Citation Nr: 22043973 Decision Date: 08/02/22 Archive Date: 08/02/22 DOCKET NO. 06-15 687 DATE: August 2, 2022 ORDER A total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is denied. Special monthly compensation (SMC) based on loss of use of his left hand pursuant to 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a)(2) is denied. SMC based upon the need for aid and attendance pursuant to 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(b) is denied. FINDINGS OF FACT 1. The Veteran's service-connected disabilities do not prevent him from performing substantial gainful employment. 2. The Veteran has not lost use of his left hand such that no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow with use of a suitable prosthetic appliance, or such that the acts of grasping, manipulation, etc., could be accomplished equally well by an amputation stump with prosthesis. 3. The Veteran's service-connected disabilities do not prevent him from attending to the needs of nature, caring for himself, or protecting himself from the hazards of his environment. CONCLUSIONS OF LAW 1. The criteria for an award of a TDIU are not met. 38 U.S.C. §§ 5110, 7105; 38 C.F.R. §§ 3.156, 3.340, 3.341, 3.400, 4.16, 4.19. 2. The criteria for special monthly compensation based on loss of use of a hand have not been met. 38 U.S.C. §§ 1114(k), 5107; 38 C.F.R. §§ 3.102, 3.350. 3. The criteria for special monthly compensation based on the need for regular aid and attendance have not been met. 38 U.S.C. §§ 1114(l), 5017; 38 C.F.R. §§ 3.102, 3.350(b), 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from August 1967 to August 1970. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 2005 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The instant matter has a long procedural history that is recounted in detail in a prior Board decision. Most recently, in June 2020, the Board denied entitlement to a TDIU. The Veteran subsequently appealed the June 2020 Board decision denying a TDIU to the United States Court of Appeals for Veterans Claims (Court). In an Order dated February 2021, the Court granted a Joint Motion for Remand (JMR), which remanded this appeal back to the Board for development consistent with the JMR. Per the JMR, the parties agreed that the Board 1) failed to provide adequate reasons and bases for discounting an April 2020 private vocational assessment that opined that the Veteran was unable to maintain substantially gainful employment since May 2010, and 2) failed to consider the Veteran's explicitly raised argument that entitlement to SMC based on loss of use of the left hand was warranted. In compliance with the JMR, the Board remanded the case in June 2021 for additional development. Of note, the Veteran seeks SMC for loss of use of the left hand and based on the need for aid and attendance. Both are addressed in this decision. 1. A total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is denied. The Veteran asserts that he is unable to work due to his service-connected disabilities. The Veteran reports that his left upper extremity, from the wrist down, is basically non-functional. Specifically, the Veteran notes restriction in lifting, continuous pain, and limitation of motion have precluded his ability to perform occupational tasks and had a detrimental impact on his employment as a mechanic, pharmacy technician, and customer service representative. These complaints are often accompanied by complaints of non-service-connected impairment of his right hand. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38C.F.R. §4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38C.F.R. §§3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is a sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rating boards will refer to the Director of the Compensation Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The Veteran is service-connected for the following disabilities: fracture, left wrist (rated 20 percent from June 26, 2003); tinnitus (rated 10 percent from June 26, 2003); medial entrapment neuropathy, left wrist (rated 10 percent from October 28, 2013); bilateral hearing loss (rated noncompensable from June 26, 2003); and left wrist scar (rated noncompensable from October 28, 2013). The Veteran's combined rating is 30 percent from June 26, 2003; and 40 percent from October 28, 2003. Therefore, the schedular criteria for a TDIU are not met. See 38 C.F.R. § 4.16(a). Since the Veteran's claim of entitlement to a TDIU on an extraschedular basis was denied by the Director, the Board may address the merits of the Veteran's claim for entitlement to a TDIU on an extraschedular basis. Wages v. McDonald, 27 Vet. App. 233, 239 (2015). In a resume submitted in conjunction with the VA vocational rehabilitation program, the Veteran reported that he obtained a certificate in written and oral communication from Cornell University. Review of the file shows the Veteran worked as a mechanic with the post office for over 30 years before his retirement. Thereafter, he worked as a laborer with the city government, in phone sales, and as a pharmacy technician. As a pharmacy technician, the Veteran's primary duties included typing. June 2010 treatment records reflect that the Veteran had a history of back pain and left wrist symptoms due to arthrosis with worsening of his back condition. The record notes that the Veteran's problems were making it difficult for the Veteran to pursue gainful employment and it was recommended that the Veteran rest from working for three months. A June 2010 doctor's note indicates that the Veteran was on a temporary three month "no work" status due to treatment for lumbar spondylosis, chronic discogenic pain, non-stenosing tenosynovitis, a weakened right hand, and left-hand wrist arthrosis with symptoms of weakness and loss of range of motion. A July 2010 Social Security Administration (SSA) disability questionnaire notes that the Veteran reported that he was unable to squeeze with either hand, and he had low back pain with pain radiating down his right leg. The Veteran reported that bending, prolonged walking, laying down, using his hands, and dressing in the morning caused increased pain. In pertinent part, this questionnaire also notes that the Veteran reported he could not dress himself, requiring assistance of a shoe and sock horn and help buttoning his shirts; he had sleeping problems because he could not lie on his back comfortably and would awaken several times a night due to the pain. He indicated that he did very little driving due to the limited range of motion of his left hand and did no yard work because he could not hold anything with his right hand. In a July 2010 SSA determination, the Veteran was found disabled as of February 2010 and awarded disability benefits for a primary diagnosis of "osteoarthrosis and allied disorders" and a secondary diagnosis of "disorders of the back (discogenic and degenerative.)" In a July 2010 SSA physical residual functioning capacity assessment, the Veteran's primary diagnoses were listed as hypertension, secondary arthritis, and obesity. However, the Veteran reported that his main issues were his hands as they limited him from driving, dressing, and cooking. The Veteran was observed to have difficulty with sitting, standings, hearing, walking, using his hands and writing. In August 2010 VA treatment records, the Veteran was noted to have progressively worsening symptoms in his wrist and hands with the inability to perform work duty of continuous keyboard use. The clinician noted limited range of motion, tenderness, and paresthesia in the left hand, and the inability to fully bend the right middle finger. Additionally, the Veteran had difficulty performing activities of daily living requiring fine manipulation due to his bilateral hand pain and weakness. An August 2010 hand therapy record notes that the Veteran had bilateral hand and wrist pain and limited use due to pain. He experienced difficulties with activities of daily living due to bilateral hand pain and weakness. In a December 2010 letter from the Veteran's employer, the employer noted that the Veteran had begun a leave of absence in May 2010 for medical reasons without specifying the reasons; the employer noted they could no longer accommodate the leave of absence, and if the Veteran did not return to work by January 2011, it would be considered voluntary resignation/job abandonment. A December 2010 medical treatment record notes that the Veteran reported bilateral hand numbness, with left hand decreased range of motion and decreased grip strength. Testing revealed bilateral carpal tunnel syndrome. A functional assessment from December 2010 indicated the Veteran could bathe, care for his hygiene, dress, toilet, ambulate, transfer, feed, cook, clean, do laundry, grocery shop, bank, make telephone calls, and use transportation. He had no barriers to learning. VA Vocational Rehabilitation records note that the Veteran reported that he stopped working because the weakness in his hands caused him to drop objects and he suffered a hernia. After his recovery, he found it difficult to lift and turn wrenches, which forced him into retirement. He indicated that his last job required typing and, due to carpel tunnel, he was forced to go part time. The records also note that the Veteran reported that constant ringing in his ears kept him up at night; he also had to use speaker phone due to his hearing loss, although his last hearing test reflected less than a five percent decrease in hearing. The Veteran had problems with his right hand, including a weak grip and his middle digit locks, and high blood pressure. An opinion notes that the Veteran's service-connected and non-service-connected disabilities prevented him from preparing for, obtaining, or maintaining employment consistent with his abilities, aptitudes, and interests. Specifically, limitation of motion of the left wrist, trigger thumb, locking middle right digit, and bilateral carpal tunnel syndrome prevented pulling, pushing, grasping, twisting, repetitive motion, and lifting/carrying heavy objects. Tinnitus can result in difficulty getting along with others, lack of concentration and focus, and difficulty performing duties efficiently and accurately. The Veteran's hearing loss was minimal but required the use of speaker phone. Finally, the Veteran should avoid stress due to high blood pressure, and he would benefit from a job allowing him to alternate sitting and standing due to his hip. A February 2011 treatment record notes that the Veteran had degenerative changes in the left wrist, but these results were unchanged since his prior wrist x-rays in December 2009. A March 2011 orthopedic examination report notes that the Veteran reported constant left wrist pain, with weakness, stiffness, occasional feelings of giving way, occasional locking, and some swelling. He reported flare-ups occurring twice per week, lasting two to three hours, restricting the use of his left upper extremity. He reported that he needed help getting dressed and he was unable to drive because he was unable to hold the steering wheel with his left hand, his nondominant hand. The Veteran reported that he worked as a pharmacy assistant up until January 2011 when he was fired after being on medical leave for nine months. The Veteran reported that the medical leave was due to problems with both hands, not only with the left hand. He also noted that his primary duties in that position were sitting and typing. The Veteran had decreased range of motion, without ankylosis, of the left wrist due to his osteoarthritis associated with his left wrist fracture, but he had full range of motion of his digits. The examiner indicated that repetitive motion had no impact on the Veteran's range of motion, pain, fatigability, weakness, endurance, or coordination. An August 2011 treatment record notes that the Veteran was unemployed, and he spent long hours at the computer. He was independent in all activities of daily living. A December 2011 medical treatment record notes that the Veteran reported that he had to retire in 2006 from his job as a mechanic because he could no longer handle the work responsibilities. He described applying for telephone sales type work, but he had been turned down due to being unable to pass the screening examinations. In January 2012, as part of the Veterans physical therapy he was doing multiple upper body exercises and the goal was for him to be able to use equipment commonly found at gyms. At the time he was bench pressing 75 pounds and doing shoulder diagonals of 20 pounds. He could bathe, dress, feed himself, cook, clean, laundry, grocery shop, and transport himself with no barriers. In February 2012, the Veteran was considering driving people to the airport and to appointments as a source of income. In a March 2012 addendum, the examiner commented that the Veteran would be restricted in performing repetitive motion of his fingers bilaterally due to his bilateral carpal tunnel syndrome, and he would be restricted in lifting in excess of 15 pounds due to his left wrist disability. The examiner opined that the Veteran would be able to do sedentary, lightwork with restrictions. On the Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940) completed in August 2012, he reported that disabilities of the left wrist, a back injury, insomnia, and anxiety attacks prevent him from working. The Veteran indicated that he worked full time as a customer service representative from 2007 to 2009 and full time as an attendant for the city for six months in 2009. This form also shows he completed high school and received training in marketing, and computer hardware and software. He also reported education and training as follows: Mack Diesel 1&2 Oklahoma Postal Training Operations and Cummings Diesel OPTO. On another VA Form 21-8940, received in February 2013, he amended the disabilities that affected his employability to also include tinnitus. A March 2012 VA psychiatric treatment record notes that the Veteran reported problems sleeping and that worrying about his bills kept him up at times. An April 2012 VA examination for mental health disorders notes that the Veteran reported problems sleeping, which he attributed to sleep apnea; however, the Veteran was not receiving treatment for sleep apnea. Various other medical treatment records throughout 2012 note that the Veteran had received a diagnosis of major depressive disorder and had been prescribed medication to help with his depression and sleep; however, the Veteran was noncompliant with his medication. He reported experiencing tinnitus two to three times a week, which he indicated made him angry because there was no treatment for it. Around this time period, the Veteran was talking with friend on the phone, and using email, social media, telehealth. There is no indication that hearing was limiting the Veteran's ability to perform these tasks. In fact, the Veteran's hearing was not considered a barrier to learning until May 2014. Tinnitus became a barrier in September 2011, but in April 2012 he stated he only had symptoms of 2-3 times per week. In July 2012, the Veteran was encouraged to stop napping as it prevented him from engaging in activities. VA Form 21-4192, Request for Employment Information, received in May 2014 from the Veteran's former employer with the city, notes that the Veteran worked full time as a laborer from January 2007 to May 2007, with no lost time due to disability and no concessions due to disability were reported. VA Form 21-4192, Request for Employment Information, received in May 2014 from another former employer, notes that the Veteran worked between 38 and 52 hours per week from May 2007 to May 2010 in phone sales with no lost time due to disability reported; however, the form notes that the Veteran's schedule was adjusted from full to part-time and he was afforded extended leave due to disability. A June 2014 physical therapy assessment for left hand carpal tunnel notes that the Veteran had left wrist pain, although he was independent with self-care and activities of daily living. The Veteran's functional mobility was described as having difficulty with wrist twisting motions, such as opening a jar or turning a key, and activities that require force. A July 2014 VA examination notes diagnoses of bilateral carpal tunnel syndrome but was asymptomatic on the right side. The Veteran was experiencing recurrent daily pain and numbness of the left second, third, and fourth digits. Pain was worse at night and aggravated by repetitive use of left hand. The Veteran's left wrist injury with advanced degenerative arthritis of the wrist bones and ligaments would impact any job requiring repetitive use of the left hand; the Veteran is right-handed. An October 2014 Disability Benefits Questionnaire (DBQ) shows the Veteran was found to have occupational impairment due not only to his service-connected left wrist fracture, but also the bilateral carpal tunnel syndrome. The Veteran reported numbness in his left-hand digits and limited range of motion in his left wrist. The Veteran had functional loss performing activities of daily living, such as turning a doorknob and twisting the lid on a jar; there would be pain, weakness, and impairment, including with his grip. The report notes that the Veteran's ability to lift, push, pull, and grasp were affected by his left wrist disabilities. At a VA examination in April 2016, the Veteran reported constant pain, weakness, and numbness of the left hand and wrist with loss of mobility to the point that he is unable to perform routine activities of daily living, such as driving, putting on and buttoning shirts, and any other activity requiring repetitive use of both hands. He also had frequent swelling of the left wrist and fingers with nocturnal left hand and wrist pain that woke him up. He wore a wrist brace in neutral position at all times. The Veteran reported daily flare ups after repetitive use of the left hand with further loss of function due to pain and swelling. The examiner opined that the left wrist fracture residuals will impact any job requiring prolonged or repetitive use of the left-hand including gripping, typing, transferring objects from one place to other, or using tools. An April 2016 hearing loss and tinnitus VA examination notes that the Veteran reported difficulty with television and telephone use and normal everyday communications. Additionally, he reported that he had intermittent ringing in his ears that sometimes woke him up at night, but it was not always present. An October 2017 VA examination notes that the Veteran reported his progressive pain and limited range of motion due to worsening osteoarthritis of the left wrist caused him to retire from his occupation as an auto mechanic in 2006. Also in 2006, he began having progressive numbness of left second through fourth distal fingers. He was diagnosed with left carpal tunnel syndrome and was given a splint. He had sharp pain in the left wrist, which many times woke him up at night associated with numbness of the left second through fourth fingers. His pain was worse with lifting, pulling, pushing, driving, and his pain improved with use of a splint. He noted constant numbness and flare ups of his wrist pain three to four times per day, lasting a few minutes. The examiner indicated that due to chronic, progressive arthritis in the left wrist, the Veteran had physical limitation in lifting, pulling, and pushing. The examiner further indicated that symptoms of left wrist arthritis included wrist pain, wrist stiffness, and limited range of motion, and symptoms of left wrist carpal tunnel included numbness and burning pain of the second, third and fourth distal end of digits. In December 2019, the Veteran reported that he could lift 10 pounds with his left hand and more than that with both hands. While the Veteran stated that his wife helped him put on his shirt, tie his shoes, and button his pants for the past fifteen years, there are multiple instances in the record indicating the Veteran could dress himself without assistance, although the record did not state whether dressing himself required buttoning clothing or needing a shoehorn. The Veteran noted he has difficulty with fine motor skills, not that he has none, and reported that he can lift a pen. On an updated Application for Increased Compensation Based on Unemployability (VA Form 21-8940) completed in December 2019, the Veteran indicated that he was currently working as a crossing guard, working 25 hours per week, and he received an income of approximately $846.00 per month. An April 2020 private vocational assessment indicates that, due to the Veteran's left wrist fracture, hearing loss, and tinnitus, the Veteran has been unemployable since May 2010. Additionally, the Veteran's left carpal tunnel syndrome further contributed to his inability to work since October 2013. Specifically, the assessment notes that the Veteran had stiffness and limited range of motion in the left wrist; he was unable to turn a doorknob with his left hand, and weakness and giving way resulted in his inability to hold or grip even marginal weight; he had difficulty with small objects and fine manipulation and could not use a keyboard effectively because he did not have finger dexterity. He also was only able to drive short distances due to difficulty grasping the steering wheel with his left hand. The evaluator noted that the Veteran was "essentially limited to using one hand." His hearing loss and tinnitus resulted in his inability to effectively communicate, and his tinnitus woke him at night and made it difficult to concentrate. Moreover, the assessment notes that the Veteran had difficulty sleeping due to his pain and tinnitus, which resulted in low stamina, difficulty concentrating and focusing, fatigue, and napping during the day. Based on the foregoing, the evaluator indicated that the Veteran's left wrist pain would affect his focus and attention and require unscheduled breaks; his chronic sleep impairment due to his left wrist pain and tinnitus would result in daytime fatigue, need for naps, and concentration problems; his hearing loss and tinnitus impair his ability to communicate effectively. Thus, the evaluator opined that the Veteran, although currently employed, is only engaged in marginal employment. The vocational evaluator added the Veteran has been unable to secure and follow substantially gainful employment since May 2010 due to his left wrist fracture and hearing loss and that tinnitus and his left wrist carpal tunnel further contributed to his ability to work since October 2013. In May 2021, the Veteran reported helping diffuse fights between his wife and his father in-law, indicating an ability to communicate with others. The Veteran reported speaking with others, facetiming with his daughter, visiting family, watching TV, reading the news, going grocery shopping, doing laundry, using social media, and playing cards and boardgames. In June 2021, he had a phone conversation while in the grocery store. In July 2021, the Veteran reported he was using the internet, shopping, and looking for a place to rent. He added that his concentration improved when he drove to visit his son. His leisure activities included cooking, watching television, reading the news, shopping for groceries, doings laundry, taking his dog for walks, and using social media. Also, in 2021, he helped move out of the house in which he was living, which he described as physically exhausting, and he was able to attend multiple one-hour sessions for weight management. These aforementioned tasks show that the Veteran is able to use his left hand, hear, and concentrate, to some degree. During a November 2021 VA examination, the Veteran reported that hearing loss made it difficult to hear the television, speak on the phone and maintain everyday conversations. At the time, he had excellent speech discrimination, indicating hearing aids should help him hear. The examiner suggested that he work in a position that does not require phone conversations or high levels of background noise. The Veteran also reported intermittent tinnitus that sometimes interfered with sleep. The examiner noted that some devices could mask the tinnitus and that with proper hearing and/or adaptive devices, the Veteran would have no work restrictions due to hearing loss or tinnitus. A December 2021 VA examination indicated that the Veteran was impaired due to pain associated with lifting and that he had limited fine motor skills. However, the examiner opined that the impairments were not severe enough that no effective function remained in his left hand as to prevent him from completing every activity of daily living. The following limitations were noted: difficulty cutting while eating, getting dressed, an inability to drive, and difficulty lifting heavy items. At the time, the Veteran had a reduced range of motion and pain on both active and passive use that caused functional loss. Medical records from February 2022 indicate that the Veteran was able to write in a journal, which likely required the use of his left hand, if nothing else to hold open the journal he was writing in. Moreover, he used a bike daily, which would require holding onto a handlebar. He was also, an active member in his condominium board, while working as a school guard. This indicates an ability to concentrate, at least for brief periods of time. At the time, he traveled to Orlando, felt he could travel on a cruise, and was able to walk his dog. He did not need assistance dressing himself, going to the bathroom, standing or sitting up, and feeding himself. Based on the foregoing, the Board finds that the award of a TDIU is not warranted. In reaching this determination, the Board initially notes that the Veteran has, on numerous occasions, reported that he is unable to work due to a combination of service-connected and non-service-connected disabilities. He is not service-connected for any psychiatric disorder, to include anxiety; nor is he service-connected for his back disability, right hand or wrist disabilities, or insomnia. The probative evidence of record shows occupational impairment due to a combination of service-connected (left wrist fracture residuals and left wrist medial nerve entrapment) and several non-service-connected conditions (including a back disability and right-hand carpal tunnel syndrome) that result in the Veteran being unable to work. The VA and non-VA treatment records as well as VA examination reports show the Veteran has some difficulties due to his left wrist fracture and median nerve entrapment. However, VA examiners have indicated that he remains capable of work, with certain restrictions such as repetitive use of his fingers, pulling, pushing, and heavy lifting. Private treatment records dated in June 2010 show a clinician opined that the Veteran had multiple medical problems, including lower back pain (discogenic), left wrist hand arthrosis and weakness, and stenosis of the right third finger, which make it difficult to work. VA treatment records note that the Veteran was unable to work due to his bilateral hand disabilities, not just his left hand, and his inability to pass screening examinations. VA Vocational Rehabilitation records also indicated that the Veteran had impairment to employment as a result of both service-connected and non-service-connected disabilities, including his right wrist, high blood pressure, and hip pain. Also, the SSA determined that his non-service-connected back disability renders him disabled in addition to other unspecified osteoarthrosis and allied disorders. While the VA examiners are not experts as to whether the Veteran could obtain employment, they are experts in discussing the Veteran's physical limitations, such as his ability to manipulate his hand and carry items. The Board utilizes their opinions to determine the Veteran's limitations and not in the analysis of whether these limitations would preclude work. Similarly, the Board constrains the analysis of the private vocational examiner's to whether the limitations found in the record would limit the Veteran's ability to work, not as to the limitations determined by the examiner that are not supported by medical evidence or by statements made by the Veteran. That being said, the Board appreciates the opinion of the April 2020 private vocational evaluator; however, the Board affords the opinion only minimal probative value. In this regard, the assessment notes that the Veteran was unable to engage in substantial gainful employment due to symptoms of sleep impairment resulting in a lack of concentration and focus due to his service-connected tinnitus and left wrist disabilities; pain, decreased range of motion, weakness of his non-dominant, left wrist that essentially rendered his left hand useless; and being unable to effectively communicate due to his hearing loss and tinnitus. The Board finds that although the assessment notes that the Veteran's left wrist and tinnitus were responsible for his problems sleeping, the evidence of record, including the Veteran's own reports throughout the period on appeal have indicated that the Veteran reported problems sleeping due to, not only tinnitus and left wrist pain, but also due to back pain, a sleep disorder, and thoughts of his financial situation. Indeed, his psychiatric treatment records often note problems sleeping as associated with his psychiatric disorder and indicate that he was, in fact, prescribed medication for treatment of his depression and sleep problems. The Board does not doubt that there may have been occasions in which he had problems sleeping due solely to his service-connected tinnitus and left wrist pain, nor does the Board disagree that lack of sleep may result in fatigue or difficulty concentrating; however, the evaluator applied a blanket impact statement on his employability due to problems sleeping without addressing the evidence which showed that he had problems sleeping due to non-service-connected disabilities as well. Moreover, the examiner noted that the Veteran needed to nap for 30 minutes every day due to fatigue. However, the Veteran has been encouraged to stop napping and that stopping napping would be beneficial for him to engage more during the day. Thus, there is not a complete discussion as to whether those naps are necessary. In addition, although the Veteran takes naps, for a significant portion of the record, naps were noted to be needed by the Veteran only once or twice a month. While the Veteran stated concentrating can be difficult, he admits, he can give his full concentration to being a crossing guard if he applies himself and also when he drives. The evaluator does not discuss what if any situations the Veteran is able to concentrate. Furthermore, the private assessment suggests that the Veteran is unable to perform any type of work because most duties require use of the bilateral upper extremities, and the Veteran was "essentially limited to one hand." The Board finds this statement is inconsistent with the medical evidence of record. Indeed, the records reflect only decreased functional ability and range of motion; none of the Veteran's VA examinations or medical records have indicated that the Veteran was completely unable to use his left hand or that his left hand was useless. The Veteran stated that when he worked at 1-800-Pet-Meds, after an hour or two of typing with both hands, his service-connected left wrist would flare-up and he would have to pause between calls for a few minutes to rest his wrists. Thus, there is not an inability to type, but rather a limited ability. The private assessment's conclusion does not adequately account for this nuance, in the same way it does not account for the Veteran being able to carry some weight for a brief period. Building on this point, the Veteran's limitations are very well documented throughout the record, but they are not all encompassing, and the Veteran's reliance on his wife for many activities is not indicative of a wrist that cannot be used. Going back to early in the appeal period, the Veteran was bench pressing 75 pounds and lifting 20 pounds. The Veteran never said he could not pick up anything. The amount he can pick up has changed considerably it has been 15 pounds, 3 pounds, a pen, or not even a notebook. The conclusion is he can pick up something. Reiterating a prior fact to February 2022, the Veteran was able to write in a journal, which likely required the use of his left hand, if nothing else to hold open the journal or the paper he was writing on. He has some ability to grip as indicated by his ability to ride a bicycle. As recently as February 2022, the Veteran did not need assistance dressing himself, going to the bathroom, standing or sitting up, and feeding himself. While the Board acknowledges that there are times the Veteran has relied on his wife, his level of reliance has varied. In addition, the vocational evaluator stated the Veteran would be unable to concentrate for two consecutive hours a day. It is unclear how the examiner determined that limitation. Such a conclusion is not found in the record and never reported by the Veteran. The same can be said as to the conclusion that the Veteran would be off task 10 percent of the day due to an inability to concentrate. This is all in addition to the 30-minute nap the evaluator stated that the Veteran would take every day due to poor sleep caused by service-connected disabilities. Once again, tinnitus is not the only cause of the Veteran's poor sleep, and the examiner did not account how much extra sleep the Veteran would need solely due to the tinnitus or wrist pain and that the Veteran was encouraged not to nap during the day. The Board acknowledges that there are times the Veteran stated his tinnitus keeps him up every night, but more often than not, the Veteran attributes his lack of sleep to a host of problems. Also, the Veteran regularly reported the tinnitus was not constant. Adding everything up, the examiner believes the Veteran would be off task more than 3.5 hours a day. The record does not support such a conclusion. Just like the examiner did not properly analyze the Veteran's sleep disturbances by solely relying on the statement that tinnitus kept the Veteran up every night as opposed to other contradictory statements made by the Veteran, the examiner lumps the worst of the Veteran's symptoms together and does not look at the regularity and severity of symptoms temporally. For example, the private evaluator note the Veteran could only drive short distances because of difficulty grasping the wheel with his left hand but fails to acknowledge the fact the Veteran wanted to serve as a chauffeur and drive trucks part time. Similarly, it failed to acknowledge the Veteran's sleep pattern when happy. It fails to acknowledge the Veteran's ability to cook as recently as 2021. The examiner noted the Veteran reported constant tinnitus at one point, but never noted that there were times the Veteran only had tinnitus a few times per day. Thus, his ability to concentrate might not be affected for two hours at time. The examiner assumed the worst-case scenario would manifest each day for the Veteran and made his conclusion on that false assumption and then added further limitations such as being off task for two hours a day. With regard to his ability to communicate, although the Board notes that the vocational rehabilitation records seemingly support the April 2020 private vocational evaluator's assessment that hearing loss and tinnitus can result in difficulty getting along with others, lack of concentration and focus, and difficulty with effective communication, the Board notes that the Vocational Rehabilitation opinion, while noting tinnitus "can" result in such effects, did not indicate that the Veteran, in fact, suffered from those effects. The probative evidence reflects that the Veteran only has minimal hearing loss, for which he is in receipt of a noncompensable disability rating, and there is no evidence of record to support that he was unable to effectively communicate or had difficulty focusing or concentrating; nor is there any evidence in the record, nor has the Veteran ever indicated that he had difficulty getting along with others. Simply requiring use of speaker phone or asking people to repeat themselves is not in itself evidence of ineffective communication. With regard to concentration, the Board notes that this private assessment was the first time the Veteran mentioned problems with concentration, and the frequency with which he reported that he experienced tinnitus has been inconsistent throughout the period on appeal. Specifically, although his Vocational Rehabilitation records reflect reports of constant ringing in his ears, the Veteran did not report that he had difficulty concentrating during the vast majority of the appeal period. For example, in March 2012 and April 2016, the Veteran reported only intermittent tinnitus. Thus, to the extent that the Veteran now contends that he experienced constant tinnitus, which caused problems concentrating and focusing, the Board finds the probative value of these statements is outweighed by the remaining evidence of record. Thus, while hearing loss and tinnitus may make certain activities or tasks more difficult, the Board does not find that the Veteran's hearing loss and tinnitus result in his inability to effectively communicate and concentrate as may be required for substantially gainful employment. Although the Board acknowledges that the Veteran's employment history has consisted of duties involving frequent typing and the use of tools, which may indeed require the Veteran to take frequent breaks due overuse of his left hand, that is not to say that every form of employment consistent with the Veteran's education and occupational experience requires such duties or with the same level of frequency. While the Board agrees with the April 2020 evaluator to the extent that the use of the upper extremities is necessary in most jobs, the Board reiterates that the Veteran is not service-connected for his right upper extremity, and there is no evidence of record that the Veteran's left wrist disability renders his left upper extremity continuously useless, at the same time that his tinnitus was solely responsible for his ability to sleep, causing him to need to nap every day, while at the same time, not being able to concentrate for large portions of the day. The vocational assessment fails to account for the intermittentness of the Veteran's symptoms in his conclusion. To the extent that the evidence of records suggests that the Veteran was capable of performing sedentary work, the Board is cognizant of the recent decision of the Court in Withers v. Wilkie, which held that the term "sedentary" has no legal significance to the issue of employability under VA regulations; it is not defined for VA employability purposes; and, when it is used, there must be an explanation as to how it is applied to a veteran's individual case. Withers v. Wilkie, 30 Vet. App. 139 (2018). In this case, the Board interprets sedentary work to be that which does not require significant repetitive motion of his left-hand fingers, as well as pulling, pushing, and heavy lifting using his left hand and wrist. Given that the Veteran is right-hand dominant and his training and work experience in written and oral communication, sales, and customer service, the Board finds that the Veteran would be capable of a variety of forms of employment that require some degree of communication, less frequent use of a nondominant hand, or other tasks consistent with such an education and work history. Arguendo, assuming the SSA's regulations applied to the VA, the vocational expert's argument still is wanting. For example, the examiner stated the Veteran cannot perform sedentary work because there are too few jobs at that level that did not require use of both hands. However, the Veteran's service-connected disabilities do not render him unable to stand or walk. The examiner does not discuss positions the Veteran can perform that would be at the light level due to standing and walking, but that do not require lifting, pushing, pulling, etc. at the light level. The examiner's discussion of jobs available to the Veteran is overly constrained. The Board has acknowledged and considered the Veteran's lay statements addressing his employability. The Board notes that the Veteran is competent to report the subjective symptoms and functional limitations he experiences regarding his service-connected disabilities. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nonetheless, the Board emphasizes that the Veteran's description of his service-connected disability must be considered in conjunction with the clinical evidence of record, as well as the pertinent rating criteria. In summary, a TDIU is based upon the severity of the service-connected disability or disabilities. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The Board finds that the symptoms associated with the Veteran's service-connected disabilities are appropriately compensated via the currently assigned ratings. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38C.F.R. §§3.321(a), 4.1. The key difference between the Board's and the evaluator's conclusion is the Board noted that the Veteran's functional capacity waxed and waned and reached this decision after analyzing the holistic evidence. The evaluator on the other hand, while noting that the Veteran had difficulties that varied throughout the record limited the Veteran's ability to the worse instances and then went even further when assessing the Veteran's time off work Based on the Board's review, the evidentiary record fails to demonstrate that the Veteran is unemployable due solely to his service-connected disabilities. Accordingly, evidence does not support entitlement to a TDIU evaluation, to include on an extraschedular basis. As such, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Special monthly compensation (SMC) based on loss of use of his left hand pursuant to 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a)(2) is denied. Special monthly compensation (SMC) is a monetary benefit that is paid for service-connected disabilities which result in impairment of the senses, loss of use (of the extremities, creative organ, breast, or buttocks), or which render the Veteran housebound or in need of the regular aid and attendance of another person. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. SMC is authorized under subsections (k) through (s), with the rate amounts increasing the later in the alphabet the letter appears (except for the "s" rate). SMC at the "k" and "r" rates are paid in addition to any other SMC rates, with certain monetary limits. Id. The rate of SMC "varies according to the nature of the veteran's service-connected disabilities." Moreira v. Principi, 3 Vet. App. 522, 524 (1992). While schedular rates of compensation are predicated on the average reduction in earning capacity, special monthly compensation benefits are meant to provide additional compensation based on noneconomic factors such as personal inconvenience, social inadaptability, or the profound nature of the disability. VAOPGPREC 5-89 (Mar. 23, 1989). Here, the Veteran is seeking SMC for the loss of use of a hand. SMC for the loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.150(a)(2). In October 2014, the Veteran provided a disability questionnaire that indicated the Veteran's wrist's functioning that was not so diminished that an amputation or a suitable prosthetic appliance would equally serve the Veteran. April 2016 and December 2021 VA examiners provided similar opinions. The above opinions are informative; however, even without them, the Board would find that the Veteran has some use of his hand, and, therefore, would not be equally served by amputation with prosthetic appliance. In reaching this conclusion, the Board incorporates its discussion in section one and highlights some relevant information. Although all of the ensuing activities can be performed with limitations (duration, frequency, amount of weight, etc.), they can still be performed: the Veteran can hold something as small as a pen, lift weight (although the amount of weight in the record varies considerably), write, type, bathe, and play cards. The Veteran's ability to perform these activities has decreased as time has gone on (for example the Veteran may no longer be driving), but according to the Veteran, after some manipulation in the morning, he is able to use his hand for limited purposes. Moreover, the Veteran complains of flare-ups after overuse. The key here is that there is use before the flare-ups begin. Since the Veteran still has some functioning of his left hand, he would not be equally served by an amputation. The only opinion in the record that the Veteran lost total use of his left hand is from the Veteran's attorney and the private the vocational evaluator. The Board finds both of these opinions to be inaccurate as there is still some amount of movement the Veteran is capable of performing with his left hand, even if it does result in pain after extended use. In fact, the evaluator said the Veteran could only drive short distances because of the resulting discomfort in the Veteran's left hand. That statement in and of itself contradicts the argument that the Veteran has no use of his left hand. As a result, the claim for SMC for the loss of use of a hand is denied because some effective function remains. 3. SMC based upon the need for aid and attendance pursuant to 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(b) is denied. Special monthly compensation (SMC) is a monetary benefit that is paid for service-connected disabilities which result in impairment of the senses, loss of use (of the extremities, creative organ, breast, or buttocks), or which render the Veteran housebound or in need of the regular aid and attendance of another person. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. SMC is authorized under subsections (k) through (s), with the rate amounts increasing the later in the alphabet the letter appears (except for the "s" rate). SMC at the "k" and "r" rates are paid in addition to any other SMC rates, with certain monetary limits. Id. The rate of SMC "varies according to the nature of the veteran's service-connected disabilities." Moreira v. Principi, 3 Vet. App. 522, 524 (1992). While schedular rates of compensation are predicated on the average reduction in earning capacity, special monthly compensation benefits are meant to provide additional compensation based on noneconomic factors such as personal inconvenience, social inadaptability, or the profound nature of the disability. VAOPGPREC 5-89 (Mar. 23, 1989). The Veteran is seeking special monthly compensation (SMC) under 38 U.S.C. § 1114, subsection (l) and 38 C.F.R. § 3.350(b) on account of being so helpless as to be in need of regular aid and attendance while not hospitalized at U.S. government expense. This is defined by statute and regulation that when, as a result of a service-connected disability, the Veteran is so helpless (due to physical or mental incapacity), that he or she requires the aid of another person to perform the personal functions required in everyday living. 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.350(b), 3.351(b), 3.352(a). A Veteran considered in need of regular aid and attendance if he/she is: blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to five degrees or less; a patient in a nursing home because of mental or physical incapacity; and/or establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a); see also 38 C.F.R. § 3.351(c)(3). These criteria include: inability to dress or undress, or to keep ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without such aid; inability to feed oneself through the loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or, incapacity (physical or mental) which requires care or assistance on a regular basis for protection from the hazards or dangers incident to daily environment. Id. Being "bedridden" will also be a proper basis for finding that a veteran needs regular aid and attendance. The term "bedridden" means a condition which, through its essential character, actually requires that the claimant remain in bed. However, the fact that someone has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure is not sufficient. Id. The Veteran need not show all of the disabling conditions identified in 38 C.F.R. § 3.352(a) to establish entitlement to aid and attendance; the United States Court of Appeals for Veterans Claims (Court) has held that it is logical to infer there is a threshold requirement that "at least one of the enumerated factors be present." Turco v. Brown, 9 Vet. App. 222, 224 (1996). In this case, the Veteran can dress himself if clothes do not have buttons. In July 2010, the Veteran said that could prepare "heat and eat" food for himself. The record does not indicate that he is no longer able to operate the microwave. For a while, he was able to drive. The Veteran's ability to drive himself has changed multiple times throughout the record, but for the most part he has been able to drive short distances. There are no service-connected disabilities that would prevent him from taking public transportation. He can talk with others, although he has difficulty hearing if there is background noise or if the phone is not on speaker. He is able to travel, has a good relationship with some of his family, and is able to be an arbiter during familial disagreements. There is no noted difficulty with toileting or an inability to bathe. He still goes shopping, even if his wife picks out the food. The Veteran is not blind. He does not live in a nursing home. He is not bedridden. Moreover, the Veteran is able to feed himself, toilet, bathe and functioning outside. There are no allegations that he cannot avoid hazards. His ability to avoid hazards is supported by his ability to bike, shop, and travel. Therefore, the claim for SMC under the provisions of 38 U.S.C. § 1114(l) based on the need for aid and attendance is denied. T. SHERRARD Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Chalker, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.