considering questions of incurrence or aggravation in service bear in mind the etiology and clinical course of each separate disease. considering conditions of infectious origin consider both the circumstances of infection and the incubation period. determining aggravation for conditions such as multiple sclerosis, progressive muscular atrophy, and myasthenia gravis be aware that increased symptomatology over a period of a few months may reflect natural progression of the disease. Base determinations on the developed medical evidence of record. b Identifying Epilepsy Seizures must be witnessed or verified by a physician to warrant service connection (SC) for epilepsy. Verification may be by an electroencephalogram (EEG), which measures electrical activity in the brain. A physician does not have to witness an actual seizure before a diagnosis of epilepsy can be accepted for evaluation purposes. Verification by a physician based upon factors other than observing an actual seizure is sufficient. References: For more information on identifying epilepsy, see , and psychomotor epilepsy, see . c. Evaluating Progressive Spinal Muscular Atrophy Progressive muscular atrophy, , refers to progressive spinal muscular atrophy, which is a disease of the spinal cord. Progressive muscular atrophy is subject to presumptive SC because it is an organic disease of the nervous system. d. Other Organic Diseases of the Nervous System Under 38 CFR 3.309(a) For purposes of establishing presumptive SC under , the term other organic diseases of the nervous system includes any commonly recognized neurological disease which is not otherwise specifically enumerated under . This includes, but is not limited to, the following conditions: carpal tunnel syndrome migraine headaches sensorineural hearing loss glaucoma progressive spinal muscular atrophy diseases of the cranial nervous system cranial nerve conditions, and peripheral nerve conditions. Important: If is uncertainty as to whether or not a claimed disability may be considered as an organic disease of the nervous system for purposes
Change Date August 6, 2015 a. Definition: TBI The term TBI means the physical, cognitive and/or behavioral/emotional residual disability resulting from an event of external force causing an injury to the brain. b. TBI Events The TBI event is a traumatically induced structural injury and/or physiological disruption of brain function resulting from an external force indicated by at least one of the following clinical signs immediately following the event any period of loss of consciousness or decreased consciousness any loss of memory for events immediately before or after the injury any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) neurological deficits, whether or not transient, or intracranial lesion. Notes: The TBI event has two necessary components: the external force and the identifiable acute manifestations of brain injury immediately following the external force. Not all individuals exposed to an external force will have brain injury, and therefore, they will not meet the criteria for having a TBI event. The acute manifestations may resolve without chronic disability, or a chronic disability may result. Although unconsciousness or reduced consciousness is common in TBI events, these are not required. Any one of the five signs will be sufficient. c. External Force for the Purpose of TBI Events External force means any of the following events a foreign body (such as a bullet or shell fragment) penetrating the brain the head being struck by an object (such as a fist, a hatch, or flying debris) the head striking an object (such as the ground or a windshield) the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, force generated from events such as a blast or explosion, or other force yet to be defined. Note: TBI events may occur during combat or non-combat situations (such as a motor vehicle accident, fall, or personal assault).
presenile dementia of the Alzheimer type frontotemporal dementia, and dementia with Lewy bodies depression moderate or severe award SC if depression manifested within three years after the TBI. mild award SC if depression manifested within one year after the TBI. a disease of hormone deficiency that results from hypothalamo-pituitary changes (any condition in the endocrine system section of the rating schedule, , or any condition evaluated analogous to one of those conditions) moderate or severe award SC if the condition manifested within one year after the TBI g. Considerations When Establishing Secondary SC When evaluating TBI-related secondary conditions, avoid pyramiding when considering the initial TBI evaluation and symptoms that are now associated with the five secondary conditions. Also, consider Notes 1 and 2 under , while ensuring that the claimant receives the highest overall evaluation under the provisions of (Combined Ratings Table). Depending on the most advantageous combined evaluation, it is permissible to reduce an existing TBI evaluation as long as the overall evaluation of both TBI and the separate secondary SC condition is not reduced. Use the combinator tool in VBMS-R to determine the combined evaluation of TBI and the secondary SC condition. Thoroughly explain the decision narrative in the rating decision. Use the table below to consider symptoms which apply to both TBI and the secondary conditions. If ... Then ... the symptoms associated with one of the five conditions were also used to provide the highest of evaluation for any facet under consider removing evaluation of the facet, and use the next highest-evaluated facet as the evaluation for the TBI residuals, as long as the symptoms of that facet are not used to establish SC for one of the five diagnosable conditions.
Examiner: Please identify the specific nerve(s) affected. If you are unable to identify the specific nerve(s), please provide a rationale in the Remarks section. Thank you. Follow the guidance in the table below when reviewing medical evidence pertaining to peripheral nerve disabilities of the upper or lower extremities. If the DBQ or equivalent indicates… And… Then evaluate… the specific nerve(s) affected there is no conflicting information the specific under the appropriate DC. there is conflicting information on what nerve is affected, but the nerves identified are within the same nerve branch the nerve that is most beneficial to the Veteran as long as the DC supports the symptoms. the identified nerves are in different nerve branches; however, the symptoms identified in the medical evidence are not clearly associated with an individual nerve all symptoms shown in the medical evidence for the individual nerve(s) in the associated nerve branches. the examiner is unable to specify the affected nerve(s) there is no other evidence adequately documenting the affected nerve upper extremity symptoms using (the radial nerve), or lower extremity symptoms using (the common peroneal nerve). Exception: Where the disability at issue is lower extremity radiculopathy associated with SC thoracolumbar disability, follow the guidance in M21-1, Part III, Subpart iv, 4.A.3.a and evaluate using (the sciatic nerve). Note: The nerve branches and general functions of the nerve branches are described in the table found in M21-1, Part III, Subpart iv, 4.G.4.c. f. EMG and Other Tests for Peripheral Nerve Conditions Electromyelogram (EMG) test results are required for evaluations of peripheral disabilities unless there is a previous EMG test of record or the record contains sufficient clinical evidence to determine the extent of paralysis in the peripheral nerve. As noted in the Peripheral Nerves DBQ, EMG studies are usually rarely required to diagnose specific peripheral nerve conditions in the appropriate
Note: SMC coding is 01-01-00-00-1. d. Presumptive Service Connection for MS Presumptive SC may be established for MS if the disease becomes manifest within seven years from the date of separation. Reference: For more information on requirements for establishment of presumptive SC, see and . 6. ALS Introduction This topic contains information about ALS, including definition of ALS establishing presumptive service connection for ALS assigning a 100-percent minimum evaluation for ALS evaluation guidelines for ALS, and ALS and ancillary benefits Change Date August 6, 2015 a. Definition of ALS Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease, is a neuromuscular disease that causes degeneration of nerve cells in the brain and spinal cord, resulting in muscle weakness, muscle atrophy, and spontaneous muscle activity. b. Establishing Presumptive SC for ALS Effective September 23, 2008, established a presumption of SC for ALS for any Veteran who had active, continuous service of 90 days or more, and develops the disease at any time after discharge from active service. Note: Primary lateral sclerosis (PLS) is not considered to be a qualifying disease under . Because PLS and ALS are diseases of the nervous system and both affect motor neurons, treating physicians may not be able to identify whether the Veteran has PLS or ALS in the initial stages. If the diagnosis is uncertain after reviewing the medical evidence, request a medical opinion with examiner review of all pertinent evidence in the claims folder.