Traumatic Brain Injury (TBI)

There are three main areas of dysfunction that may result from TBI and have profound effects on functioning:

  1. cognitive (which is common in varying degrees after TBI),

  2. emotional/behavioral, and

  3. physical.

Each of these areas of dysfunction may require evaluation.

Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain.

Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.”

Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table.

Evaluate emotional/behavioral dysfunction under §4.130 (Schedule of ratings—mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” This is why many TBI and other mental health ratings are combined.

Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including

  • pain, of the extremities and face;

  • visual impairment;

  • hearing loss and tinnitus;

  • loss of sense of smell and taste;

  • seizures;

  • gait,

  • coordination, and balance problems;

  • speech and other communication difficulties, including aphasia and related disorders, and dysarthria (slurred speech);

  • neurogenic bladder;

  • neurogenic bowel;

  • cranial nerve dysfunctions

  • autonomic nerve dysfunctions; and

  • endocrine dysfunctions.

  • Prostrating headaches

The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under §4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations

Consider the need for special monthly compensation for such problems as

  • SMC-K-loss of use of an extremity, certain sensory impairments, erectile dysfunction

  • SMC-T-the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc.

NOTE: In order to qualify for SMC-T, the Veteran must first qualify for SMC-L for Aid and Attendance (A&A). In order to qualify for SMC-L (A&A), the Veteran must first be rated at 100%.

Traumatic Brain Injury (TBI) is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile.

TBI can be from firearms, blast injuries from explosions, repetitive head injuries including boxing, personal assault including domestic violence or MST, vehicle accident, falls and basically anything that causes damage to the brain.

Unfortunately, when rating TBI the VBA (Veterans Benefits Administration) uses many different names for TBI. This can result in confusion

Sometimes a Veteran may think they are not already rated for TBI when they actually are.

One big issue is the major symptoms of TBI also are the same symptoms for mental health ratings. So, a rating for PTSD or Major Depressive Disorder may have a phrase like the below list or something similar. Or, the TBI may be rated at 0% along with a mental health rating. So, the Veteran continues to file for TBI or an increase and gets frustrated when the VBA denies the claim because it is already rated. Unfortunately the explanation in the letter you receive is not always clear.

Some names for TBI.

  • Acquired brain injury (ABI)

  • Status post closed head injury

  • Concussion

  • Head injury

  • Anoxia (loss of oxygen) due to trauma

  • Subdural hematoma

  • Brain contusion

  • Diffuse axonal injury (DAI)

  • Penetrating skull injury

  • Intracranial injury

Consult your advocate if this is a question for you. They can explain if you are already rated for TBI.

TBI Residuals Table

Step 1: First, sort each symptom into one of these categories.

Step 2: Next, look at all the symptoms in a single category and assign a level of impairment for that category based on the criteria for each level. (Remember, you are looking at all the symptoms in that category together. If one symptom only troubles you once a week, and another troubles you twice a week, then the symptoms cause problems 3 days a week.) If there are no symptoms in a category, that category is assigned a level of impairment of 0.

Step 3: Once each category has a level of impairment, determine which has the highest level of impairment.

Step 4: The highest level is then translated into the final rating for these remaining symptoms using this table.

EXAMPLE:

If the highest level is 2, the final overall rating is 40%. This would then be the final rating for these extra symptoms. Only the 1 rating is given for all these symptoms, no matter how many there are.

Circle each score. Use the sections to make notes for a Compensation & Pension (C&P) exam or for any review. Take the sheet with you for the exam to refer to. If it is neat, you can sign the bottom with this statement and submit with a claim as part of the claim as lay evidence. You should speak with your advocate (accredited VSO, accredited claims agent or accredited attorney) before submitted any evidence.

“I CERTIFY THAT the statements on this document are true and correct to the best of my knowledge and belief.”

Have a family member, friend or spouse score another copy. It is sometimes difficult for the person with the TBI to self-evaluate effectively.

Now that we have all the Level of Impairments assigned to each category, we need to find which is the highest cumulative score.

Take each score and place into the below chart.

A Traumatic Brain Injury (TBI) is a disruption of brain function resulting from a blow, jolt or repeated jolts to the head or penetrating head injury. A closed head injury occurs when the brain is not exposed, also called non-penetrating or blunt injury. A penetrating head injury, or open head injury, occurs when an object pierces the skull and breaches the dura mater, the outermost membrane of surrounding the brain.

There are several signs and symptoms of TBI to be aware of after a head injury. These include:

  • any loss of consciousness

  • attention issues

  • headaches

  • change in vision

  • dizziness

  • loss of balance

  • sleep disturbances

  • nausea

  • irritability

  • word-finding difficulties

  • confusion

Memory loss is the most common cognitive impairment including loss of memory of the actual event that caused the TBI. Some people seek treatment for a TBI when they find themselves having difficulty walking a straight line. Others look for help when they have speech issues caused by muscle weakness that causes disordered speech. TBI commonly has neurobehavioral effects like depression and personality changes, as well as chronic pain and substance abuse disorder. A neurologist can link these symptoms to a TBI, ruling out other causes.

In addition to these generalized symptoms, TBI patients commonly suffer functional vision problems. These symptoms include:

  • difficulty focusing

  • double vision

  • difficulty reading

  • sensitivity to light

  • aching eyes

  • loss of visual field

To break down the numerical system of the rating, the VA evaluates TBI at 0, 10, 40, 70, and 100 percent. They recognize that there are certain cases so severe that warrant a rating higher than 100%, such as when the Veteran cannot work due to the injury or need help with Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL). These ratings are called special monthly compensation (SMC). There is a specific one just for TBI called SMC-T.

In order to be eligible for SMC-T, a Veteran must show several factors:

  1. The Veteran needs aid and attendance

  2. Without in-home aid and attendance, the Veteran would require hospitalization, nursing home care, or another type of residential institutionalized care.

  3. The Veteran doesn’t otherwise qualify for a higher level of Aid & Attendance under 38 U.S.C.S. § 1114 (R-2).

To break this down further, the VA has a special definition for “aid and attendance.” A Veteran must show that they are in need of aid and attendance by proving that they have the inability to perform specific daily functions called Activities of Daily Living (ADL). This includes:

  • Inability to dress and undress without assistance

  • Inability to stay clean and presentable without assistance

  • Inability to feed themselves without assistance

  • Inability to attend to the wants of nature

  • Exposure to hazards and dangers incident to daily environment

If a Veteran can prove all of the above factors to be true, they may be eligible for a 100% rating or more. This then makes them eligible for special monthly compensation for their injuries.

The Veteran should have their doctor fill out the VBA Form 2680 if applying for SMC-T.

https://www.vba.va.gov/pubs/forms/vba-21-2680-are.pdf

In 2013 the VBA recognized several assumed secondary conditions.

  • Parkinsonism (including Parkinson’s Disease) following moderate or severe TBI

  • Dementias (presenile dementia of the Alzheimer’s type, frontotemporal dementia, and dementia with Lewy bodies) that develops within 15 years of moderate or severe TBI

  • Unprovoked seizures following moderate or severe TBI

  • Depression that manifests within three years of moderate or severe TBI or within 12 months of mild TBI

  • Disease of Hormone Deficiency (resulting from hypothalamo-pituitary changes) that manifests with 12 months of moderate or severe TBI

As for determining the severity of a TBI, there are several factors that the VA considers. These include:

  • structural imaging,

  • loss of consciousness,

  • alteration of consciousness/mental state, and

  • post-traumatic amnesia.

They also use the Glasgow coma scale in their assessment if the Veteran’s TBI resulted in a coma. Depending on the severity and combination of these factors, the VA classifies the TBI as mild, moderate, or severe. However, it’s important to note that a Veteran doesn’t need to demonstrate all of these factors to fit into one level of severity. The Veteran also would qualify for the highest level of severity if they meet the criteria for multiple levels.

Again, if the TBI is severe enough and the secondary condition appeared within the listed time frame, a private medical opinion (nexus) is not necessary. However, keep in mind that it can still be helpful to gather evidence when applying for secondary service connection. And this can include past medical reports. By collecting this evidence, you are helping to ensure a more accurate VA evaluation. You can also avoid seeking a medical opinion while the evaluation is ongoing.

Physical Symptoms: Physical symptoms are ones that directly affect the functioning of the body, whether moving muscles or beating the heart. These may be rated separately depending on current diagnosis and chronicity.

  • Vision problems can be rated. This includes damage to the oculomotor nerve.

  • Hearing problems, including tinnitus

  • Total loss of smell and taste can be rated.

  • Damage to the skull bone. A skull injury can only be rated if there is a hole in the skull. Any other skull bone injury will heal and so is not ratable.

  • Slowed breathing and respiratory failure and defects of the chest wall that keep the lungs from inflating.

  • If it is a direct result of TBI, paralysis or difficulty moving any body part is caused by damage to the nerve that controls it.

    • Numbness and tingling anywhere in the body that is caused by nerve damage.

    • The inability to speak or the impaired ability to speak (dysarthria, aphonia) because of physical causes, like the necessary muscles are unable to move, is caused by damage to one or more of the cranial nerves (although only one nerve can be rated for this symptom), whichever nerve is most affected.

    • The inability to swallow is rated as impairment of the glossopharyngeal nerve or the hypoglossal nerve, whichever is damaged the most.

    • Difficulty chewing is rated as impairment of the trigeminal nerve.

    • Paralysis of the facial muscles is rated as impairment of the facial nerve.

    • Seizures: In 25-50% (depending on the severity) of cases, individuals affected by TBI experience seizures within days of the initial trauma. In the majority of these cases, the seizures stop within a week. If they continue beyond a week, then a seizure disorder can be diagnosed and rated. Similarly, seizures may not begin immediately, but may begin months or years after the initial injury. In these cases, there must be proof that the seizures are directly related to the TBI with a nexus letter. All seizure conditions are rated as the Epilepsy and Seizures.

    • Twitching or tremors of the muscles can either be rated as Athetosis or as Sydenham’s Chorea, whichever is diagnosed.

  • Migraine headaches are rated separately.

  • Pain is often a result of TBI. Since the nerves sense pain, any nerve damage will most likely also have pain in whatever area that nerve affects. Not all pain caused by TBI is a result of nerve damage, though. Pain itself can be rated as Somatic Symptom Disorder and the minimum rating that condition can have is 10%. If already rated for a mental health condition this will be placed under that rating.

  • Urinary Incontinence can occur when the nerves to the muscles that control urination are damaged. This is rated as voiding dysfunction caused by a neurogenic bladder, not under the damaged nerve.

  • Bowel Incontinence occurs when the nerves that control bowel movements are damaged. This is rated as a neurogenic bowel, not under the damaged nerve.

  • Problems staying balanced are rated under Balance Disorders.

  • Nausea and vomiting are not rated.

  • Muscle cramps are not rated.

  • Dizziness is not rated but may be under balance disorders depending on chronicity.

  • Insomnia or other trouble sleeping is rated as a mental health symptom.

  • Loss of coordination could include bumping into things, dropping things, inability to play sports, difficulty driving safely, trouble working with machinery, etc. is not rated.

  • Increased sensitivity to light or sound is not rated but can be a symptom of migraines.

  • Increased fatigability is how fast the body becomes tired during physical activities and may be rated as Chronic Fatigue Syndrome if diagnosed.