Changes to TBI Ratings

[awgv001]

CHANGE TO TBI RATING

SUPPLEMENTARY INFORMATION:

This document proposes to amend VA adjudication regulations (38 CFR Part 3) by revising 38 CFR 3.310 to add five diagnosable illnesses as secondary conditions which shall be held to be the proximate result of service-connected TBI.

 

Scientific Bases for This Rulemaking
In the National Academy of Science IOM Report, Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury, the IOM concluded there was “sufficient evidence of a causal relationship” (the IOM's highest evidentiary standard) between moderate or severe levels of TBI and diagnosed unprovoked seizures. The IOM found “sufficient evidence of an association” between moderate or severe levels of TBI and parkinsonism; dementias (which VA understands to include presenile dementia of the Alzheimer type and post-traumatic dementia); depression (which also was associated with mild TBI); and diseases of hormone deficiency that may result from hypothalamo-pituitary changes.

 

The medical literature that IOM reviewed included two primary studies and one secondary study on TBI and parkinsonism. One primary study involved 196 Parkinson's patients living in Olmstead County, Minnesota, and the second involved 93 pairs of male twins who were veterans from World War II. The secondary study involved 140 civilian Parkinson's patients in Boston, Massachusetts, who had suffered a TBI severe enough to cause loss of consciousness, blurred or double vision, dizziness, seizures, or memory loss. These three studies support a link between moderate or severe TBI and parkinsonism.

 

Medical literature supports a link between TBI and the two types of dementias listed above (presenile dementia of the Alzheimer type and post-traumatic dementia). Reported cases show that individuals with TBI often are diagnosed with dementia at ages younger than their early 50s and within 15 years of their injuries. As classic Alzheimer's disease strikes sufferers much later in life, the dementias suffered by TBI victims are unlikely to be classic Alzheimer's dementias. Classic Alzheimer's disease is the most common of many types of dementia that occur in older adults. It is difficult to conclude that Alzheimer's occurring at ages in the 60s or 70s is related to a distant TBI.

 

The IOM reviewed 4 primary studies of civilians and of troops serving in World War II and the current conflict in Iraq and five secondary studies of mood disorders including major depression. The primary studies generally supported an association between mild, moderate, or severe TBI and major depression within the first twelve months after the injury. Current research does not provide significant evidence to support association more than 12 months following mild TBI. Moderate or severe TBI appears to cause an elevated risk for depression (up to 50% in some research) for at least the first 3 years.

 

The IOM reviewed five studies on TBI and hypopituitarism, and five studies on TBI and growth hormone insufficiency. The studies generally showed increased risk of those conditions developing within months after a moderate or severe TBI and, although the effects in many cases were acute and eventually resolved, some long-term effects were observed. The medical literature reviewed by IOM supports a link between TBI and diseases of hormone deficiency resulting from hypothalamo-pituitary changes, when the disease manifests within 12 months of a moderate or severe TBI. The presence of other peripherally-mediated endocrinologic disorders (including, but not limited to diabetes mellitus) has no association with TBI.

 

After careful review of the findings of the NAS Report, Gulf War and Health Volume 7, the Secretary of Veterans Affairs has determined that the scientific evidence present in the NAS Report, Gulf War and Health Volume 7 and other information available to the Secretary indicates that a revision to VA regulations to add the five diagnosable illnesses as secondary conditions is warranted. The five diagnosable illnesses to be added are the following: (1) Parkinsonism following moderate or severe TBI; (2) unprovoked seizures following moderate or severe TBI; (3) dementias (to include presenile dementia of the Alzheimer type and post-traumatic dementia) within 15 years of moderate or severe TBI; (4) depression, if manifest within 3 years of moderate or severe TBI or within 12 months of mild TBI; and (5) diseases of hormone deficiency that result from hypothalamo-pituitary changes manifest within 12 months of moderate or severe TBI.

 

Section 501(a) of title 38, U.S. Code, establishes the Secretary of Veterans Affairs' general rulemaking authority to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by VA. Based on VA's analysis of the scientific evidence discussed in the IOM report as well as the IOM's finding of sufficient evidence of relationships between specific levels of TBI and certain diagnosable illnesses, and all other information available to the Secretary, we propose to amend 38 CFR 3.310 in order to incorporate five diagnosable illnesses as secondary conditions that are the proximate result of service-connected TBI.

 

The IOM also found associations between TBI and certain behavioral and social problems. These include diminished social relationships, aggressive behaviors, long-term unemployment, and premature death. Under 38 U.S.C. 1110, VA may only grant service connection “[f]or disability resulting from personal injury suffered or disease contracted in line of duty * * *”. Similarly, § 1310(a) states, “When any veteran dies * * * from a service-connected or compensable disability, the Secretary shall pay dependency and indemnity compensation to such veteran's surviving spouse, children, and parents.” VA does not believe it is necessary to establish new presumptions of service connection for these effects because they are not distinct physical or mental “disabilities” for VA compensation purposes. However, the behavioral, social, and occupational effects of TBI and related service-connected conditions may be considered in evaluating the severity of those conditions for compensation purposes as provided in provisions of VA's rating schedule.

 

In relevant part, § 3.310(a) states: “[A] disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.” We propose to revise § 3.310 by adding a new subsection (d)(1) that lists five diagnosable illnesses as secondary conditions that shall be held to be proximate results of service-connected TBI.

 

VA recognizes that not all those who suffer a TBI during military service seek immediate medical assistance and receive a medical assessment of the severity of the TBI. Therefore, proposed paragraph (d)(2) will clarify that neither severity levels nor time limits for manifesting secondary conditions as proximate causes of service-connected TBI shall preclude a veteran from establishing direct service connection under the generally applicable principles of service connection in 38 CFR 3.303 and 3.304.

 

Determination of the Severity of a TBI
VA and the Department of Defense have established a joint set of factors and criteria for classifying a TBI as mild, moderate, or severe. The factors and criteria were created by a team of physicians from VA and the Department of Defense who are experts on diagnosing and treating TBI. The factors are structural imaging (such as functional magnetic resonance imaging, diffusion tensor imaging, positron emission tomography (PET) scanning), duration of alteration of consciousness/mental state, duration of loss of consciousness, duration of post-traumatic amnesia, and score on the Glasgow Coma Scale. See Memorandum by Asst. Secretary of Defense for Health Affairs, “Traumatic Brain Injury: Definition and Reporting,” October 1, 2007. See also Compensation & Pension Service Training Letter 09-01, January 21, 2009.

We propose to include these severity criteria as a table in § 3.310(d)(3)(i). We also propose to explain in paragraph (d)(3)(ii) that the determination of the severity level is based on the TBI symptoms at the time of injury or shortly thereafter, rather than the current level of functioning. This provision is consistent with established medical principles for assessing the severity of TBI. See Memorandum by Asst. Secretary of Defense for Health Affairs, “Traumatic Brain Injury: Definition and Reporting,” October 1, 2007. See also Compensation & Pension Service Training Letter 09-01, January 21, 2009.

 

Some veterans may not meet all of the criteria within a particular severity level or may not have been examined for all the factors. We believe the simplest, most efficient, and fairest way to rank such veterans is to apply two rules: (1) VA will not require that a TBI meet all the criteria listed under a certain severity level to classify the TBI under that severity level; and (2) If a TBI meets the criteria relating to loss of consciousness, post-traumatic amnesia, or Glasgow Coma Scale in more than one severity level, then VA will rank the TBI at the highest of those levels. We propose to include these rules in paragraph (d)(3)(ii).

 

In some cases, it may not be clinically possible to determine the severity of a TBI (e.g., because of a lack of medical records contemporaneous with the injury or medical complications (e.g., medically induced coma)). In such cases, § 3.310(d) would not apply and the veteran's claim would be processed under § 3.310(a) which states that “disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.”

[Buck52]

I read something about the VA going full force to check the symptoms of all TBI veterans more close because  a TBI can cause serious damage that goes untested or is an underline condition that may and can occur years later ,  they don't know what all a TBI can cause but they are doing a study and also this study included past members (players) of the NFL along with some  veterans with dx TBI's

[vetquest]

Wow, that's a lot of information to digest.  It looks like the VA is taking TBI seriously.

[Vync]

Good information and good timing. I am preparing a TBI claim for my father and this will come in handy.

[Vync]

1 hour ago, Buck52 said:

I read something about the VA going full force to check the symptoms of all TBI veterans more close because  a TBI can cause serious damage that goes untested or is an underline condition that may and can occur years later ,  they don't know what all a TBI can cause but they are doing a study and also this study included past members (players) of the NFL along with some  veterans with dx TBI's

It definitely looks that way. I hope this helps my father's case. In 1969 in Vietnam, he was in a vehicle accident and was pinned underneath. In 1989, he hit his forehead head on the barrel of a cannon (field artillery) sufficient to cause a large bloody laceration and make him feel faint. We also have a VHS video showing the wound. And then in 2011 he was diagnosed with dementia, moderate memory loss, depression, and hypothyroidism. Sounds like there might be some relation there.

[El Train]

They are taking it seriously.  I put in a claim for TBI.  It got started with diagnosis from outside MD and Psychologist.  Otherwise the VA was ignoring my complaints of symptoms.  Then the VA proceeded with three C&P's.  The first one was positive.  Then they sent me for two more.  I haven't seen those yet.  I did get my claim approved since then.  They combined it with PTSD for 100% P&T.  Also migraines were secondary at 10%.  I can tell you TBI's are no joke.  Not remembering siblings names, where you put away the dishes at, whether you took your medication, fed the dogs, took a shower, sucks.  

If you are going to put in a claim, I recommend getting an outside IME first.  Otherwise these are serious claims the VA will try to dodge.  I guess that goes for all claims.

[Richard1954]

3 hours ago, El Train said:

Otherwise these are serious claims the VA will try to dodge. 

I can't disagree more.... I had a TBI in 1975 as I was thrown from a moving military jeep. i spent three days unconscious in the Hospital,  I was diagnosed with a concussion.  After this incident I had headaches, and memory loss.  For years I just lived my life,  then I learned that a concussion was a TBI, and submitted in claim in 2016. I was easily awarded 40% and further diagnosed with   left frontal brain damage. The C/P was completed by a VA doctor at the VA hospital. Other than my active duty medical records, I had no proof of the incident. I did not have to prove current symptoms either.... There was a time where the VA was dening or low-balling claims on TBI but those issues have been corrected.