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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press. doi: 10.17226/25317.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Committee on the Review of the Department of Veterans Affairs Examinations for Traumatic Brain Injury Board on Health Care Services Health and Medicine Division A Consensus Study Report of

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Department of Veterans Affairs (Contract No. 36C10X18C0019). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-48686-6 International Standard Book Number-10: 0-309-48686-6 Digital Object Identifier: https://doi.org/10.17226/25317 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the disability determination process for traumatic brain injury in veterans. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25317.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private nongovernment institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public-policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on studies’ statements of task by committees of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committees and the committees’ deliberations. Each report has been subjected to a rigorous and independent peer-review process and represents the position of the National Academies on its statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at workshops, symposia, or other events convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

COMMITTEE ON THE REVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS EXAMINATIONS FOR TRAUMATIC BRAIN INJURY DAN G. BLAZER (Chair), J.P. Gibbons Professor of Psychiatry Emeritus, Duke University Medical Center JEFF BAZARIAN, Professor of Emergency Medicine, University of Rochester JENNIFER BOGNER, Professor of Physical Medicine and Rehabilitation, The Ohio State University JOHN D. CORRIGAN, Emeritus Professor of Physical Medicine and Rehabilitation, The Ohio State University CHARLES C. ENGEL, Senior Scientist, RAND Corporation MATTHEW E. FINK, Louis and Gertrude Feil Professor of Clinical Neurology, Chairman, Neurology, Associate Dean for Clinical Affairs, Weill Cornell Medical College ANNETTE L. FITZPATRICK, Research Professor and Epidemiologist, University of Washington Schools of Medicine and Public Health JESSICA M. GILL, Deputy Scientific Director, Division of Intramural Research, National Institute of Nursing Research, National Institutes of Health JUDITH GREEN-MCKENZIE, Professor and Division Chief, Division of Occupational Medicine, University of Pennsylvania Perelman School of Medicine JEANNE M. HOFFMAN, Professor of Rehabilitation Medicine, University of Washington School of Medicine HEATHER KRULL, Senior Economist, RAND Corporation ROGER J. LEWIS, Professor and Chair of Emergency Medicine, Harbor–University of California, Los Angeles, Medical Center GEOFFREY T. MANLEY, Professor and Vice Chairman of Neurological Surgery, University of California, San Francisco GEORGE W. RUTHERFORD, Salvatore Pablo Lucia Professor, Chief of the Division of Infectious Disease Epidemiology, University of California, San Francisco JENNIFER M. ZUMSTEG, Assistant Professor of Rehabilitation Medicine, University of Washington School of Medicine Study Staff CAROLYN FULCO, Scholar BERNICE CHU, Program Officer BLAKE REICHMUTH, Research Associate JOSEPH GOODMAN, Senior Program Assistant REBECCA MORGAN, Senior Research Librarian SHARYL J. NASS, Director, Board on Health Care Services v

Reviewers This Consensus Study Report was reviewed in draft form by persons chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets institutional standards of quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain privileged to protect the integrity of the deliberative process. We thank the following for their review of this report: GERARD E. FRANCISCO, University of Texas Health Science Center PHIL HARVEY, University of Miami Miller School of Medicine ANTHONY KONTOS, University of Pittsburgh JANICE KRUPNICK, Georgetown University RICHARD MAYEUX, Columbia University SAMUEL POTOLICCHIO, George Washington University Medical Center MARY JO PUGH, The University of Utah LAWRENCE STEINMAN, Stanford University School of Medicine AMY WAGNER, University of Pittsburgh School of Medicine Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of the report was overseen by KENNETH W. KIZER, University of California, Davis, and NANCY ADLER, University of California, San Francisco. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. vii

Contents ACRONYMS AND ABBREVIATIONS xi SUMMARY 1 1 INTRODUCTION 9 Traumatic Brain Injury, 9 TBI in the U.S. Population, 9 TBI in the Military, 11 Overview of the Organization of the Department of Veterans Affairs, 12 Brief History of the Department of Veterans Affairs Compensation System, 12 Disability Compensation and the Disability Claims Process, 15 Compensation and Pension Examination, 17 VA’s Schedule for Rating Disabilities: The VASRD, 17 Statement of Task, 17 Approach to the Task, 18 Organization of the Report, 19 References, 19 2 DIAGNOSIS AND ASSESSMENT OF TRAUMATIC BRAIN INJURY 23 Traumatic Brain Injury, 23 Assessment of TBI Severity, 26 Emerging Evidence on Natural History of Mild TBI, 33 Establishing a TBI Diagnosis, 34 Co-occurring TBI, PTSD, Depression, Pain, and Sleep Disturbance, 45 Summary and Recommendation, 46 References, 48 3 DISABILITY DETERMINATION PROCESS FOR VETERANS WITH TRAUMATIC BRAIN INJURY 57 Disability and Disability Compensation, 57 Department of Veterans Affairs Disability Determination Process for Residuals of Traumatic Brain Injury, 58 The Rating Process, 60 The Appeals Process, 61 The Disability Benefits Questionnaire and a Schedule for Rating Disabilities for Residuals of TBI, 62 Credentials and Training Required in Evaluating Residuals of TBI for VA Disability Compensation, 68 Quality Assurance in the Adjudication of Disability Compensation Claims for Residuals of TBI, 72 Summary and Recommendations, 77 References, 79 4 CHARACTERISTICS OF A HIGH-QUALITY PROCESS FOR DETERMINING DISABILITY RESULTING FROM TRAUMATIC BRAIN INJURY 83 ix

x CONTENTS Definitions of Quality Domains, 83 Approaches for Ensuring Quality, 87 Summary and Recommendations, 93 References, 95 5 SUMMARY AND RECOMMENDATIONS 97 Diagnosing TBI, 98 The Adjudication Process, 99 Adequacy of the Adjudication Process, 101 A LEGISLATION DIRECTING THE STUDY 105 B DEFINITIONS OF TRAUMATIC BRAIN INJURY 107 C TIMELINE OF DISABILITY AND VETERANS COMPENSATION POLICY 115 D DISABILITY BENEFITS QUESTIONNAIRES INITIAL EVALUATION OF RESIDUALS OF TRAUMATIC BRAIN INJURY (I-TBI) DISABILITY 119 E § 4.124A SCHEDULE OF RATINGS—NEUROLOGICAL CONDITIONS AND CONVULSIVE DISORDERS. 127 F CASE DEFINITIONS OF TRAUMATIC BRAIN INJURY 133 G MACE 2: MILITARY ACUTE CONCUSSION EVALUATION 137 H FACT SHEET: CODING GUIDANCE FOR TRAUMATIC BRAIN INJURY 145 I M21-1 COMPENSATION AND PENSION MANUAL 151 J REVIEW POSTTRAUMATIC STRESS DISORDER (PTSD) DISABILITY BENEFITS QUESTIONNAIRE 155 K INFORMATION AND INSTRUCTIONS FOR COMPLETING NOTICE OF DISAGREEMENT (NOD) 163 L APPEAL TO BOARD OF VETERANSʼ APPEALS 169 M NECK (CERVICAL SPINE) CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE 175 N SUMMARY TABLE OF U.S. GOVERNMENT ACCOUNTABILITY OFFICE REPORTS RELEVANT TO ADJUDICATION OF VETERANS’ DISABILITY CLAIMS 187

Acronyms and Abbreviations A&A aid and attendance ACGME Accreditation Council for Graduate Medical Education ADD attention deficit disorder ADHD attention deficit hyperactivity disorder APA American Psychiatric Association ApoE apolipoprotein E BBB blood–brain barrier BBBD blood–brain barrier dysfunction bTBI blast-induced traumatic brain injury BTBIS Brief Traumatic Brain Injury Screen BVA Board of Veterans Appeals C&P compensation and pension CARE Concussion Assessment, Research and Education (Consortium) CDC Centers for Disease Control and Prevention CENC Chronic Effects of Neurotrauma Consortium CPG Clinical Practice Guide CT computed tomography DBQ Disability Benefits Questionnaire DEMO Disability Examination Management Office DMA [Office of] Disability and Medical Assessment DoD Department of Defense DRO decision review officer DSM Diagnostic and Statistical Manual of Mental Disorders DTI diffusion tensor imaging DVBIC Defense and Veterans Brain Injury Center ED emergency department FDA Food and Drug Administration FTE full-time equivalent FY fiscal year GAO Government Accountability Office GCS Glasgow Coma Scale GPS global positioning system ICD International Statistical Classification of Diseases and Related Health Problems IOM Institute of Medicine xi

xii ACRONYMS AND ABBREVIATIONS IPR in-process review IT information technology MACE Military Acute Concussion Evaluation MRI magnetic resonance imaging mTBI mild traumatic brain injury NCCT noncontrast computed tomography NIRS near-infrared spectroscopy PET positron emission tomography PTSD posttraumatic stress disorder QR quality review QRT quality review team RVSR rating veterans service representative SNP single nucleotide polymorphism SSA Social Security Administration STAR Systematic Technical Accuracy Review TBI traumatic brain injury TRACK-TBI Transforming Research and Clinical Knowledge in Traumatic Brain Injury VA Department of Veterans Affairs VASRD Veteran Affairs schedule for rating disabilities VBA Veterans Benefits Administration VHA Veterans Health Administration VSO veterans service organization VSR veterans service representative

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The Veterans Benefits Administration (VBA) provides disability compensation to veterans with a service-connected injury, and to receive disability compensation from the Department of Veterans Affairs (VA), a veteran must submit a claim or have a claim submitted on his or her behalf. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans reviews the process by which the VA assesses impairments resulting from traumatic brain injury for purposes of awarding disability compensation. This report also provides recommendations for legislative or administrative action for improving the adjudication of veterans’ claims seeking entitlement to compensation for all impairments arising from a traumatic brain injury.

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