Tbi Or Post Concussion Syndrome

[militarynurse]

Now here's a gem I got in a letter from the VA today: "Please be advised that you were previously denied Service-Connection for TBI and you are currently Service-connected for Post Concussive Syndrome." Huh?

Now, it would seem inherently logically that in having a post concussive syndrome that one must have suffered at minimum a concussion...which according to the VA's own manual is the result of a TBI.

Any opinions on how to respond to this?

[carlie]

militarynurse,

I refer again to the change in DC 8045 that took effect Oct 2008,

I can not be more plain than that.

jmho,

carlie

[Wings]

Traumatic Brain Injury in the War Zone

PubMed Citation

In Okie's Perspective article (May 19 issue)1 on traumatic brain injury

(TBI) from the war in Iraq, she alludes to mood disorders that result from

such injuries. Patients with TBI have been described as the "walking

wounded"2 owing to their lingering neuropsychological problems.

Lishman studied 670 cases of head injuries from the Second World War

and reported that "simple measures of the amount of brain damage . . .

were indeed related to the amount of psychiatric disability encountered one to five years later."3

As many as 77 percent of patients with TBI have been given a

diagnosis of depression.4 Mood disorders may result in the restriction of

social contact as well as increased loneliness and are major barriers to

functional and social rehabilitation.5

Technological improvements and better emergency medical care have reduced

the incidence of severe TBI while increasing the numbers of patients with

mild or moderate TBI. Such patients are more adversely affected by their

emotional problems than by their residual physical disabilities.6 It is

important to screen these patients for depression and to conduct

neuropsychological testing soon after head injury in order to facilitate

treatment and reentry into the community, as well as to optimize the

long-term outcome.

Rohit R. Das, M.B., B.S., M.P.H.

Boston Medical Center

Boston, MA 02118

rohit.das@bmc.org

Ranjani N. Moorthi, M.B., B.S., M.P.H.

Saint Vincent Hospital

Worcester, MA 01608

References

Okie S. Traumatic brain injury in the war zone. N Engl J Med

2005;352:2043-2047. [Free Full Text]

Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury.

Psychosomatics 2000;41:95-103. [Free Full Text]

Lishman WA. The psychiatric sequelae of head injury: a review. Psychol Med

1973;3:304-318. [iSI][Medline]

Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of

depression after traumatic brain injury: a comprehensive examination. Brain

Inj 2001;15:563-576. [iSI][Medline]

Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with

traumatic brain injury: a literature review and recommendations. Brain Inj

1995;9:81-92. [iSI][Medline]

Satz P, Fourney DL, Zaucha K, et al. Depression, cognition, and functional

correlates of recovery outcome after traumatic brain injury. Brain Inj

1998;12:537-553. [CrossRef][iSI][Medline]

To the Editor:

Although Okie's article described well many of the issues

involved in the current war in Iraq, we would like to clarify our comments,

reported in the article, regarding the classification of mild TBI.

We noted that the boundary between mild and moderate TBI is one hour of loss of

consciousness and that the cutoff between moderate and severe TBI is one day

of loss of consciousness. However, there is variation in the classification

of mild TBI.

Some authors use 30 minutes of loss of consciousness as the criterion, and

others 20 minutes, and still others define "brief" loss of consciousness

as lasting less than 1 hour. In practice, we more often use the duration of

post-traumatic amnesia to determine the level of severity, since that

information is available to us more often than are data on loss of

consciousness.

Deborah L. Warden, M.D.

Louis French, Psy.D.

Defense and Veterans Brain Injury Center

Washington, DC 20307

References

American Congress of Rehabilitation Medicine. Definition of mild traumatic

brain injury. J Head Trauma Rehabil 1993;8:86-87.

Rimel RW, Giordani B, Barth JT, Boll TJ, Jane JA. Disability caused by minor

head injury. Neurosurgery 1981;9:221-228. [iSI][Medline]

International classification of diseases, hospital edition, 9th rev.,

clinical modification: ICD-9-CM. 6th ed. Vol. 1, 2 & 3. Los Angeles:

Practice Management Information Corporation, 2002.

[militarynurse]

10-4 and thank you. Still I just received that VA letter today and that's what it said. No mention of any new rating criteria. IMHO, it's logically inconsistent to service-connect for PCS and deny TBI.

[carlie]

It is only the residual effects of the PCS or TBI

that is considered in the percentage evaluations.

carlie

[militarynurse]

It is only the residual effects of the PCS or TBI

that is considered in the percentage evaluations.

carlie

Carlie, Thank you for the reply. I haven't seen any new ratings under the new evaluation criteria so as far as residuals effects go, I'll take a wait and see position. Has anyone actually been rerated yet for residual effects under the new evaluation criteria?

However, would it matter if one was SC'd for TBI or PCS as far as establishing a connection for secondary conditions? As I understand it, PCS can derive from purely subjective symptoms like headaches, whereas TBI can be based on subjective symptoms and/or objective findings. Therefore, might more secondary conditions be associated to TBI than to PCS?

[carlie]

militarynurse,

This is the pre Oct 2008 rating criteria for DC 8045

Under Diagnostic Code 8045, brain disease due to trauma,

purely neurological disabilities such as hemiplegia,

epileptiform seizures, facial nerve paralysis, etc.,

following trauma to the brain, will be rated under the

diagnostic codes specifically dealing with such disabilities,

with citation of a hyphenated diagnostic code (e.g., 8045-

8207).

Purely subjective complaints such as

headaches,

dizziness,

insomnia, etc.,

which are recognized as

symptomatic of brain trauma, will be rated 10 percent and no more

under Diagnostic Code 9304.

This 10 percent rating will not be combined with any other rating for a disability due to

brain trauma.

Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of a diagnosis of multi-infarct

dementia associated with brain trauma. 38 C.F.R. § 4.124a,

Diagnostic Code 8045 (2007).

If you compare this to the post Oct 2008 rating criteria for DC 8045

you will see a tremendous, more adventageous rating allowed

for this disability.

I am currently rated under the pre Oct 2008 DC 8045 - Brain disease due to trauma

Post Concussion Syndrome criteria.

This limited me to 10 % due to headaches.

While on AD, I had 3 concussions back to back, within about a 4 month timeframe.

My Seizures due to the last concussion were rated separetly.

Dizziness, depression, change in personality and cognitive deficiencies were not

really even considered much or rated, under the old DC 8045.

I will soon be re-evaluated under the New criteria.

If you have a SC'd disability due to PCS - I would notify the VA that PCS

became ratable under the new DC 8045 - that went into effect Oct 2008

and I would like to be re-evaluated under the new rating criteria.

jmho,

carlie