General Considerations for Rating

• Evaluations by comparison.

  Disability in this field is ordinarily to be rated in proportion to the impairment of motor, sensory or mental function. Consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating disability from the conditions in the preceding sentence refer to the appropriate schedule. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 CFR §4.120 [Schedule of ratings-neurological conditions and convulsive disorders]

• Additional Autonomic and Visceral Manifestations.

  With regard to etiology and manifestations as well as severity, the field of nervous and mental diseases includes as varied a group as any field in medicine. In regards to relationship to service or disabling effects, these diseases must be viewed not as a class, but individually, bearing in mind the etiology and clinical course of each separate disease. Consider conditions of infectious origin with regard to the circumstances of infection, the incubation period, etc. Diagnoses reflecting traumatic origin require trauma adequate to produce the result. There is a large group of diseases, such as multiple sclerosis, progressive muscular atrophy, and myasthenia gravis, in which increase, over a period of a few months, generally reflects mere natural progress. (M21-1MR, Part III, Subpart iv, Chapter 4, Section H, Topic 27 [Psychiatric Conditions])

• Psychiatric conditions.

  Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 CFR §4.124 (a) [Schedule of ratings-neurological conditions and convulsive disorders]

• Residuals of Traumatic Brain Injury (TBI)

  The designation of TBI as mild, moderate, or severe is made at or close to the time of the initial injury and is a determination of acute injury severity. Once this acute level of severity is determined, it does not change, regardless of the veteran's course of residuals. While this classification has a rough correlation with prognosis, it is not a strict correlation, so that TBI classified as mild, for example, does not necessarily equate to mild disability or mean that residuals will be mild. Classification of the level of severity has no bearing on C&P evaluations.

Regarding the requirements for clinical signs immediately following the traumatic event, note that only one of the five findings under the DoD/VA definition of TBI is needed for the diagnosis. Any one of the five findings listed below is sufficient for the diagnosis. If a patient meets criteria in more than one category of severity, the higher severity level is assigned.

• Any period of loss of or a decrease in level of consciousness

• Any loss of memory for events immediately before or after the injury

• Any alteration in mental state at the time of the injury (such as confusion, disorientation, slowed thinking, etc.)

• Neurological deficits that may or may not be transient (such as weakness, loss of balance, change in vision, praxis, paresis/paralysis, sensory loss, aphasia)

• Intracranial lesion (direct injury to brain tissue)

While discussions of the evaluation of residuals of TBI into mild versus moderate or severe TBI, it is the actual findings in each case that determine what types of conditions will need evaluation and therefore which set of guidelines are most appropriate to follow.

Avoid pyramiding. Evaluate each residual disability separately as long as the same signs and symptoms are not used to support more than one evaluation. Then, combine the evaluations. Symptoms of cognitive impairment and mental disorders such as depression and PTSD often overlap. In such cases, a single evaluation taking into account both conditions may be the most appropriate way to evaluate them.

When there is no diagnosis of a mental disorder, or when there is a diagnosis of a mental disorder but there are behavioral/emotional symptoms that are reported to be residuals of TBI, and not attributed to a mental disorder, evaluate them under "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified". In that case, do not also assign an evaluation based on the same behavioral/emotional symptoms as noted in provisions 38 CFR 4.14.

Do not overlook the additional injuries that may also be present in a veteran with TBI - burns, shrapnel wounds, fractures, amputations, spine injuries, etc. Please request separate examination to determine the residuals of these injuries and base your evaluation on the examiners findings. (Also note the new changes in the rating schedule dealing with scars.)

Problematic Issues

• Fibromyalgia

• Myasthenia Gravis

• Multiple Sclerosis

• Nerve Damage

• Tic Douloureux

• Residuals of Traumatic Brain Injury (TBI)