (1999). 6. The opinion of an independent medical expert or of the Under Secretary for Health is not warranted. 38 U.S.C.A. § 7109 (West 1991); 38 C.F.R. §§ 20.901, 20.902 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Procedural Background The Board finds that the veteran's claims for increased ratings are plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation for a service-connected disability generally is a well-grounded claim). The Board is satisfied that all relevant evidence has been obtained with respect to these claims and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The record shows that the veteran's original claims for service connection for back and neck disorders were received on January 13, 1994, were continuously prosecuted thereafter, and were eventually granted by the Board in a decision dated in April 1997. The initial rating decision that implemented the Board's decision was dated later the same month and assigned a 10 percent rating for residuals of an injury of the low back under Diagnostic Code 5292 and a 10 percent rating for residuals of a neck injury under Diagnostic Code 5290. Both evaluations were made effective from the date of receipt of the original claim for compensation benefits. The veteran disagreed with the evaluations assigned, and evaluations were eventually entered granting a 40 percent rating for low back disability, effective from January 26, 1998, and a 20 percent rating effective from May 27, 1997. The veteran's initial claim for service connection for post- traumatic stress disorder was received on May 27, 1997, and was continuously prosecuted thereafter. Service connection was established for post-traumatic stress disorder in a rating decision dated in May 1998, and a 30 percent rating was assigned and made effective from the date of receipt of the original claim for service connection. The veteran disagreed with the evaluation assigned. The veteran's claims for higher evaluations for low back and cervical spine disabilities, and for post-traumatic stress disorder, were original claims that were placed in appellate status by his disagreement with the initial rating award. Furthermore, as held in AB v. Brown, 6 Vet. App. 35, 38 (1993), "on a claim for an original or an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation. . . . " The distinction between an original rating and a claim for an increased rating may be important, however, in terms of determining the evidence that can be used to decide whether the original rating on appeal was erroneous and in identifying the underlying notice of disagreement and whether VA has issued a statement of the case or supplemental statement of the case. In these circumstances, the rule in Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("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"), is not applicable to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings may be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Pertinent Rating Criteria Under the rating schedule, slight limitation of motion of the cervical segment of the spine warrants a 10 percent evaluation; a 20 percent evaluation requires moderate limitation of motion; a 30 percent evaluation is warranted where severe limitation of motion is shown. 38 C.F.R. § 4.71a, Diagnostic Code 5290. Slight limitation of motion of the lumbar segment of the spine warrants a 10 percent evaluation; a 20 percent evaluation requires moderate limitation of motion. A 40 percent evaluation is warranted where severe limitation of motion is shown. 38 C.F.R. § 4.71a, Diagnostic Code 5292. Under Diagnostic Code 5293, a 10 percent evaluation requires mild intervertebral disc syndrome. A 20 percent evaluation is warranted for moderate intervertebral disc syndrome with recurring attacks. A 40 percent evaluation is warranted for severe intervertebral disc syndrome with recurring attacks with intermittent relief. A 60 percent evaluation requires pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy (i.e., with characteristic pain and demonstrable muscle spasm and an absent ankle jerk or other neurological findings appropriate to the site of the diseased disc) and little intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293. A 10 percent evaluation for lumbosacral strain under Diagnostic Code 5295 requires characteristic pain on motion. A 20 percent evaluation is warranted for lumbosacral strain where there is muscle spasm on extreme forward bending and unilateral loss of lateral spine motion in a standing position. A 40 percent evaluation requires severe lumbosacral strain with listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space. A 40 percent evaluation is also warranted if only some of these manifestations are present if there is also abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295. Where there is a question as to which of two evaluations is to 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. The evaluation of the same disability under various diagnoses is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestations under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. With respect to the service-connected post-traumatic stress disorder, a 30 percent evaluation under Diagnostic Code 9411 of the rating schedule contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation under Diagnostic Code 9411 contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation under the rating criteria contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation under the rating criteria requires total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (effective November 7, 1996). Analysis A. Increased rating for low back disability Service connection was initially established for residuals of an injury of the low back and rated 10 percent disabling under Diagnostic Code 5292 from the date of receipt of the original claim. In a rating decision dated in September 1998, however, the service-connected disability was reclassified as residuals of a low back injury, with radiating pain to both lower extremities, and rated 40 percent disabling under Diagnostic Code 5292, effective from the date of receipt of the attorney-representative's letter contesting the evaluation in January 1998. As indicated above, under Diagnostic Code 5292 of the rating schedule, a 40 percent evaluation is the highest schedular evaluation available for limitation of motion of the lumbar spine, although limitation of motion is considered in evaluating the severity of intervertebral disc syndrome under Diagnostic Code 5293. See VAOPGCPREC 36-97, 63 Fed. Reg. 31,262 (1998). A 40 percent evaluation is also the maximum schedular rating available under Diagnostic Code 5295 for severe lumbosacral strain, which is arguably applicable by analogy. 38 C.F.R. § 4.71a, Diagnostic Code 5295; see 38 C.F.R. § 4.20. However, diagnostic imaging and clinical examinations have resulted in findings consistent with lumbosacral strain of a degree less than severe, and Diagnostic Code 5295 is therefore without application in rating the low back disability. Although the service-connected low back disorder may be rated by recourse to more than one diagnostic code, the rule against pyramiding precludes the use of multiple diagnostic codes to artificially inflate the service-connected evaluation. 38 C.F.R. § 4.14 (1999). The diagnostic code is applied that best reflects the overall disability picture shown for the specific anatomical part involved. The service-connected evaluation is assigned that most accurately reflects the degree of functional impairment shown by the evidence of record. The Board is of the opinion that the 40 percent rating assigned under Diagnostic Code 5292 for severe limitation of motion of the lumbar segment of the spine accurately reflects the actual degree of functional impairment demonstrated in this case. 38 C.F.R. §§ 4.10, 4.40. This is especially so in light of the most recent orthopedic and neurologic examination findings that show that the veteran's range of motion, including with pain and pain on flare-ups, is, if anything significantly improved since the examination by VA in June 1998. On VA neurologic examination in September 1999, the veteran had forward flexion of his lumbar spine to 95 degrees, which the examiner noted was normal. Although he had backward extension to 20 degrees, his lateroflexion was normal, bilaterally. He had paraspinal muscle spasm the length of his spine from his neck to his lumbar region. He had a couple of trigger points on palpation of the paraspinal muscles, but he "did not jump out" when the examiner touched them; the veteran merely indicated that he would get pain at these points of palpation. The veteran did not have muscle spasm on a VA orthopedic examination conducted about a week later. However, he walked with a very short stride in his gait and with a decrease in his lumbar lordosis and in his neck flexion posture. He had some tenderness to palpation of the paraspinous musculature in his lower back. His back appeared very flat in the lumbar area, but he had no true spinous tenderness. The veteran had forward flexion of the lumbar spine to 35 degrees before pain stopped him. He had backward extension to 20 degrees before pain stopped him. He had lateroflexion to 20 degrees, bilaterally, and rotation to 25 degrees, bilaterally. X-rays of the lumbosacral spine showed Schmorl's node at the L4-5 vertebral bodies. A Schmorl's node is an irregular or hemispherical bone defect in the upper or lower margin of the body of the vertebra. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1143 (28th ed. 1994). There was no evidence of acute fractures, dislocation or degenerative changes. Magnetic resonance imaging of the lumbar spine in July 1998 was reportedly normal. The pertinent impression was chronic musculature strain of the lumbar spine with occasional flares that impeded his ability to work in jobs that required excessive standing or manual labor. The examiner was of the opinion that the veteran was having back and neck pain that more muscular in nature. On VA orthopedic examination in June 1998, the veteran reported that he had muscle spasm in his back daily. The examiner stated that painful motion was noted on examination. The veteran had some difficulty and walked somewhat slowly, although he seemed to be in good physical shape overall. The veteran said that he used to work out a lot but that he could not do that anymore because his back and neck were so uncomfortable. The back musculature seemed strong, however. He did not have any fixed deformity, but he walked slightly hunched over because he had a slight abnormality to his posture. Most of his pain was over the posterior neck and the upper lumbar spine. It was reported that the veteran had much difficulty in flexing his trunk and only did so to about five degrees. He was very hesitant to flex any further because of discomfort. He had backward extension to five degrees; lateroflexion to 10 degrees, bilaterally, with some difficulty; and rotation to 25 degrees, bilaterally, without difficulty. The pertinent diagnosis was chronic muscular strain of the lumbar spine with occasional episodes of radiculopathy in the lower extremities. Magnetic resonance imaging of the lumbar spine performed the following month was normal. The Board notes that when initially examined by VA for compensation purposes in February 1994, the veteran gave a history of having been involved in a motor vehicle accident while on active duty in April 1990. He reported that while stopped at a red light, he was struck by a vehicle traveling at such a high rate of speed that the impact pushed him through the intersection. He had only a vague recollection of the accident, and it was unclear whether he actually experienced loss of consciousness. He was apparently treated as an outpatient at a private hospital and told to seek further treatment from a service facility. On VA orthopedic examination in February 1994, the veteran was observed to arise quite slowly when called in from the waiting room and to ambulate slowly with a limp to the left leg. His swinging of the arms was more pronounced on the left than the right, and when seated in the examination room, the veteran changed his position several times during the examination. The musculature of the back was found to be normal, but some tenderness was noted to percussion of the lumbosacral area. He had forward flexion to about 65 degrees, backward extension to a "a near normal" 30 degrees. He had lateroflexion to 35 degrees, bilaterally, which the examiner described as "near normal". He also had rotation to 35 degrees, bilaterally, which the examiner again described as "near normal". The examiner further remarked that the veteran was quite slow to regain his upright position from forward flexion and had to use his hands on the anterior portion of his legs to regain his upright position. The examiner stated that the veteran "certainly appears to be in discomfort upon this attempted movement." The examiner also noted a "large crepitance or popping noise" to the lumbosacral spine on rotation. X-rays of the lumbosacral spine, however, were negative. The diagnosis was history of trauma to the cervical and lumbosacral spine with residual chronic pain in the lumbosacral spine. However, on VA orthopedic examination in July 1995, the veteran was found by the examiner to be "highly limited" in his forward flexion to 45 degrees. He had normal backward extension to 35 degrees; normal lateroflexion, bilaterally, to about 40 degrees; and normal rotation to about 35 degrees. There was objective evidence of pain on forward flexion, and a large popping sound was again heard on rotation to the left and right. X-rays of the lumbosacral spine were again normal. The diagnosis was chronic lumbosacral spine pain secondary to a motor vehicle accident. Steven L. Mason, M.D., the veteran's private treating orthopedist, reported in January 1996 that the lumbar spine showed no significant limitation of motion. On VA neurologic examination in August 1997, however, the veteran had forward flexion to 40 degrees; backward extension to 20 degrees; lateroflexion to 30 degrees, bilaterally; and rotation to 30 degrees, bilaterally. He also complained that he experienced sharp pain in his left buttock that had been present since the accident in 1990, and he complained of pain that radiated down the anterior aspect of the thigh to his left knee, which caused him to limp. An appreciable limp when walking was not observed at that time, however. X-rays of the lumbosacral spine were normal, and the pertinent diagnosis was history of trauma to the lumbosacral spine with residual chronic pain. The private treatment reports for the period prior to January 26, 1998, are essentially similar in their findings or, if anything, indicative of somewhat less severe residuals of injury to the lumbosacral spine. It appears, however, that throughout the prosecution of his claim prior to January 26, 1998, the veteran has demonstrated limitation of motion of the lumbar spine that has been moderate in degree. This is especially so in view of the fact that the very important plane of excursion - forward flexion - has been the most severely restricted. However, the other planes of excursion were only slightly limited in their range of motion prior to January 26, 1998. In considering the overall severity of impairment, pain on motion, pain on flare-ups, and weakened movement, excessive fatigability, incoordination of the affected joints must be considered under the principles announced in DeLuca v. Brown, 8 Vet. App. 202 (1995). See 38 C.F.R. §§ 4.40, 4.45. While the provisions of 38 C.F.R. § 4.40 do not require separate ratings based on pain, the Board is obligated to give reasons and bases pertaining to that regulation. Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). However, chronic pain of the lumbosacral spine inhibiting the range of motion of that segment of the spine has been a consistent feature of this aspect of the veteran's appeal. When the DeLuca factors are considered, the Board is of the opinion that moderate limitation of motion of the lumbosacral spine has been demonstrated since the veteran filed his initial claim for compensation. It follows that a 20 percent evaluation is warranted for low back disability under Diagnostic Code 5292 for the period from January 13, 1994, to January 26, 1998. See 38 C.F.R. § 4.7. An evaluation in excess of 40 percent requires a showing of pronounced intervertebral disc syndrome. In order for a rating in excess of 20 percent for low back disability to be warranted between January 13, 1994, and January 28, 1998, the criteria for a 40 percent rating under diagnostic codes 5292, 5293, or 5295 would have to be equaled or more nearly approximated. In neither case has symptomatology of such severity been demonstrated. For the period from the receipt of the claim in January 1994 to January 1998, when the evaluation was increased to 40 percent, there is no basis for assigning a 40 percent evaluation by analogy to lumbosacral strain under Diagnostic Code 5295. Clinical examinations did not show listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, or loss of lateral motion with osteoarthritic changes. There was, moreover, no demonstration that there was abnormal mobility of the low back on forced motion. Although private X-rays of the lumbar spine were interpreted by a private orthopedist in January 1996 as visualizing mild disc space narrowing, this was not confirmed by subsequent diagnostic imaging. Although a compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 may be assigned where there is painful motion with joint or periarticular pathology, a compensable evaluation is warranted in these circumstances only where there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also Hicks v. Brown, 8 Vet. App. 417, 421 (1995) (under § 4.59, painful motion is considered limited motion even though a range of motion may be possible beyond the point when pain sets in). The painful motion contemplated by 38 C.F.R. § 4.59 has been considered and subsumed in the 40 percent evaluation currently assigned and in the 20 percent rating now assigned for the period from January 13, 1994, to January 26, 1998. See 38 C.F.R. § 4.14. The medical reports throughout the prosecution of this claim show that the veteran was seen on a recurring basis for treatment of his low back. However, neurologic symptoms referable to the low back have been mostly absent throughout this period. The veteran was neurologically intact on VA general medical examination in February 1994. A VA neurologic examination in July 1995 was negative for symptomatology associated with intervertebral disc syndrome in the low back. When the veteran was examined by Dr. Mason in January 1996, his deep tendon reflexes in the lower extremities were within normal limits, and there was no evidence of radiculitis to the lower extremities. His sensory examination was within normal limits. Dr. Mason was of the opinion that the veteran's lower extremities showed no evidence of neurologic deficit. Although he interpreted X- rays of the lumbar spine as showing mild disc space narrowing, this was not confirmed on subsequent magnetic resonance imaging studies. The pertinent diagnosis entered by Dr. Mason in January 1996 was lumbosacral pain disorder. On neurologic examination by VA in August 1997, the veteran complained of some radiation of pain to the left buttock and lower extremity and of severe muscle spasm in his low back, but a neurologic disorder was not diagnosed. It was reported that he saw a chiropractor once or twice a week for adjustments to improve the pain in his low back, but it was further reported that he had never worn a back brace for his lower spine. The record reveals no evidence of surgery for any low back disorder. The record further shows that the veteran began work as an assembly line worker on February 1, 1994, although he later became a computer programmer. It appears, moreover, that he has worked throughout the period of the prosecution of his claim. In any case, significant neurologic manifestations of low back disability are not shown prior to January 26, 1998. His complaints were mostly subjective. Straight leg raising, where elicited, has not been positive. Diagnostic imaging, as mentioned above, did not confirm the presence of any significant degenerative changes in the lumbar spine. Examinations have been negative for muscle wasting (atrophy), reduced motor strength in the lower extremities, sensory deficits, bowel or bladder dysfunction, or incoordination or ataxia. Objective examination has indicated some gait disturbance, but this has not been significant, at least insofar as signifying any severe neurologic dysfunction. The record is essentially negative for evidence of footdrop indicative of sciatic neuropathy. The pertinent diagnosis in August 1997 reflected only trauma to the lumbosacral spine with residual chronic pain; a neurologic deficit resulting from the low back disability was not shown. X-ray studies of the lumbosacral spine were requested but were normal. The Board therefore concludes that the criteria for a 40 percent evaluation under Diagnostic Code 5293 for severe intervertebral disc syndrome between January 13, 1994, and January 26, 1998, have not been met or more nearly approximated. 38 C.F.R. § 4.7. An evaluation in excess of 40 percent for low back disability from January 26, 1998, is also not warranted, as the symptoms of pronounced intervertebral disc syndrome are not shown. On VA neurologic examination in September 1999, the veteran complained of daily back pain that limited his daily activities. He indicated, however, that shooting pain down his left knee was infrequent. On examination, however, a normal gait was observed. The veteran displayed 5/5 strength in the lower extremities, and deep tendon reflexes were 2/4 throughout. Plantar responses were downgoing, bilaterally (negative Babinski), and his Romberg test was negative. Sensory examination with respect to pinprick and position sensation was normal. The examiner noted that magnetic resonance imaging of the lumbar spine was normal. The neurologic examiner diagnosed chronic muscle spasm but remarked that he did not think the veteran's symptoms were due to (nerve) root injury or spinal or bone injury. It is interesting to note that on VA examination in June 1998, the veteran reportedly had muscle spasm in his back daily. He also had some difficulty walking and walked somewhat slowly. However, he seemed to be in good physical shape overall. His pain was mostly over the upper lumbar spine, and although he did not have any fixed deformity, he walked slightly hunched over because he had a slight abnormality to his posture. His major problem was on forward flexion of the lumbar spine, which was severely limited. However, the examiner stated that no neurological abnormalities were noted on examination. The pertinent diagnosis was chronic muscular strain to the lumbar spine with occasional episodes of radiculopathy in the lower extremities. The examiner requested magnetic resonance imaging to determine whether any specific disc or spinal injury could be visualized. However, magnetic resonance imaging was normal. It is reasonably inferable from these findings that the veteran's low back problems are primarily of an orthopedic nature and that there is only occasional neurologic involvement. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1361 (1998) (Board has fact-finding authority to assess the quality of the evidence before it, including the duty to analyze its credibility and probative value, as well as authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Although severe limitation of motion of the lumbar spine has been found, the neurologic component of the low back disability is not sufficiently severe to equal or more nearly approximate the criteria necessary for a 60 percent rating under Diagnostic Code 5293. Certainly, the treatment prescribed for the veteran's low back has been conservative, involving mostly rest, medication, and chiropractic adjustment. Surgical intervention has not been necessary or recommended. Despite some gait disturbance, the veteran does not seem to require assistive devices in walking. This is not to deny that the veteran has significant low back disability; it is only to find that a pronounced degree of impairment necessary for the next higher evaluation of 60 percent under Diagnostic Code 5293 is not equaled or more nearly approximated. See 38 C.F.R. § 4.7. Although the veteran is certainly capable of providing evidence of symptomatology, a layperson is generally not capable of opining on matters requiring medical knowledge, such as the degree of disability produced by the symptoms or the condition causing the symptoms. See Stadin v. Brown, 8 Vet. App. 280, 284 (1995). It follows that an evaluation in excess of 40 percent for low back disability from January 26, 1998, is not for application. B. Increased rating for post-traumatic stress disorder A rating decision dated in May 1998 granted service connection for post-traumatic stress disorder and assigned a 30 percent rating, effective from the date of receipt of the initial claim for service connection in May 1997. Service connection was established for post-traumatic stress disorder based on the stressor of the veteran's involvement in the motor vehicle accident in service. The applicable criteria for evaluating the service-connected psychiatric disorder have been set forth above. The record shows that the veteran has recurrent thoughts and dreams of being hit from behind by a vehicle, as well as hyperreactivity whenever he is driving, which he must do to get to work. As a consequence of the accident, he avoids driving whenever he possibly can. His avoidance of social occasions, however, has been attributed, at least in part, to his chronic pain syndrome and his difficulty walking. Although he is detached physically and emotionally from the rest of the world, and has a job where he works primarily with a computer instead of people, the computer work has been partly a response to orthopedic problems that are more manageable in such a setting. Although he has reportedly lost interest in life and outside activities, and has difficulty with affective attachment, he has worked at several different jobs throughout the course of this appeal. Nevertheless, the examiner described his social impairment as "massive". The record further shows that the veteran has trouble sleeping, falling asleep and staying asleep. He also has trouble controlling his anger, and when he does, he gets depressed. He cannot concentrate and is hypervigilant. However, on mental status examination, the veteran was punctual, alert and cooperative, and dressed appropriately and neatly as a middle class or upper middle class person would be, according to the examiner. Although the veteran made attempts to be friendly and humorous, the examiner said that he clearly was in pain, which appeared to be due to his orthopedic problems. The veteran reported chronic weekly headaches that influence his ability to function significantly. He also complained of a daily headache that was more of a tension-type headache. These headaches interfered daily in what the veteran was doing. However, his speech was spontaneous and productive. He reached "goal ideas" without difficulty. His affect, however, was very sad. The veteran used humor to cover it. His mood was depressed. Although his mood was not suicidal at the time of the examination, the veteran indicated that it had been at times previously. Currently, however, the veteran had what the examiner described as more of a problem with sadness and frustration than with significant impairment of mood itself. There was, moreover, no evidence of a thought disorder. His stream of mental activity showed no difficulty with his sensorium. His consciousness was clear, and he exhibited good orientation to time, place and person. His concentration ability, however, was markedly reduced by his headaches "and also in general." His memory for recent and remote events was intact. His intelligence was described by the examiner as "bright-normal". His insight and judgment were good. He was capable of managing his own funds. The diagnosis on Axis I was post-traumatic stress disorder. His Global Assessment of Functioning (GAF) on Axis V was 60 to 65 as a result of his post-traumatic stress disorder. The GAF is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.'" Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV)). Although the GAF in this case suggests only mild to moderate impairment as a result of the service-connected psychiatric disorder, the evidence on VA psychiatric examination in February 1998 indicates a somewhat more severe degree of impairment. The examination revealed ideas of reference, particularly at work, in addition to classic post-traumatic stress disorder symptoms, which caused the examiner to remark that the veteran was not "absolutely on the paranoid side." However, the veteran did not have delusions and did not feel persecuted. The examiner indicated that the veteran's headaches caused the veteran a great deal of difficulty keeping a job because of poor attendance and indicated that the headaches substituted for panic attacks. Although the veteran's memory was mostly intact, he had memory impairment "for short-time or new learning ability." He was also depressed and anxious and had impaired sleep. Moreover, his fear of driving made it difficult for the veteran to be mobile. The examiner was also of the opinion that the veteran had very low self-confidence, low self-esteem, and a feeling of a foreshortened future as a result of the motor vehicle accident in service. He has become a social recluse and primarily has headaches instead of panic attacks. This case is problematic because the veteran's current symptomatology does not neatly fit the criteria for a 50 percent evaluation, especially in light of the fact that a significant portion of his current occupational impairment has been attributed to organic disabilities. On the other hand, the headaches have been characterized as a substitute for panic attacks and the symptoms of post-traumatic stress disorder have significantly affected the veteran's ability to drive and hence to work. In these circumstances, the Board will accord the veteran the benefit of the doubt and find that the symptoms of his service-connected psychiatric disability more nearly approximate the criteria for a 50 percent rating under Diagnostic Code 9411. 38 U.S.C.A. § 5107(b). However, an evaluation in excess of 50 percent is not warranted under Diagnostic Code 9411. Although the veteran has experienced some difficulty in adapting to stressful circumstances (including work or a worklike setting), this has been due in no small part to his organic disabilities, not his psychiatric one. Although he has an inability to establish and maintain effective relationships, and apparently had some prior suicidal ruminations, he has been able to work and has not exhibited symptoms such as obsessional rituals that interfere with routine activities; intermittently illogical, obscure or irrelevant speech; near- continuous panic or depression affecting his ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; or neglect of his personal appearance and hygiene. The criteria for a 70 percent evaluation under Diagnostic Code 9411 are thus not shown or more nearly approximated. See 38 C.F.R. § 4.7. Similarly, the current psychiatric symptomatology does not demonstrate total occupational and social impairment. Although the veteran has ideas of reference, these have not resulted in gross impairment of his thought processes or communication. He has been found to be without delusions, and there is no evidence any grossly inappropriate behavior. Although the veteran has some anger and irritability, he is not shown to be a persistent danger to himself or others. He had no current suicidal ideation on recent psychiatric examination. There is no evidence of an intermittent inability to perform the activities of daily living, including the maintenance of minimal personal hygiene, nor has he been shown to be disoriented to time or place. Moreover, he has not demonstrated memory loss for names of close relatives, his own occupation, or his own name. The criteria for a total schedular evaluation under Diagnostic Code 9411 are simply not shown. It follows that an evaluation in excess of the 50 percent rating granted herein is not warranted. The evidence is not so evenly balanced as to raise doubt concerning any material issue. 38 U.S.C.A. § 5107(b). C. Increased rating for cervical spine disability The April 1997 rating decision initially evaluated the service-connected residuals of a neck injury as 10 percent disabling under Diagnostic Code 5290, effective from the date of receipt of the original claim for compensation in January 1994. However, a rating decision dated in January 1998 reclassified the disability as residuals of a neck injury with radiating pain and numbness to the arms, hands and fingers, and assigned a 20 percent evaluation by analogy to intervertebral disc syndrome under Diagnostic Code 5293, effective from May 27, 1997. The medical evidence of record prior to May 27, 1997, shows that the veteran sustained what amounted to a whiplash injury in the motor vehicle accident in service. However, when examined by VA in February 1994, significant findings referable to the cervical spine were not noted. The veteran complained of chronic daily pain, which he treated with Excedrin. Since starting a job recently, he had noticed mid- back pain with radiculopathy down the right arm and some numbness to the distal digits of the right hand, as well as to the anterior medial surface of the forearm. (It was reported that the veteran was right handed.) Orthopedically, however, his upper extremities were intact, and he was also found to be neurologically intact overall. X-rays of the cervical spine were negative. On VA orthopedic examination at that time, there was some tenderness on percussion of the paraspinous area between the shoulder blades. The pertinent diagnosis was history of trauma to the cervical. On VA examination of the neck in July 1995, the veteran complained of stiffness and soreness of the cervical spine and reported that he took non-steroidal medications daily for this problem. He gave a history of left upper extremity pain originating in the cervical spine and a history of bilateral upper extremity numbness and tingling originating in the cervical spine. On examination, he had forward flexion of the cervical spine to about 30 degrees, backward extension to 30 degrees; right lateroflexion to 30 degrees and left lateroflexion to 35 degrees. The veteran had rotation to about 50 degrees, bilaterally. No deformity or weakness of the cervical spine was noted. X-rays of the cervical spine were again normal. The diagnosis was status post trauma, motor vehicle accident, with residual cervical spine pain. Dr. Mason stated in February 1996 that he had been treating the veteran for a cervical and lumbar pain disorder and that, on examination, the veteran had forward flexion of the cervical spine to 40 degrees; backward extension to 40 degrees; lateroflexion to 30 degrees, bilaterally; and rotation to 60 degrees, bilaterally. Dr. Mason said that the veteran carried a diagnosis of cervical discogenic pain syndrome. Private treatment notes from Dr. Mason dated in January and February 1996 indicate that the veteran was now unable to participate in any sports, which he once enjoyed, due to cervical pain syndrome. It was reported that the veteran quantified his neck pain as 8 out of 10 on a regular basis. On examination in January 1996, the veteran had multiple trigger points throughout the upper back, parascapular region and central neck region. The Spurling maneuver, however, showed no evidence of radiculitis of the upper extremities. Although there was no evidence of neurologic deficit in the upper extremities, he had pain with flexion and extension. The range of motion of the cervical spine was limited. Deep tendon reflexes in the upper extremities were within normal limits. Cervical spine X-rays were interpreted as visualizing evidence of a cervical spondylolysis and disc space narrowing that was most significant at the C5-6 level. The veteran had relative loss of the cervical lordosis. The pertinent impressions were cervical discogenic pain syndrome, and whiplash-type injury sustained in a motor vehicle accident. Aggressive conservative treatment was instituted, including physiotherapy and multiple medications. When seen by Dr. Mason the following month, the veteran had not yet instituted physical therapy but indicated that medication had given him significant anti-inflammatory effect and pain relief. Chiropractic manipulation was also recommended. John F. Klinginsmith, D.C., reported in April 1996 that he had seen the veteran initially in February 1996 and that the veteran had forward flexion of the cervical spine to 35 degrees with pain at that time. He had backward extension to 30 degrees with pain; lateroflexion to 30 degrees with pain, bilaterally; and rotation to 50 degrees with pain, bilaterally. The initial course of treatment, which included the thoracic and lumbar spine, was three manipulations a week for three weeks; two a week for two weeks; and then one a week. In a statement dated in March 1997, Dr. Klinginsmith stated that the veteran continued to receive treatment once a week. He said that the veteran had daily pain and that his condition was chronic. He would get manipulations at least once a week for six months, once every two weeks for a year, and once a month for life thereafter. The range of motion of the cervical spine was unchanged from the initial visit. The Board is of the opinion that the evidence prior to May 27, 1997, demonstrates that the veteran had moderate limitation of cervical spine motion as a result of his service-connected neck disorder. Under Diagnostic Code of 5290 of the rating schedule, motion restricted to a moderate degree warrants a 20 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5290. Although this was first definitively demonstrated some time after the veteran filed his original compensation claim, the Board will accord him the benefit of the doubt and find that the restriction of the range of motion of his cervical spine more nearly approximated moderate severity at the time he filed his claim on January 13, 1994. However, severe limitation of cervical spine motion is not demonstrated at any time during the prosecution of this claim, even when the DeLuca factors are considered. Although there is some evidence of cervical spondylolysis, a showing of severe lumbosacral strain or severe intervertebral disc syndrome is not shown or more nearly approximated if the cervical spine disability were rated by analogy to either those diagnoses. See 38 C.F.R. §§ 4.20, 4.71a, diagnostic codes 5293, 5295. On VA orthopedic examination in September 1999, the veteran could flex and touch his chin to his chest. He had backward extension to 35 degrees and rotation to 55 degrees. He had a negative Spurling maneuver. He had a normal sensory examination of his upper extremities and exhibited good strength in those extremities. His cervical spine was essentially nontenure on examination. It was reported that magnetic resonance imaging in July 1998 showed a normal cervical spine. The pertinent diagnosis was chronic musculature strain of the cervical spine with occasional flares, but the examiner was of the opinion that there was no indication on clinical examination of disc herniation or fracture. He felt that the neck pain was more muscular in nature. Moreover, electromyographic and nerve conduction velocity (EMG/NCV) studies in August 1997 were interpreted as consistent with asymptomatic carpal tunnel syndrome on the right. There was no evidence of compression neuropathy at the elbow. Carpal tunnel syndrome is a complex of symptoms resulting from compression of the median nerve in the carpal tunnel, with pain and burning or tingling paresthesias in the fingers and hand, sometimes extending to the elbow. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1626 (28th ed. 1994). Although the service-connected disability includes radiating pain to the arms, hands and fingers, the evidence indicates that any current neurologic deficits of the upper extremity are partly attributable to pathology not associated with the service-connected cervical spine disability. The service- connected evaluation may not be predicated on symptoms not resulting from the service-connected disability. See 38 C.F.R. § 4.14. There must be evidence of severe recurring attacks of intervertebral disc syndrome with only intermittent relief to warrant a 40 percent evaluation under Diagnostic Code 5293. The evidence, including the most recent orthopedic findings, strongly indicates that the cervical spine disability is primarily muscular in nature. This in turn suggests that a rating by analogy to lumbosacral strain under Diagnostic Code 5295 might be appropriate. However, the symptoms necessary for a 40 percent rating by analogy under that diagnostic code simply are not demonstrated. There is, for example, no showing that the cervical spine exhibits marked limitation on forward bending, listing of the whole cervical spine to the opposite side, or loss of lateral motion with osteoarthritic changes. Despite some disc space narrowing and degenerative changes suggested by private X-rays in January 1996, the fact remains that such pathology was not visualized on subsequent X-rays or on magnetic resonance imaging in July 1998. There is, moreover, no showing of abnormal mobility on forced motion of the cervical spine. Indeed, the current neck pathology seems to most closely track the criteria for a 20 percent rating under Diagnostic Code 5295, which involves muscle spasm on extreme forward bending of the spine. See 38 C.F.R. § 4.7. Here, as in the case of the low back, the provisions of 38 C.F.R. § 4.59 are without application because a compensable limitation of motion of the cervical spine has been shown on repeated clinical examinations. See Lichtenfels v. Derwinski, 1 Vet. App. at 488; Hicks v. Brown, 8 Vet. App. at 421. The painful motion contemplated by 38 C.F.R. § 4.59 has been considered and subsumed in the 20 percent evaluation assigned for cervical spine disability both before and after May 27, 1997. See 38 C.F.R. § 4.14. There is no question that the veteran sustained significant cervical spine disability as a result of the motor vehicle accident in service. However, the current residuals of the neck injury then sustained do not result in symptoms sufficiently severe to warrant a rating higher than 20 percent, either before or after May 27, 1997. The evidence is not so evenly balanced as to raise doubt concerning any material issue. 38 U.S.C.A. § 5107(b). Request for an Advisory or Independent Medical Opinion The attorney-representative in September 1998 requested an advisory or independent medical opinion because of the alleged inadequacy of the examinations provided by VA. Subsequent VA examinations were of course provided. The Board notes that the provisions of 38 U.S.C.A. § 7109 permit the Board to refer a matter for a medical opinion upon a showing of good cause, such as the identification of a complex or controversial medical or legal issue involved in the appeal under consideration. The Board has the discretionary authority to request an opinion from an independent medical expert outside VA or to seek an opinion from the Chief Medical Director (now the Under Secretary for Health) when such medical expertise is needed for an equitable disposition of an appeal. 38 C.F.R. § 20.901. However, the Board is of the opinion that good cause has not been demonstrated to seek such an opinion. As indicated, the objection lodged by the attorney-representative has been addressed by the provision of subsequent VA examinations. However, the Board is of the opinion that complex or controversial medical questions are not in any case presented by this appeal. The issues before the Board involve solely the current severity for rating purposes of the service- connected disabilities, not the origin or etiology of those disabilities. In the latter case, a cogent opinion can be elicited based on the record alone, but in the former case, the veteran must normally be examined. To properly gauge the severity of a service-connected disorder, it is usually necessary to elicit complaints, history, and signs and symptoms through clinical examination. Neither the Under Secretary for Health nor an independent medical expert is in a position to actually examine a claimant. The request for an advisory or independent medical opinion must therefore be denied. ORDER An evaluation in excess of 40 percent for low back disability from January 26, 1998, is denied. A 20 percent evaluation for low back disability from January 13, 1994, to January 26, 1998, is granted, subject to controlling regulations governing the payment of monetary benefits. A 50 percent evaluation for post-traumatic stress disorder is granted, subject to controlling regulations governing the payment of monetary benefits. An evaluation in excess of 20 percent for cervical spine disability from May 27, 1997, is denied. A 20 percent evaluation for cervical spine disability from January 13, 1994, to May 27, 1997, is granted, subject to controlling regulations governing the payment of monetary benefits. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals