d. TBI Residuals The resultant disabling effects of a TBI event beyond those that follow immediately from the acute injury to the brain are known as TBI residuals or TBI sequelae. The signs and symptoms of TBI residuals can be organized into the three main categories of physical, cognitive, and behavioral/emotional residuals for evaluation purposes. Examples of TBI residuals in each of the three categories may include, but are not limited to, those listed below. Physical Cognitive Behavioral/Emotional Apraxia (inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness) Dementias (pre-senile Alzheimer’s type, dementia pugilistica, post traumatic dementia) Depression Aphasia (difficulty communicating orally and/or in writing) Attention and concentration deficits Agitation and irritability Paresis (muscle weakness or incomplete paralysis) Memory, processing, and learning impairment Impulsivity Plegia (paralysis or stroke) Language deficiencies Aggression Dysphagia (difficulty swallowing) Planning difficulties Anxiety Disorders of balance and coordination Judgment and control difficulties Posttraumatic stress disorder Diseases of hormone deficiency Reasoning and abstract thinking limitations Parkinsonism Self-awareness limitations Nausea/vomiting Headaches Dizziness Blurred vision Seizure disorder Sensory loss Weakness Sleep disturbance Note: TBI residuals can resolve in a short period of time or can persist chronically or even permanently. Chronic TBI residuals may include some or all of the clinical signs that developed immediately during the TBI event. Others (such as seizures or spasticity) may have a delayed onset. e. Determining the Issues in TBI A claim for SC for TBI may also be worded as a claim for “head injury,” or “concussion.” A claim document mentioning any of the above must be sympathetically read and understood as a claim for all identifiable TBI residuals that can be attributed to one or more TBI events.
A Veteran has severe incomplete paralysis of the common peroneal nerve under and moderate incomplete paralysis of the tibial nerve under . In this case, a single 30-percent evaluation is assigned under . Analysis: Both of these nerves are part of the same sciatic branch, and therefore the functions associated with these nerves are not separate and distinct. The 30-percent evaluation shall be assigned under DC 8521 since it represents the predominant disability. Note: The amputation rule under is not applied in evaluating peripheral nerves of the lower extremity as long as separate evaluations are warranted, as described above. References: For more information separate evaluations and pyramiding, see M21-1, Part III, Subpart iv, 6.C.5.d, and nerve branches of the lower extremities, see M21-1, Part III, Subpart iv, 4.G.4.c e. Determining Individual Nerves Affected in the Upper and Lower Extremities When Evaluating Disabilities When evaluating peripheral nerve disabilities of the upper or lower extremities, the rating activity must conduct a thorough review of the medical evidence of record to determine the individual nerve(s) affected. VA examiners are required, to the extent possible, to select the individual nerves affected when completing DBQs. However, the examiner may not necessarily conduct a review of all previous clinical records or perform comprehensive tests to pinpoint the exact nerve and/or symptoms attributable to that nerve. Important: It is the responsibility of the rating activity, in accordance with , to interpret the DBQ along with the whole recorded history, and accurately identify and assess the current level of peripheral nerve disability. This includes identifying the appropriate nerve from a review of the evidence so that the appropriate evaluation can be assigned. Include the following language in all Peripheral Nerves DBQ requests: Examiner: Please identify the specific 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… And… Then… indicates the specific nerve affected there is no conflicting information evaluate the specific nerve under the appropriate DC. indicates the specific affected there is conflicting information on what nerve is affected, but evaluate the nerve that is most beneficial to the
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. c. Assigning a 100 Percent Minimum Evaluation for ALS ALS is evaluated under . Effective January 19, 2012, the diagnostic criteria for ALS was amended in to provide a 100-percent evaluation for any Veteran with SC ALS. A diagnosis of ALS alone is sufficient to support an evaluation of 100 percent. A total disability evaluation is the minimum evaluation to be assigned for ALS because of the possibility of SMC and automatic entitlement to ancillary benefits. Note: This rule will be applied to all cases pending before VA on or after, January 19, 2012, and does constitute a liberalizing VA regulation under and for determination of effective dates and retroactive benefits. d. Evaluation Guidelines for ALS Determine the proper evaluation for all complications of ALS prior to coding a single 100-percent evaluation under . Refer to the table below for guidance.