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Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans (2019)

Chapter: Appendix B: Definitions of Traumatic Brain Injury

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Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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 107
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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 108
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 109
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 110
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 111
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 112
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 113
Suggested Citation:"Appendix B: Definitions of Traumatic Brain Injury." 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.
×
Page 114

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B Definitions of Traumatic Brain Injury TABLE B-1 Case Definitions of Traumatic Brain Injury Organization Definition Reference/Year National Institute Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma NIH, 2018 of Neurological causes damage to the brain. TBI can result when the head suddenly and violently hits an object or Disorders and when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, Stroke moderate, or severe, depending on the extent of the damage to the brain. A person with a mild TBI may remain conscious or may experience a loss of consciousness for a few seconds or minutes. Other symptoms of mild TBI include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with memory, concentration, attention, or 107 thinking. A person with a moderate or severe TBI may show these same symptoms, but may also have a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, an inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation. Centers for CDC defines a traumatic brain injury as a disruption in the normal function of the brain that can CDC, 2017 Disease Control be caused by a bump, blow, or jolt to the head, or penetrating head injury. and Prevention Concussion in Sport-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. McCrory et al., Sport Group Several common features that may be utilized in clinically defining the nature of a concussive 2017 (Berlin) head injury include • SRC may be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head.

Organization Definition Reference/Year • SRC typically results in the rapid onset of short-lived impairment of neurological function 108 that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours. • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. • The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.), or other comorbidities (e.g., psychological factors or coexisting medical conditions). Department of Traumatic brain injury (TBI) can occur from direct contact to the head or when the brain is shaken VA, 2017 Veterans Affairs within the skull, such as from a blast or whiplash during a car accident. The person may also have a loss of memory for the time immediately before or after the event that caused the injury. Not all injuries to the head result in a TBI, however. The severity of the TBI is determined at the time of the injury and is based on the length of the loss of consciousness, the length of either memory loss or disorientation, and how responsive the individual was after the injury. International The Department of Veterans Affairs (VA) provides instructions for coding traumatic brain injury VA, 2015 Classification of (TBI) using ICD-10. ICD-10 codes based on loss of consciousness (LOC) time after the injury. In Diseases, Tenth order to ensure the most accurate and appropriate level of coding, documentation for initial Revision, Clinical encounters must clearly state if there was an LOC due to the injury and the duration of the LOC. If Modification documentation does not clearly define the LOC then unspecified state of consciousness must be coded. Follow-up care should be coded for sequelae of TBI using the symptom code(s) best representing the patientʼs chief symptoms. American Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain AAN, 2013 Academy of function, typically affecting memory and orientation, which may involve loss of consciousness Neurology (LOC). Symptoms are discussed as risk factors for severe or prolonged early impairments include headache, fatigue/fogginess, and dizziness. Signs include headache, fatigue/fogginess, early amnesia, alteration in mental status, and disorientation. A multidisciplinary approach to assessment and management is advocated in diagnosing concussion. Computerized tomography (CT) imaging should not be used to diagnose sports-related concussion, but might be obtained to

Organization Definition Reference/Year rule out more serious traumatic brain injury (TBI) such as an intracranial hemorrhage in athletes with a suspected concussion who have LOC, post-traumatic amnesia, persistently altered mental status (Glasgow Coma Scale score 15), focal neurologic deficit, evidence of skull fracture on examination, or signs of clinical deterioration. Diagnostic and Traumatic brain injury (TBI) is defined as brain trauma with specific characteristics that include at APA, 2013 Statistical Manual least one of the following: loss of consciousness, posttraumatic amnesia, disorientation and of Mental confusion, or, in more severe cases, neurological signs (e.g., positive neuroimaging, a new onset Disorders of seizures or a marked worsening of a pre-existing seizure disorder, visual field cuts, anosmia, (DSM-5) hemiparesis). To be attributable to TBI, a neurocognitive disorder must present either immediately after the injury or immediately after the individual recovers consciousness after the injury and persist past the acute post-injury period. The cognitive presentation is variable. Difficulties in the domains of complex attention, executive ability, learning, and memory are common as well as slowing in speed of information processing and disturbances in social cognition. In more severe TBI in which there is brain contusion, intracranial hemorrhage, or penetrating injury, there may be additional neurocognitive deficits, such as aphasia, neglect, and constructional dyspraxia. Severity rating criteria include loss of consciousness, posttraumatic amnesia, and disorientation and confusion at initial assessment (Glasgow Coma Scale Score). Military Acute The Military Acute Concussion Evaluation, or MACE, is a standardized mental status exam that is DVBIC, 2012 Concussion used to evaluate mild TBI, or concussion, in a combat or other deployed setting. This screening Evaluation tool was developed to evaluate a person with a suspected concussion, and is used to identify symptoms of mild TBI. The MACE form consists of four sections: 1. Concussion screening—includes a description of the injury event and screening questions about loss of consciousness (LOC), alteration of consciousness (AOC), and posttraumatic amnesia (PTA). If any of the screening questions are answered “yes,” the evaluator continues with the other portions of MACE. 2. Cognitive exam—assigns scores for orientation, immediate memory, concentration, and delayed recall. The scores are totaled out of 30 possible points and reported at the end of the MACE form. 3. Neurological exam—tests for normal or abnormal pupil response to light, speech fluency and word finding, grip strength and pronator drift (an indicator of muscle weakness and compensation), and balance. Normal results are reported as “Green” and abnormal results are reported as “Red” at the end of the MACE form. 109

Organization Definition Reference/Year 4. Symptom screening—screens for symptoms including headache, dizziness, memory 110 problems, balance problems, nausea/vomiting, difficulty concentrating, irritability, visual disturbances, and ringing in the ears. It also asks about concussion history in the past 12 months. Having no symptoms is reported as “A” and having one or more symptoms is reported as “B” at the end of the MACE form. MACE results are reported using the score from the cognitive exam, the color from the neurological exam, and the letter from the symptom screening. For example, a result of 24/Red/B would mean a cognitive score of 24 out of 30, an abnormal neurological response, and the presence of one or more symptoms. Future MACE scores can be used to determine whether the patient’s cognitive function has improved or worsened over time. Brain Injury TBI is defined as an alteration in brain function or other evidence of brain pathology caused by an BIAA, 2011 Association of external force. America (BIAA) The Brief The Brief Traumatic Brain Injury Screen screens for traumatic brain injury (TBI) using the DVBIC, 2007 Traumatic Brain following three questions: Injury Screen 1. Did you have any injury(ies) during your deployment from any of the following? (check all that apply) • Fragment • Bullet • Vehicular • Fall • Blast • Other (specify) 2. Did any injury received while you were deployed result in any of the following? (check all that apply) • Being dazed, confused, or “seeing stars” • Not remembering the injury • Losing consciousness (knocked out) for less than a minute • Losing consciousness for 1–20 minutes • Losing consciousness for longer than 20 minutes • Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) • Head injury

Organization Definition Reference/Year • None of the above 3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? (check all that apply) • Headaches • Dizziness • Memory problems • Balance problems • Ringing in the ears • Irritability • Sleep problems • Other (specify) Mayo According to the Mayo System there are three main classifications: Definite Moderate-Severe Malec, 2007 Classification TBI, Probable Mild TBI (mTBI), and Possible TBI. A classification of a Definite Moderate- System Severe TBI would be made if one of the following was present: death due to this TBI, loss of consciousness of 30 minutes or more, posttraumatic amnesia (PTA) of 24 hours or more, worst Glasgow Coma Scale score in the first 24 hours <13 (unless invalidated by factors such as intoxication, sedation, systemic shock). In addition if there was evidence of hematoma, contusion, penetrating TBI, hemorrhage, or brain stem injury, the TBI would be classified as Definite Moderate-Severe TBI. A classification of Probable mTBI is made if one or more of the following criteria apply: loss of consciousness is momentary to 30 minutes and PTA does not extend beyond 24 hours. If the individual sustains a depressed, basilar, or linear skull fracture (dura intact), then the TBI is still a probable mTBI. A classification of Possible TBI is made if one or more of the following symptoms are present: blurred vision, confusion, dazed, dizziness, focal neurological symptoms, headache or nausea. World Health Mild traumatic brain injury (mTBI) is an acute brain injury resulting from mechanical energy to Holm, 2005 Organization the head from external physical forces. Operational criteria for clinical identification include (i) Collaborating one or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or Center Task Force less, posttraumatic amnesia for less than 24 hours, and/or other transient neurological on Mild Traumatic abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; (ii) Brain Injury Glasgow Coma Scale score of 13–15 after 30 minutes post-injury or later upon presentation for health care. These manifestations of mTBI must not be due to drugs, alcohol, or medications; caused by other injuries or treatment for other injuries (e.g., systemic injuries, facial injuries, or 111

Organization Definition Reference/Year intubation); caused by other problems (e.g. psychological trauma, language barrier, or coexisting 112 medical conditions); or caused by penetrating cranio-cerebral injury American A patient with mild traumatic brain injury is a person who has had a traumatically induced Kay et al., 1993 Congress of physiological disruption of brain function, as manifested by at least one of the following: Rehabilitation 1. any period of loss of consciousness; Medicine 2. any loss of memory for events immediately before or after the accident; (ACRM) 3. any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and 4. focal neurological deficits that may or may not be transient; but where the severity of the injury does not exceed the following: loss of conscientiousness for approximately 30 minutes or less; after 30 minutes an initial Glasgow Coma Scale (GCS) of 13–15; posttraumatic amnesia not greater than 24 hours.

APPENDIX B 113 REFERENCES American Academy of Neurology. 2013. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. https://www.aan.com/Guidelines/home/GuidelineDetail/582 (accessed August 12, 2018). APA (American Psychiatric Association). 2013. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Arlington, VA: American Psychiatric Association. BIAA (Brain Injury Association of America). 2011. BIAA adopts new TBI definition. https://www.biausa.org/public-affairs/public-awareness/news/biaa-adopts-new-tbi-definition (accessed August 12, 2018). CDC (Centers for Disease Control and Prevention). 2017. Traumatic brain injury & concussion. https://www.cdc.gov/traumaticbraininjury/index.html (accessed August 12, 2018). DVBIC (Defense and Veterans Brain Injury Center). 2007. Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: Initial investigation of the usefulness of a short screening tool for traumatic brain injury. https://dvbic.dcoe.mil/research/screening-traumatic-brain- injury-troops-returning-deployment-afghanistan-and-iraq-initial (accessed August 24, 2018). DVBIC. 2012. Military acute concussion evaluation form. https://health.mil/Reference- Center/Forms/2015/04/30/MACE-2012 (accessed August 28, 2018). Holm, L., J. D. Cassidy, L. J. Carroll, and J. Borg. 2005. Summary of the WHO collaborating centre for neurotrauma task force on mild traumatic brain injury. Journal of Rehabilitation Medicine 37(3):137– 141. Kay, T., D. E. Harrington, R. Adams, T. Anderson, S. Berrol, K. Cicerone, C. Dahlberg, D. Gerber, R. Goka, P. Harley, J. Hilt, L. Horn, D. Lehmkuhl, and J. Malec. 1993. Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation 8(3):86–87. Malec, J. F., A. W. Brown, C. L. Leibson, J. T. Flaada, J. N. Mandrekar, N. N. Diehl, and P. K. Perkins. 2007. The Mayo classification system for traumatic brain injury severity. Journal of Neurotrauma 24(9):1417–1424. McCrory, P., W. Meeuwisse, J. Dvorak, M. Aubry, J. Bailes, S. Broglio, R. C. Cantu, D. Cassidy, R. J. Echemendia, R. J. Castellani, G. A. Davis, R. Ellenbogen, C. Emery, L. Engebretsen, N. Feddermann-Demont, C. C. Giza, K. M. Guskiewicz, S. Herring, G. L. Iverson, K. M. Johnston, J. Kissick, J. Kutcher, J. J. Leddy, D. Maddocks, M. Makdissi, G. T. Manley, M. McCrea, W. P. Meehan, S. Nagahiro, J. Patricios, M. Putukian, K. J. Schneider, A. Sills, C. H. Tator, M. Turner, and P. E. Vos. 2017. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 51(11):838–847. NIH (National Institutes of Health). 2018. Traumatic brain injury information. https://www.ncbi.nlm.nih.gov/pubmed (accessed August 12, 2018). VA (Department of Veterans Affairs). 2015. Fact sheet: Coding guidance for traumatic brain injury (TBI). http://www.rstce.pitt.edu/va_tbi/documents/11192015/11192015_03.pdf (accessed August 11, 2018). VA. 2017. VA research on traumatic brain injury. https://www.research.va.gov/topics/tbi.cfm (accessed August 12, 2018).

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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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