TBI Residuals C&P Exam Prep

Cognitive Screening (Facet-Based Assessment)

What it measures: Memory, attention, concentration, and executive function impairment. The examiner may administer brief tests such as the Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), or review prior neuropsychological testing. The DBQ uses a 0-to-Total scale: 0 = no complaints, 1 = subjective complaints without objective findings, 2 = mild objective impairment with mild functional impact, 3 = moderate objective impairment with moderate functional impact, Total = severe objective impairment with severe functional impact.

What to expect: The examiner will ask about memory problems, word-finding difficulty, ability to follow conversations, concentration during tasks, and your ability to plan or organize activities. They may ask you to recall a short list of words, do simple arithmetic, or draw a clock. Reference any formal neuropsychological testing you have had.

Pain considerations: Cognitive fatigue is a legitimate TBI residual - describe how sustained mental effort causes increased symptoms, headaches, or need to rest.

Behavioral and Emotional Facet Assessment

What it measures: Irritability, depression, anxiety, impaired judgment, and social interaction deficits as direct TBI residuals. The DBQ uses the same 0-to-Total scale. Critically, the examiner must distinguish whether these symptoms are attributable to TBI residuals, a separate psychiatric condition, or a combination - as separate evaluations may be warranted.

What to expect: The examiner will ask about mood changes since the TBI, anger or irritability that is out of character, social withdrawal, judgment errors (financial, safety, relationship), and anxiety. They may use brief depression or anxiety screening tools.

Pain considerations: Emotional lability (unpredictable emotional reactions) and disinhibition are distinct TBI residuals - describe episodes accurately including their frequency and impact on family and work relationships.

Neurological Physical Examination - Motor Function

What it measures: Muscle strength (graded 0/5 to 5/5), tone, coordination, reflexes, and presence of atrophy in upper and lower extremities bilaterally. The DBQ captures biceps, triceps, brachioradialis, wrist flexion/extension, grip, pinch, knee extension, and ankle dorsiflexion/plantar flexion reflexes and strength for both sides.

What to expect: The examiner will test your grip strength, finger opposition, arm and leg push/pull resistance, and deep tendon reflexes. They will observe for tremor, spasticity, atrophy, or incoordination. Gait will be observed - note if you use an assistive device.

Pain considerations: TBI-related motor deficits may worsen with physical or cognitive exertion - describe how your strength or coordination changes later in the day or after activity.

Headache Assessment

What it measures: Frequency, duration, severity, and functional impact of post-traumatic headaches. Headaches are one of the most common TBI residuals and may be separately rated under DC 8100 (migraine) in addition to the TBI facet evaluation.

What to expect: The examiner will ask about headache frequency (how many per month), duration, severity on a 0-10 scale, associated symptoms (nausea, light/sound sensitivity, visual disturbances), and impact on work and daily activity.

Pain considerations: Describe your worst headache days in full detail. Note how long recovery takes after a severe episode and whether you lose work time or miss obligations.

Sleep Disturbance Assessment

What it measures: Insomnia, hypersomnia, daytime sleep attacks, and sleep apnea as TBI residuals. The DBQ captures insomnia, hypersomnolence, sleep apnea (including device use and severity), and their functional impact.

What to expect: The examiner will ask about your sleep patterns, use of CPAP or BiPAP, daytime fatigue, and whether sleep disturbance affects your daily function. They may ask about sleep study results.

Pain considerations: Sleep deprivation significantly worsens cognitive and emotional TBI symptoms - describe the cumulative daily functional impact, not just the nighttime disruption.

Gait and Balance Assessment

What it measures: Presence and severity of abnormal gait, ataxia, vertigo, and balance deficits as TBI neurological residuals. The examiner will observe your walk, may test tandem gait, and will note any assistive device use.

What to expect: You will be observed walking, potentially in tandem (heel-to-toe), and the examiner may perform Romberg testing. They will note whether you use a cane, walker, or other device and how frequently.

Pain considerations: If your balance worsens with fatigue or cognitive load (e.g., walking while talking), describe this dual-task impairment explicitly.

0%

A TBI diagnosis is established with service connection, but no current ratable residuals are identified. All facets of the TBI evaluation table are rated at Level 0. The 0% rating preserves the service connection and the door open for future increases if residuals develop or worsen.

From 38 CFR: Grant SC for TBI under 38 CFR 4.124a, DC 8045, 0 percent when the examiner marks all facets as normal and post-service records show no disabling signs or symptoms. A 0% rating still establishes SC for future claims.

10%

One or more facets rated at Level 1: subjective complaints of mild cognitive, behavioral, or physical impairment without objective evidence on testing. Functional impact is minimal. This is the entry-level compensable rating for documented TBI residual symptoms.

From 38 CFR: A complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing.

40%

One or more facets rated at Level 2: objective evidence on testing of mild impairment in memory, attention, concentration, or executive functions resulting in mild functional impairment; OR comparable mild objective impairment in behavioral, emotional, or physical facets. The highest single facet level drives the overall rating.

From 38 CFR: Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. (Level 2 on the TBI facet scale.)

70%

One or more facets rated at Level 3: objective evidence on testing of moderate impairment in memory, attention, concentration, or executive functions resulting in moderate functional impairment; OR comparable moderate impairment in behavioral, emotional, or physical facets. Significant impact on occupational and social functioning expected.

From 38 CFR: Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. (Level 3 on the TBI facet scale.)

100%

One or more facets rated at the Total level: objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment; OR the veteran requires continuous observation and direction due to cognitive impairment; OR vegetative state or other severe neurological manifestation. This rating also triggers evaluation for Special Monthly Compensation (SMC) for aid and attendance, housebound status, or loss of use of an extremity.

From 38 CFR: Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. (Total level on the TBI facet scale.) Also consider SMC for aid and attendance and protection from hazards of the daily living environment due to cognitive impairment.

Memory and Cognitive Deficits

How to describe it: Be specific, concrete, and anchored to daily life failures. Avoid vague generalities. Describe the type of memory problem (working memory, short-term, prospective), the frequency of failures, the consequences, and any compensatory strategies you have adopted (e.g., using phone reminders because you cannot remember appointments without them).

Example: On a bad day, I cannot follow a conversation with my spouse without losing track of what we were talking about mid-sentence. I will walk into a room and have no idea why. I miss appointments even when I wrote them down. I cannot read more than a paragraph before I have to start over. My wife handles all our finances now because I made several errors that cost us money. I forget whether I took my medications even minutes after taking them.

Examiner listens for: Specific behavioral examples of memory failure, evidence that the problem causes real functional consequences, use of compensatory strategies suggesting awareness of deficit, impact on employment and independent living, and any neuropsychological test results in the file that corroborate the self-report.

Avoid: Saying 'my memory is a little off' or 'I forget things sometimes' - everyone forgets things sometimes. The examiner needs to understand that your forgetting is frequent, disruptive, and qualitatively different from normal age-related forgetting.

Headaches

How to describe it: Report frequency in episodes per month, typical duration of each episode, peak severity (0-10), and the functional impact - specifically whether they force you to stop activity and lie down (prostrating). Describe associated symptoms such as light and sound sensitivity, nausea, visual aura, and how long recovery takes after a severe episode.

Example: My worst headaches come on suddenly, usually triggered by noise, bright light, or stress. The pain reaches an 8 or 9 out of 10. I have to go into a dark, quiet room and lie completely still for 3 to 4 hours. I cannot work, drive, or care for my children during an episode. This happens at least 6 times per month. The day after a severe headache I am still foggy and fatigued.

Examiner listens for: The word 'prostrating,' frequency per month, duration, functional incapacitation during episodes, triggers, and whether the veteran has sought medical treatment or adjusts their schedule around headache risk.

Avoid: Describing headaches only as 'pretty bad' without detailing how they completely stop your activity. If you push through a headache and go to work anyway, you may be underreporting the actual severity. The standard is the level of impairment, not your stoicism.

Behavioral and Emotional Changes

How to describe it: Describe how your personality, temperament, or emotional responses have changed since the TBI event compared to before. Use before-and-after comparisons. Give specific examples of behavioral incidents. Include family or employer observations where relevant. Distinguish between reactive anger (triggered by something specific) and organic irritability (out of proportion, seemingly unprovoked).

Example: Before my injury I was patient and calm. Now I lose my temper over minor things - my children dropping something, a small delay in traffic. I have thrown objects and said things I deeply regret. My wife says I am 'a different person.' I have no filter now - I say things in social situations that I know are inappropriate but I cannot stop myself. I have stopped socializing because I embarrass myself and my family. I have been passed over for promotion twice because my supervisor said I have an attitude problem.

Examiner listens for: Concrete behavioral incidents, corroboration from family or treatment records, evidence that the change is organic to the TBI rather than purely psychological, and functional impact on employment, family stability, and social relationships.

Avoid: Minimizing behavioral changes by saying 'I just have a shorter fuse now.' The examiner needs to understand the severity, frequency, and real-world consequences of these changes.

Physical Neurological Symptoms - Dizziness, Balance, and Coordination

How to describe it: Describe the type of dizziness (room spinning versus lightheadedness versus off-balance feeling), its triggers (head movement, position change, activity, fatigue), frequency, duration, and functional impact. Note any falls, near-falls, or activity restrictions due to balance problems.

Example: When I turn my head quickly, the room spins. I have to grab a wall or sit down. This happens daily. I have fallen twice in the past six months - once on the stairs. I no longer drive on the highway because I get disoriented and dizzy when checking my blind spot. I cannot be on ladders or scaffolding. I need my cane when I am tired because my balance is much worse later in the day.

Examiner listens for: Falls, near-falls, activity restrictions, use of assistive devices, worsening with fatigue or dual-tasking, and whether the veteran has been evaluated for vestibular disorder or cervicogenic dizziness.

Avoid: Saying 'I feel a little dizzy sometimes' without describing the functional limitation. Leaving out fall history is a common omission that affects the documented severity.

Sleep Disturbance

How to describe it: Describe the specific sleep problem (difficulty falling asleep, staying asleep, early awakening, nightmares, non-restorative sleep, excessive daytime sleepiness), its frequency, and its daytime functional consequences including fatigue, cognitive worsening, and impact on daily obligations.

Example: I average 4 to 5 hours of broken sleep per night. I wake up 3 to 4 times, usually from nightmares or pain. Even on nights when I do sleep more, I wake up feeling unrefreshed. By early afternoon I am so fatigued I cannot focus or function. I have fallen asleep at my desk at work twice this month. My cognitive problems are significantly worse on days after poor sleep. On my worst days I cannot leave the house because I am too impaired to drive safely.

Examiner listens for: Objective sleep studies (if available), daytime functional impact, how sleep deprivation compounds cognitive TBI symptoms, CPAP use and compliance, and whether nightmares are PTSD-related versus non-PTSD TBI-related - important for separate rater consideration.

Avoid: Saying 'I do not sleep great' without quantifying the problem or describing its functional consequences. Do not omit the compounding effect of poor sleep on your cognitive TBI symptoms.

Motor Deficits, Weakness, and Coordination

How to describe it: Describe which limbs are affected, what tasks you can no longer do or do with difficulty, and how weakness or coordination problems have changed your daily life. If deficits are asymmetric, specify which side and whether it affects your dominant hand.

Example: My right hand is significantly weaker than before my injury. I drop items without warning - cups, tools, my phone. I cannot open jars or turn a wrench with any force. My handwriting is illegible now. My wife cuts food for me. On days when I am fatigued, my hand barely works and I have dropped hot items causing minor burns. I can no longer do the manual labor my job requires.

Examiner listens for: Specific grip and pinch failure examples, dominant hand involvement, impact on employment and self-care, whether atrophy is visible or measurable, and whether deficits are consistent with an upper motor neuron versus lower motor neuron pattern from the TBI.

Avoid: Demonstrating full strength during the examination when you actually have functional weakness - push to the point of your actual limit, do not stop early to appear compliant.