Citation Nr: 0003357 Decision Date: 02/09/00 Archive Date: 02/15/00 DOCKET NO. 94-14 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased evaluation for a low back disability, currently evaluated as 10 percent disabling. 2. Entitlement to an increased evaluation for a cervical spine disability, currently evaluated as 10 percent disabling. 3. Entitlement to an increased (compensable) evaluation for status post carpal tunnel syndrome, right hand. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Christopher P. Kissel, Counsel INTRODUCTION The appellant was honorably discharged from the United States Air Force in March 1993 with over twenty years of active duty service. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a June 1993 rating decision of the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO). The procedural history of this case is set forth in the Board's remand dated June 19, 1998. The appellant's representative has requested consideration of what appears to be a claim seeking a total disability rating based on individual unemployability due to service-connected disabilities. See Written Brief Presentation, p. 3-4 (November 19, 1999). As this claim is not presently before the Board or otherwise shown to be inextricably intertwined with the issues on appeal, the Board refers this claim to the RO for appropriate development and adjudication. FINDINGS OF FACT 1. The appellant's low back disability is manifested by reports of chronic low back pain with episodic flare-ups of more severe pain with muscle spasm. 2. The appellant's cervical spine disability is manifested by complaints of chronic pain and stiffness in the neck, with x-ray evidence showing some degenerative changes of the cervical spine and narrowing of the C5-6 disc spaces, but with no clinically demonstrated evidence of limitation of motion or any other residual disability. 3. The medical evidence of record does not show any clinical findings of residual disability as a result of in-service surgical repair of carpal tunnel syndrome of the appellant's right hand. 4. The evidence in this case does not reflect that the appellant has an exceptional or unusual disability picture as to render impractical the application of the regular schedular disability rating standards for his low back, cervical spine or right hand carpal tunnel syndrome disabilities. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 20 percent disability rating, but not higher, for the appellant's low back disability pursuant to the regular schedular rating standards are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.40, 4.45, Part 4, Diagnostic Code 5295 (1999). 2. The appellant's cervical spine disability is no more than 10 percent disabling pursuant to the schedular criteria. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. Part 4, Diagnostic Code 5003-5290 (1999). 3. The appellant's status post carpal tunnel syndrome, right hand, is no more than noncompensably disabling pursuant to the schedular criteria. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. Part 4, Diagnostic Code 8515 (1999). 4. Application of extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The appellant was most recently evaluated on VA orthopedic, neurological and peripheral nerves compensation examinations conducted in August 1998 and April 1999, pursuant to the Board's remand instructions of June 1998. Prior to 1998, the appellant's service-connected back and carpal tunnel disabilities were evaluated on a VA compensation examination conducted in June 1993. The balance of the medical evidence consists of service medical records and outpatient records from the Blanchfield Army Hospital, Fort Campbell, Kentucky, dated in 1996-98. As alluded to above, the appellant was honorably discharged from the Air Force in March 1993 with over twenty years of active duty service. He filed his original claim for VA disability compensation benefits in April 1993, and by rating decision in June 1993, service connection was granted for the low back, cervical spine and the right hand carpal tunnel syndrome disabilities at issue here on appeal. The low back disability (described as degenerative changes of the lumbosacral spine with low back pain) was assigned a 10 percent rating under Diagnostic Code 5003-5295, while the other two conditions were rated noncompensably disabling under appropriate diagnostic criteria (Diagnostic Code 5003- 5290 for osteoarthritis of the cervical spine and Diagnostic Code 8515 for status post carpal tunnel syndrome of the right hand). In November 1993, the appellant filed a notice of disagreement with the schedular ratings assigned for these disabilities. He perfected his appeal to the Board in March 1994. In his notice of disagreement of November 1993, the appellant stated that he had loss of range of motion in the cervical and lumbar spines, and that he had current symptoms of carpal tunnel syndrome in his right hand. He added that treatment records from the Fort Campbell hospital would be furnished to the RO as soon as possible to corroborate his contentions. In his substantive appeal of March 1994, the appellant stated the following with respect to these disabilities: I have difficulty bending because of the pain in my lower back. It will go out even if I sneeze too hard. I can't lift without causing pain. I was told by a doctor not to lift over 20 lbs. I can't stand for very long periods without pain nor can I walk for other than short periods without causing pain in my back. I've had problems sitting in a c[hair] or a car where my back would hurt and my right leg would go numb from the waist down. This even happens when I am standing. I have been bedridden for 2-3 days because my back hurt so bad that I couldn't walk. I have been given muscle relaxers, motrin & tylenol 3 to eleviate [sic] the pain. I am currently taking Salsalate for the arthritis. This has also elevated into my neck. I have been treated lately for pain. The arthritis has started to spread into my hands affecting my ability to use hand tools. I have to use tools in my job and this creates problems at times. My hands cramp so bad I have to stop. The neck pain causes headaches so severe that I can only lie down in a dark room away from light and take motrin for the pain. The report of the June 1993 VA general medical examination noted the appellant's complaints of lower back and neck pain of long duration, with current inability to bend and stoop and right leg pain with prolonged sitting. Notwithstanding these complaints, clinical findings on the 1993 VA examination revealed that he had full range of motion of the lumbar spine in all directions (95 degrees of forward flexion, 35 degrees of backward extension, 40 degrees of left and right lateral extension, and 35 degrees of rotation to the left and right). In addition, there were no reported abnormalities of the appellant's motor and sensory functioning of his back and lower extremities. X-ray studies of his lumber spine were interpreted as essentially negative; the only abnormal finding was "minimal" degenerative changes in the lower lumbar spine. Regarding the cervical spine, the only clinically significant findings reported were x-rays showing some degenerative changes of cervical spine with narrowing of the C5-6 disc spaces. There was no reported evidence of limitation of motion or any other residual disability of the cervical spine. Based on these findings, diagnoses of low back pain and disc disease at C5-6 were reported. With regard to carpal tunnel syndrome of the right hand, the appellant reported no complaints referable to his right wrist as a result of his carpal tunnel surgery on the 1993 VA examination and the examiner found no evidence of neurological impairment of the right upper extremity other than some cutaneous hypothesia over the right forearm, which is a separate service-connected disability rated 10 percent disabling. The Board notes, however, that a status-post carpal tunnel surgery nerve conduction study completed shortly before the appellant's retirement from the Air Force in December 1992 showed that he had "[m]oderately severe [right] median nerve compression at the wrist (right carpal tunnel syndrome)." As noted previously, the appellant was examined on a VA neurological examination in August 1998. With regard to his low back, the appellant related a history of injuring his back in a motor vehicle accident in 1968. He indicated that he had chronic low back pain ever since, with worsening of his pain symptoms whenever he bent over or increased his physical activities. The appellant also stated that he had occasional radicular-type pain symptoms into his legs, but that these symptoms were not associated with any weakness. He added that that he experienced intermittent numbness as well. However, he reported that he did not wear a back brace or take any medications for this condition at the time of the examination. Objectively, the appellant had full range of motion of the lumbar spine with normal forward flexion and extension backward, lateral flexion and rotation. There was, however, mild pain in the lower back with range of motion testing. X-rays of the lumbar spine taken on the August 1998 neurological examination showed loss of disc space height at L5-S1 with a vacuum disc phenoma; otherwise, the vertebral body heights were well maintained and there was no significant degenerative changes in the facet joints. The interpretation of the x-rays was described as "minor abnormality." Based on these findings, the examiner diagnosed lumbar spine pain with normal physical examination, likely secondary to degenerative disc disease as shown by the x-rays. The appellant related a history of injuring his neck in the 1968 motor vehicle accident on the August 1998 VA neurological examination with chronic neck pain and stiffness since that injury. He indicated that his pain was presently worse when looking up and changing positions, but it was relieved by rest, specifically, lying down. He denied current use of medications for this neck pain complaints at the time of the examination. Objectively, clinical findings were similar to those noted above with regard to the low back; specifically, he had full range of motion of the cervical spine with normal forward flexion and extension backward, lateral flexion and rotation, but with mild pain while completing the range of motion test. X-rays of the cervical spine showed loss of disc space height at C5-6 and C6-7 with small anterior osteophytes at C6-7. In addition, the x-rays showed a slightly narrowed left-sided neural foramina at C5-6; otherwise, the alignment of the cervical spine was normal and no acute fracture was seen. The interpretation of the x-rays was also described as a "minor abnormality." Based on these findings, the examiner diagnosed cervical spine pain with normal physical examination, likely secondary to degenerative disc disease as shown by the x-rays. With regard to his carpal tunnel syndrome, the appellant stated on the August 1998 VA neurological examination that he developed the condition in the mid-to-late 1980's while operating a computer. He complained of severe numbness and cramping at that time and he indicated that his pain symptoms worsened whenever he used his fingers or a keyboard. He stated that a splint was used with some relief and that he took anti-inflammatories and other medications until finally undergoing a carpal tunnel release procedure at Fort Campbell in 1987. The appellant stated that the procedure was only partially successful as at the present time, he continued to experience similar symptoms and was therefore unable to use a computer. Objectively, examination of his right wrist revealed the presence of the surgical scar from the release procedure, but otherwise, the Tinel sign was negative and his grip strength was intact. Tinel's sign is a test to determine whether a tingling sensation in the distal end of a limb is present when percussion is made over the sight of a divided nerve; a positive sign indicates a partial lesion or the beginning regeneration of the nerve. See Dorland's Illustrated Medical Dictionary, 27th edition (1988). The outpatient records from Fort Campbell dated in 1996-98 indicated that the appellant was seen for a flare-up of his low back pain complaints in January 1997, as described above, but otherwise, these records are negative for any additional treatment for the low back, and there is no evidence in these records of any treatment for his neck pain complaints or for his carpal tunnel syndrome disability. The January 1997 report indicated that the appellant had normal range of motion and no neurological deficits or sciatica, but that he had a spasm at L4-5. These records were received in response to the RO's letter to the appellant dated in August 1998 requesting that he provide the names and addresses of all health care providers from which he received treatment for his disabilities. On the basis of the August 1998 VA neurological examination, the RO denied increased ratings for the low back and carpal tunnel syndrome disabilities, but awarded a 10 percent rating for the cervical spine disability effective from the date of claim, April 1, 1993. The April 1999 VA orthopedic and peripheral nerves examinations were conducted with benefit of review of the appellant's claims file by the examining physicians. On the VA orthopedic examination, the examiner provided a detailed summary of the appellant's medical history pertinent to his neck and low back, as reflected in the service medical records, as well as the following synopsis with regard to his current complaints: Neck pain: He says that he has stiffness of his neck and occasional mild pain which goes to his jaw. He denies weakness, fatigability or incoordination. If he moves his head a lot, he may have some associated headaches. He denies any flare-up of his neck pain. He has had no other injury to his neck and has never had neck surgery. Back pain: [The appellant] reports that he has back pain on a daily basis. The pain goes down his right lower extremity and on a grade of 1-10, with 1 being minimal pain and 10 being extreme pain, he feels that his pain is usually grade 4-5. He describes some stiffness of his back, especially first thing in the morning. He denies any weakness or fatigability or incoordination but does report that when he has the pain, he has to sit down. He does have flare-ups of his back pain approximately once a month, usually lasting from half an hour to a couple of hours in duration. The pain then is a sharp, stabbing, twisting pain in the middle of his low back. During the flare-up, his pain is 7-8 on the 10- point scale. In 1997, he had a severe flare-up where he was not able to walk due to pain and the flare-up lasted for two days. A flare-up could be precipitated by making a wrong motion or overexertion or even a sneeze. The flare-ups are alleviated by sitting down and not moving and taking medications. He denies any other back injury or ever having had back surgery. For treatment purposes, the appellant stated at the time of the April 1999 VA orthopedic examination that he was currently taking aspirin, 2-4 tablets a day, and occasionally, Motrin, for his pain symptoms in the neck and low back. He reported no side effects with this treatment regimen and indicated he received some relief. He denied ever using crutches, braces or canes. In the past, he took Motrin and muscle relaxants and had some physical therapy, including traction for his neck, which he indicated was not helpful. At the time of the examination, the appellant stated that he was employed as an electronics technician, and although he was able to perform his job, he indicated that he sometimes needed to sit down and take a break if his back started bothering him. In addition, he stated that he used a computer at home which would sometimes make his neck stiff looking into the screen. He also stated that he used a riding lawnmower because it was less stressful on his back. The appellant added that he exercised caution while bending and stooping and indicated that his leg would get numb whenever he sat or drives a car for more than 15 to 20 minutes. Objectively, clinical findings on the April 1999 VA orthopedic examination revealed that the appellant had normal musculature of the back, with a normal posture and no fixed deformities. In addition, there was no evidence of back spasm or tenderness on palpation and percussion. There was also no evidence of weakness. The appellant was able to walk on his heels and toes without difficulty as well, and there was no evidence of related weakness or incoordination. Sensation in the lower extremities was grossly intact. Range of motion testing of the lumbar spine was normal (95 degrees of forward flexion, 15 degrees of backward extension, 30 degrees of left and right lateral extension, and 35 degrees of rotation to the left and right) and he had no complaints of discomfort with any of these movements. He also had normal range of motion of the cervical spine (30 degrees of forward flexion, 30 degrees of backward extension, 30 degrees of left and right lateral extension, and 55 degrees of rotation to the left and right), but with some complaints of discomfort at the full backward extension; otherwise, no other complaints with discomfort. The examiner indicated that with a flare-up of low back pain, the appellant could not perform forward flexion at all and he related an associated inability to walk normally ("very shuffling gait"). Between the two, however, the appellant indicated that the shuffling gait was the major functional limitation during a flare-up. Repeat x-rays of the spine were deemed unnecessary by the examiner in light of the recent studies taken in August 1998. Based on the above, together with a review of the evidence in the claims file, the examiner offered the following diagnoses: 1. Degenerative disc disease of the lumbosacral spine with unremarkable exam. 2. Degenerative disc disease of the cervical spine with unremarkable physical examination. 3. There is history of mechanical low back pain with flare-ups of pain during which he has significant limitations of function as described above. On the VA peripheral nerves examination conducted in April 1999, the appellant reported that his main problem was attacks of back spasms and sharp, twisting-type low back pain occurring three to four times a year, and possibly more frequently recently, with each attack lasting anywhere from 30 minutes to three to four days. The appellant indicated that his pain would originate in the middle of his low back and radiate down to the knee and circumferentially around the thigh on the right. When he experienced one of these attacks, he indicated that he would take muscle relaxants and nonsteroidal anti-inflammatory medications. The appellant also stated that he was advised to rest when one of these attacks occurred. In between attacks, the appellant described very slight stiffness and pain, although he could perform his job as an electronics technician. Regarding his neck, the appellant stated that it did not actually disable him presently, although he feared that it would at some future date. He indicated, however, that he experienced neck stiffness and had difficulty looking up. He also stated that he experienced occasional numbness and tingling in his right arm. With respect to his carpal tunnel syndrome, the appellant reported that he did not have any frank complaints of this problem, although he apparently believed that his numbness in his right arm was related to the disability. He stated, however, that he occasionally had some wrist pain predominantly on the dorsum of his hand. Objectively, the following clinical findings were reported on the April 1999 VA peripheral nerves examination: He seems to have decreased range of motion in his legs to passive straight leg raising. He gets to approximately 50 degrees with his leg fully extended. With the knee bent, he is able to achieve 90+ degrees of hip flexion. This is consistent with a lumbar spondylosis. Neck range of motion is actually normal at this time. His shoulder abduction is just slightly less than normal but greater than 150 degrees. He complains of some numbness and stiffness in his arm which appears to be related to his old musculocutaneous injury. He has some pain and just real frank limitation of range of motion of his shoulder both posteriorly as well as in abduction. Muscle strength appears to be normal compensating for his pain. There is no atrophy in the forearms or hands. Pinprick sensation and proprioception are very slightly decreased but probably within normal limits. Gait is normal. Balance and posture appear to be normal. On the basis of these findings, the examiner stated that the appellant's carpal tunnel syndrome appeared to be stable and in remission. He specifically indicated that, "[t]here are no active symptoms or signs that suggest carpal tunnel syndrome." Regarding the back disabilities, the VA peripheral nerves examiner stated that the appellant had chronic degenerative disease of his spine as evidenced by previous x-rays. He further stated the following with respect to the functional limitations caused by the low back disability: Given the episodic nature of his flare[- ]ups, a precise determination of disability is difficult. However, it appears clear that he does have periods of severe disability related to muscle spasms and back pain. The appropriate treatment for this problem is periodic rest and physical therapy along with nonsteroidal agents and muscle relaxants, such as what he is already receiving. There really is no better alternative treatment for this. As a result of this medical regimen, it would be expected that he would require sick leave at times, and whether this may in the long run affect his overall employability is unclear. In June 1999, the RO requested all available medical records from the Nashville-VA Medical Center dating from January 1993 to the present, but the only records received were duplicative copies of VA compensation examinations conducted between 1993 and 1999. II. Analysis The Board finds that the appellant's increased rating claims are well grounded based on his complaints and medical records on file. 38 U.S.C.A. § 5107(a) (West 1991) and Shipwash v. Brown, 8 Vet. App. 218 (1995). Further, the Board finds that the appellant has not been prejudiced by the RO's or the Board's description of these claims as "increased ratings" even though the appeal was perfected to the Board from his April 1993 original claim seeking entitlement to service connection for the disabilities at issue herein. Upon review of the procedural history, it is found that throughout the pendency of the appeal, based on evidence received as a result, the RO has evaluated all the disabilities in question effective from the date of original entitlement in April 1993, and hence, there was no need to address the question of staged ratings for these disabilities. See Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, although the appellant was awarded an increased evaluation for his cervical spine disability during the pendency of this appeal, this claim remains in appellate status because he has not withdrawn it and less than the maximum available benefits have been awarded. See AB v. Brown, 6 Vet. App. 25 (1993). A merits-based review of the appellant's claim requires the Board to provide a written statement of the reasons or bases for its findings and conclusions on material issues of fact and law. 38 U.S.C.A. § 7104(d)(1) (West 1991). The statement must be adequate to enable a claimant to understand the precise basis for the Board's decision, as well as to facilitate review by the United States Court of Appeals for Veterans Claims (the Court). See Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Moreover, as the Court has pointed out, the Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, the Board has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997), and cases cited therein. Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Low Back and Cervical Spine Disabilities With respect to the rating of musculoskeletal joint disabilities, the Court has held that the Board must consider the application of 38 C.F.R. § 4.40 (1999) regarding functional loss due to joint pain on use or during flare-ups, and 38 C.F.R. § 4.45 (1999) regarding weakness, fatigability, incoordination, or pain on movement of a joint. DeLuca v. Brown, 8 Vet. App. 202, 203 (1995) (sections 4.40 and 4.45 make clear that pain must be considered capable of producing compensable disability of the joints); see also Quarles v. Derwinski, 3 Vet. App. 129 (1992) (failure to consider section 4.40 was improper when that regulation had been made potentially applicable through assertions and issues raised in record). Accordingly, the Court's holding in DeLuca requires the Board to consider whether increased schedular ratings for the appellant's low back and cervical spine disabilities may be in order on three independent bases: (1) pursuant to the relevant schedular criteria, i.e., notwithstanding the etiology or extent of his pain complaints, if the medical examination test results reflect findings which support higher ratings pursuant to the delineated schedular criteria; (2) pursuant to 38 C.F.R. § 4.40 on the basis of additional functional loss due specifically to complaints of pain on use or during flare- ups; and (3) pursuant to 38 C.F.R. § 4.45 if there is additional functional loss due specifically to any weakened movement, excess fatigability, or incoordination. Additionally, with regard to assigning an evaluation for degenerative or traumatic arthritis under Diagnostic Code 5003 or 5010, the General Counsel recently held that the Board must consider whether an increased schedular or separate rating may be in order pursuant to 38 C.F.R. § 4.59 on the basis of painful motion "with joint or periarticular pathology." See VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). With respect to the above, the General Counsel also held the Board's consideration of sections 4.40, 4.45 and 4.59 depended on whether the musculoskeletal disability was rated under a specific diagnostic code that did not involve limitation of motion and where another diagnostic code based on limitation of motion was potentially applicable to the particular disability under consideration. Id. However, the General Counsel cautioned that the applicability of a separate or multiple rating for a musculoskeletal disability was subject to the limitations of 38 C.F.R. § 4.14, which prohibits "the evaluation of the same manifestation [of a disability] under different diagnoses." Id. After review of all material issues of fact and law, the Board concludes that the recent medical findings of record support a 20 percent evaluation for the appellant's low back disability pursuant to the schedular criteria under Diagnostic Code 5295. However, the Board also concludes that a preponderance of the evidence found probative to this claim is against entitlement to more than a 20 percent schedular evaluation for this disability. The severity of the appellant's low back disability is ascertained for VA purposes by application of the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (1999). A rating greater than that which is currently in effect (10 percent) is available if there are residuals of a fracture to the vertebra without cord involvement, but with abnormal mobility requiring a neck brace (jury mast) (60 percent rating) (Diagnostic Code 5285); if there is complete bony fixation (ankylosis) of the spine, either in a favorable (60 percent rating) or unfavorable angle (100 percent rating) (Diagnostic Code 5286); if there is favorable (40 percent rating) or unfavorable (50 percent rating) ankylosis of the lumbar spine (Diagnostic Code 5289); if there was moderate (20 percent ) or severe (40 percent) limitation of motion of the lumbar spine (Diagnostic Code 5292); or if the disability is manifested by lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in a standing position (20 percent) or severe lumbosacral strain with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of motion of forward bending in a standing position, loss of lateral motion with osteoarthritis changes, or narrowing or irregularity of joint space, or some of these manifestations with abnormal mobility on forced motion. (40 percent rating) (Diagnostic Code 5295). With respect to Diagnostic Code 5285, cases that fall outside the criteria cited above under that code are rated in accordance with definite limited motion or muscle spasm, adding 10 percent for demonstrable deformity of the vertebral body. According to the Rating Schedule, the Board concludes that the findings detailed above are most consistent with a 20 percent under Diagnostic Code 5295 for lumbosacral strain manifested by complaints of chronic pain and occasional flare-ups of more severe pain with muscle spasm. The August 1998 VA neurological examination was negative with regard to the low back except for some pain with range of motion testing and x-ray evidence of degenerative disc disease of the lumbar spine. The April 1999 VA orthopedic examination disclosed an essentially normal physical examination as well with full range of motion of the lumbar spine and no evidence of tenderness on palpation/percussion, muscle spasm or abnormalities of posture or the musculature of the lumbar spine. However, the appellant's clinical history was considered by the examiner in 1999 to be significant for daily low-grade back pain and a history of flare-ups of more severe pain complaints with muscle spasm occurring with range of motion testing. In addition, it was noted at that time of the April 1999 orthopedic examination that he had been seen at the Fort Campbell hospital in 1997 for a flare-up of his low back pain complaints. Clinical records confirm such a history and denote that he had muscle spasm at L4-5 at that time. The VA peripheral nerves examination conducted in April 1999 further detailed the functional limitations the appellant experienced with regard to the flare-ups of pain and spasms in his lower back, noted as recurring three to four times per year. From this evidence, it is apparent that the medical examiners who evaluated the appellant in 1998 and 1999 believed that the appellant suffers from spasm with flare-ups of his pain complaints. Accordingly, as the disability picture more closely resembles the criteria for strain with muscle spasm, the appellant is entitled to an increased rating to 20 percent under Diagnostic Code 5295. 38 C.F.R. § 4.7 (1999). A higher rating (above 20 percent) is clearly not in order pursuant to the schedular criteria as there is no medical evidence whatsoever showing that his low back disability involves (or ever involved, for that matter) abnormal mobility requiring a neck brace (Diagnostic Code 5285); complete bony fixation (ankylosis) of the spine, either in a favorable or unfavorable angle (Diagnostic Code 5286); or favorable or unfavorable ankylosis of the lumbar spine (Diagnostic Code 5289). A higher rating under Diagnostic Code 5292 (40 percent) is also not applicable in this case as it was not shown by the medical evidence of record that the appellant has (or has ever had) "severe" range of motion loss in his lumbar spine. His range of motion in the lumbar spine was described as normal on all VA examinations conducted since 1993. Hence, there is no basis to award increased disability compensation on the basis of limitation of motion under Diagnostic Code 5292. A higher rating under Diagnostic Code 5295 is not in order as well. "Severe" lumbosacral strain according to the schedular criteria requires current medical findings showing listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation on forward bending in a standing position with osteo-arthritic changes and irregularity of joint space, or some of these deficits with abnormal mobility on forced motion. As noted above, the clinical findings on the recent VA examinations of 1998 and 1999 did not show that the appellant had any spinal column listing; in fact, it was specifically noted that he had a normal gait and posture with no fixed deformities. In addition, although it was not specifically indicated whether Goldthwaite's sign was tested, the examiners did not report testing for same and so it is assumed that in his clinical evaluation of the appellant, this sign was not deemed relevant to the examination results. Further, while the appellant had some loss of disc space height at L5-S1 seen on the August 1998 x-rays, the other vertebral bodies were well maintained and there was no significant degenerative changes in the facet joints. When these findings are read together with the other evidence that does not clinically demonstrate the other findings for higher ratings (above 20 percent) under Diagnostic Code 5295, the Board finds that the overall disability picture does not reflect a "severe" disability under these schedular criteria. A separate rating under Diagnostic Code 5003 is not in order as it is not shown that his low back disability is manifested by symptoms primarily or uniquely attributable to the degenerative arthritis shown on the August 1998 x-rays. As indicated above, it appears that his low back disability is manifested by the pain complaints with intermittent flare-ups of more severe pain with muscle spasm, which supports entitlement to a 20 percent rating under Diagnostic Code 5295. By reason of the above findings, the Board concludes that the disability picture presented does not support a rating above 10 percent under any of the potentially applicable diagnostic codes for the cervical spine. In the absence of clinical evidence of same as shown on the 1993, 1998 or 1999 VA examinations, the appellant's neck disability is not entitled to a higher rating pursuant to Diagnostic Codes for ankylosis (Diagnostic Code 5287) or impairment/limitation of motion (Diagnostic Code 5290). There is simply no medical evidence which shows that the appellant has any limitation of motion in his cervical spine or other impairment besides the x-ray findings showing degenerative changes at the C5-6 disc spaces. It appears that his disability is clinically manifested only by some occasional pain and stiffness with decreased ability to look up, which as noted on the 1998 and 1999 VA examinations, was not clinically substantiated by evidence of limited range of motion. There is also no evidence of current medication use for pain complaints and, as detailed above, there is no evidence that he has sought in/outpatient treatment for the cervical spine disability in the recent or remote past following service. In addition, as the recent x-rays do not substantiate that he has any other disability in the cervical spine besides the degenerative changes, a separate rating under Diagnostic Code 5003 is not otherwise in order for this disability. As alluded to above, the Board must also address whether increased ratings for the appellant's back disabilities are warranted under 38 C.F.R. §§ 4.40, 4.45. The regulation for musculoskeletal system functional loss in section 4.40 provides: Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursions, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, which respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity[,] or the like. Section 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as movement abnormalities, weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). The appellant's pain complaints in his back do not warrant an increased rating above the now assigned schedular levels under 38 C.F.R. §§ 4.40 and 4.45 because a preponderance of the medical evidence does not substantiate "additional" range- of-motion loss in the back due to pain on use or during flare- ups, or due to weakened movement, excess fatigability, or incoordination. Indeed, although it was noted on the recent VA examinations of 1998 and 1999 that the appellant had functional loss due to pain with range of motion in his low back, the Board notes that such findings were considered as the primary positive evidence to support an increased level of strain impairment under Diagnostic Code 5295, as detailed above. Thus, it cannot be said that the appellant has "additional" range-of-motion loss under 38 C.F.R. § 4.40 because the schedular criteria as applied to the facts in this case encompasses an increased level of impairment due in significant part to painful forward bending in a standing position. Thus, it is the Board's judgment that to award increased compensation for these symptoms would in effect violate the anti-pyramiding provisions under 38 C.F.R. § 4.14. On this point, the Board observes that the examiners in 1998 and 1999 specifically related that the appellant's functional loss due to pain with range of motion was present when he had flare-ups of the strain condition and hence, the schedular criteria under Diagnostic Code 5295 were used to support the increased rating to 20 percent. Thus, to find entitlement to further increased disability compensation under 38 C.F.R. § 4.40 would in the opinion of the Board violate the anti- pyramiding provisions because these findings would be overlapping or duplicative in nature in light of consideration of even higher ratings under section 4.40. Further, as noted above, the appellant denied symptoms of weakness, fatigability or incoordination in his neck and low back when examined in April 1999. When viewed together with the fact that he does not have any of the other findings deemed critical under sections 4.40 and 4.45, the Board can only conclude that he does not actually have any "additional" functional impairment of these back disabilities which warrant entitlement to higher disability ratings then those now assigned. Regarding section 4.45, the Board notes that at the time of the 1999 VA examination it was not reported that the appellant was using a brace or experiencing any episodes of instability. There is also no evidence of recent outpatient care, physical therapy, or current medication use for these disabilities. These findings preponderate against a finding that he has any additional functional loss due to movement abnormalities, weakened movement, or incoordination. Thus, as the record currently stands, there is no objective medical evidence which confirms the presence of additional functional loss in the appellant's neck or low back beyond what is contemplated in the present disability ratings. In summary, the recent clinical findings do not reflect a level of impairment in the neck or low back that would support higher schedular ratings under any applicable criteria found in 38 C.F.R. Part 4. With respect to the above, it appears that the exact degree or "extent" of functional loss due the appellant's pain complaints, expressed either in mathematical or medically certain terminology, is an elusive concept from a medical standpoint. As the Court has stated, "[m]edicine is more art than exact science" and therefore, mere reliance on pain complaints is insufficient to establish an increased level of disability, especially where the clinical findings are not remarkable. Lathan v. Brown, 7 Vet. App. 359, 366 (1995). Moreover, although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the rating schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1996). In view of the above, the Board concludes that increased disability ratings for the low back and cervical spine disabilities is not warranted, based on the application of 38 C.F.R. §§ 4.40, 4.45, and 4.59. The Board has considered the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the appellant. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, for the reasons discussed above, the Board concludes that the currently assigned ratings for the appellant's service-connected low back and cervical spine disabilities adequately reflect the level of impairment pursuant to the schedular criteria. It should be emphasized that the diagnoses and clinical findings of record are essentially uncontradicted by any other medical evidence of record. There is no evidence of record showing that the appellant is qualified to render a medical diagnosis or opinion. Hence, the medical evidence of record cited above specifically outweighs his views as to the etiology of his complaints and/or the extent of functional impairment caused by these disabilities. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (lay assertions will not support a finding on questions requiring medical expertise or knowledge). The Board has also given consideration to evaluating these disabilities under different Diagnostic Codes. The Board notes that the assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). However, in the instant case, and for the reasons discussed herein, the Board finds that Diagnostic Codes cited above are the most appropriate schedular criteria for the evaluation of the appellant's back disabilities. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Since there is no currently diagnosed clinical evidence of intervertebral disc syndrome, the appellant's back disabilities are not entitled to a higher rating pursuant to Diagnostic Code 5293. The appellant has never been diagnosed with intervertebral disc syndrome and although he clearly has some right-sided radicular pain and numbness symptoms with flare-ups of his low back pain, there is no evidence which supports a finding that such complaints reflect a "severe" or "pronounced" level of neuropathic impairment, which would support a higher rating under Diagnostic Code 5293. Neurologically, the appellant was essentially normal at the time of the 1998 and 1999 VA examinations. Thus, a higher rating under Diagnostic Code 5293 would not otherwise be in order in any case. B. Right Hand Carpal Tunnel Syndrome Notwithstanding the Air Force examination findings of December 1992, cited above, a clear preponderance of the evidence is against entitlement to an increased rating for the appellant's carpal tunnel syndrome of the right hand, rated noncompensably disabling under Diagnostic Code 8515. A compensable evaluation requires medical findings of mild impairment of the medium nerve as indicated by "incomplete paralysis" of the affected peripheral nerve. Incomplete paralysis is indicated where the involvement is wholly sensory, as opposed to physical impairment (cannot make fist or pronate fingers) or deformity (ape hand). Stated succinctly, the post-service medical evidence which now extends from 1993 to 1999 does not show that the appellant has active residuals of carpal tunnel syndrome in his right hand. On the VA examination in June 1993, the appellant reported no complaints referable to his right wrist as a result of his carpal tunnel surgery and the examiner found no evidence of neurological impairment of the right upper extremity other than some cutaneous hypothesia over the right forearm, a separate service-connected disability rated 10 percent disabling. Similarly, no findings of active pathology were found on the VA neurological examination conducted in August 1998 or on the VA peripheral nerves examination conducted in April 1999; indeed, the diagnosis entered on the latter examination which included review of the medical records in the file was "no active symptoms or signs that suggest carpal tunnel syndrome." Further, there is no evidence of any medical treatment for this condition in the post-service period. Thus, the medical evidence of record does not show any clinical findings of residual disability stemming from the carpal tunnel syndrome of the appellant's right hand. Accordingly, the Board concludes that the disability picture presented supports no more than a noncompensable disability evaluation according to the schedular criteria set forth under Code 8515 since there is no evidence of lost function, deformity or sensory impairment. 38 C.F.R. § 4.31 (1999). As a preponderance of the evidence is against this claim, application of the benefit of the doubt rule is not required. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). III. Extraschedular Consideration The RO declined referral of these increased rating claims for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b) (1999) when it last adjudicated the case by supplemental statement of the case in July 1999. The Board agrees as it does not appear from review of the medical evidence that referral for consideration of an extraschedular rating is indicated. In Floyd v. Brown, 9 Vet. App. 88 (1996), the Court held that the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law and regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) or from reaching such a conclusion on its own. Moreover, the Court did not find the Board's denial of an extraschedular rating in the first instance prejudicial to the appellant, as the question of an extraschedular rating is a component of the appellant's claim and the appellant had full opportunity to present the increased rating claim before the RO. Bagwell, 9 Vet. App. at 339. In exceptional cases where schedular evaluations are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). "The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. In this regard, the schedular evaluations assigned for the appellant's disabilities described above are not deemed to be inadequate. As fully detailed above, the medical evidence does not reflect that the appellant's disabilities warrant entitlement to increased compensation for the levels presently assigned under the schedular criteria and hence, it does not appear that the appellant has "exceptional or unusual" disabilities. It is not shown by the evidence that the appellant has required hospitalization in the recent past for these disabilities. In addition, the appellant is shown to be presently employed and hence, there appears to be no specific evidence of "marked interference" in employment as a result of these disabilities. Thus, in the absence of any evidence which actually shows that these disabilities are exceptional or unusual such that the regular schedular criteria are inadequate to rate them, an extraschedular rating is not in order. ORDER An increased rating to 20 percent, but no higher, for the appellant's low back disability is granted. An increased rating above 10 percent for the cervical spine disability is denied. An increased (compensable) rating for the right hand carpal tunnel syndrome disability is denied. A. BRYANT Member, Board of Veterans' Appeals