The Department of Veterans Affairs (VA) has issued a proposed rule that would make it easier for veterans with certain secondary illnesses to demonstrate that the illnesses are related to service-connected traumatic brain injuries (TBIs). Currently, VA rules state that, “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,” [38 C.F.R. Sec. 3.310(a).] After reviewing a report issued by the National Academy of Sciences, Institute of Medicine (IOM), the VA determined that five types of illnesses, when present in a veteran with a service-connected TBI, should automatically be considered secondary service-connected injuries.
Traumatic Brain Injuries
TBIs are increasing among veterans, possibly due to the more frequent use of advanced explosive devices in modern warfare. Of patients exposed to blasts who were admitted to Walter Reed Army Medical Center from January, 2003 through February, 2005, 59% had TBIs. TBIs have caused roughly 22% of the casualties in Iraq and Afghanistan. According to the IOM, blast-induced neurotrauma (BINT), a closed head form of TBI, “has been called the signature wound of the war in Iraq.” Open head, or penetrating, injuries are caused when objects, such as bullets, pass through the skull. Closed head injuries occur when an object hits the head, or vice versa, with great force.
Based upon joint work by the VA and the Department of Defense (DOD), the proposed rule would rate the severity of a TBI as mild, moderate, or severe based upon ratings of the following factors at the time of injury:
structural imaging of the brain;
loss of consciousness (LOC);
alteration of consciousness/mental state (AOC);
post-traumatic amnesia (PTA); and
Glasgow Coma Scale (GCS). (Physicians rate the severity of injuries according to the GCS, which measures eye opening, verbal response, and motor function. Scores range from 15, representing a patient with no deficits, to 3, representing a comatose patient.)
However, TBIs need not necessarily meet all criteria in a category to be classified as such.
The IOM reviewed extensive literature regarding clinical and epidemiological studies of adults with TBI to determine what, if any, effects were connected to TBIs at various levels of severity. It found “sufficient evidence of a causal relationship” to link severe or moderate TBI to unprovoked seizures. It also found “sufficient evidence of an association” (emphasis added) with varying levels of TBI and Parkinsonism, depression, endocrine dysfunction, growth hormone insufficiency, and dementia. TBI sufferers, for example, are often diagnosed with preclinical dementia of the Alzheimer type well before they enter their fifties, which is typically the earliest that Alzheimer’s Disease would manifest itself, making it more likely that the dementia stems from the TBI, rather than an early onset of Alzheimer’s Disease. In addition, the IOM found sufficient evidence of an association between TBI and aggressive behaviors, and between moderate to severe TBI and long-term social consequences, such as unemployment. The evidence of associations involving varying levels of TBI or remaining illnesses was merely limited or suggestive.
After considering the IOM’s study, the VA proposed to amend its adjudication regulations relating to service-connection to deem the following illnesses proximately related to service-connected TBIs:
- Parkinsonism following moderate or severe TBI;
- Unprovoked seizures following moderate or severe TBI;
- Dementia (presenile dementia of the Alzheimer type and post-traumatic dementia), if manifest within 15 years following moderate or severe TBI;
- Depression if manifest within 3 years of moderate or severe TBI or within 12 months of mild TBI; or
- Diseases of hormone deficiency that result from hypothalamo-pituitary changes if manifest within 12 months of moderate or severe TBI.
The VA specifically excluded other behavioral and social problems from the list because they were not “distinct physical or mental ‘disabilities.'” However, those problems may be considered when determining the severity of service-related conditions for compensation purposes. In instances where physicians cannot rate the severity of a TBI or cannot identify the dates of manifestations of listed illnesses, the illnesses will be evaluated for service-connectedness in accordance with existing section 3.310(a).
The VA will accept comments on the rule no later than February 8, 2013, at www.regulations.gov. Commenters should reference RIN 2900-AN89-Secondary Service Connection for Diagnosable Illnesses Associated with Traumatic Brain Injury. It will also accept written and faxed comments.