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Moderate to severe traumatic brain injury S023
Current RMA Instruments
|Reasonable Hypothesis SOP||94 of 2018|
|Balance of Probabilities SOP||95 of 2018|
Changes from previous Instruments
- ICD-9-CM Codes: 850.2-4
- ICD-10-AM Codes: S06.03, S06.04, S06.05
This SOP covers significant brain injury from physical trauma. Mild brain injury from physical trauma is covered by the companion SOP for ‘concussion’. Both SOPs cover the direct effects of injury only.
If the brain injury was associated with an explosive blast, then the SOP for ‘explosive blast injury’ may also apply. A decision will then need to be made as to which SOP is appropriate in the circumstances of the case.
Confirming the diagnosis
The diagnosis is preferably made based on contemporary medical records demonstrating:
- A transfer of kinetic energy to the brain, resulting in damage to the brain, as evidenced by:
- Loss of consciousness for more than 30 minutes;
- Anterograde amnesia for more than 24 hours;
- A Glasgow coma score of less than 13 (out of 15);
- A traumatic intracranial lesion seen on imaging; or
- Penetration of the dura mater (the outer covering of the brain, within the skull).
Military medical records (e.g. contemporary Military Acute Concussion evaluation (MACE or MACE 2), if available, may assist the diagnosis. Other military medical records and records or reports from an emergency department, a general practitioner or a specialist may all be useful for confirming a diagnosis.
In the absence of contemporary records, the reported history and any associated evidence needs to be evaluated and the reasonable satisfaction (balance of probabilities) test applied to decide whether an acute trauma-induced disturbance of brain function has occurred. See comments section below.
There are no specific investigations required for diagnosis. Brain imaging (CT scan or MRI) is likely to have been performed either at the time of injury or subsequently, and can be used to confirm the diagnosis. Neuropsychological testing may also have been undertaken.
Any new investigation that is undertaken should be ordered and interpreted by a specialist and should not be used on a stand-alone basis for diagnostic purposes.
If persistent symptoms are present, further evidence may be required to establish a permanent cognitive injury caused by TBI. A neurologist, neuropsychiatrist or geriatrician are the appropriate specialists.
Although most claims for persistent symptoms will require specialist review, consideration should also be given to whether the claimed symptoms may be better attributable to e.g. a psychiatric condition, a condition that results in persistent pain, chronic insomnia, or the effects of treatment for such conditions.
Other SOPs that should be considered
- Cerebrovascular accident
- Explosive blast injury
- Posttraumatic stress disorder
- Subarachnoid haemorrhage
- Subdural haematoma
- Tension type headache
Conditions excluded from SOP
- Post concussion syndrome (not a disease or injury - as declared by the RMA)
- Acute stress disorder*
- Post traumatic stress disorder*
* another SOP applies
The clinical onset will be at the time of the head injury event (the transfer of kinetic energy to the head).
As the SOP covers only the direct effects of an acute injury, the issue of clinical worsening should not arise. Impairment related to head injuries is generally static following the trauma and does not worsen significantly over time.
Absence of contemporary evidence
Contemporaneous evidence of head injury should generally be available for a diagnosis of ‘moderate to severe traumatic brain injury’. Head trauma that did not warrant medical treatment at the time of injury is unlikely to have been sufficient to cause a moderate to severe brain injury in normal circumstances.
The evidence needs to be sufficient to support a diagnosis at the balance of probabilities standard of proof.
A moderate to severe traumatic brain injury may result in permanent damage and be associated with persistent symptoms. However, such symptoms will generally be present from the time of the initial injury.
The longer the period of time between the head injury and the onset of symptoms, the less likely it is that they are related and the greater the weight of evidence required to establish a causative link. In these scenarios, consideration of the following may assist the delegate:
- Specialist opinion;
- Whether the described level of impairment could have persisted from the time of injury to the assessment/diagnosis date without medical intervention;
- Whether the veteran has continued in their ADF role or other employment since that time and their performance;
- Whether the described impairment is something that should reasonably have been picked up on routine assessment e.g. MECR/PHE etc.
Specialist opinion that is reliant only on the history from the client may not be sufficient to establish causation in the absence of supportive contemporary evidence.
Alternative diagnoses/explanations for reported symptoms attributed to a head injury should be considered.