DC 8520Neurological ConditionsLast verified: APR 22, 2026

Secondary Conditions for Paralysis of

Paralysis of is a service-connected condition that can cause or aggravate 5 additional disabilities under 38 CFR § 3.310. Common secondaries include Charcot Foot / Neuropathic Arthropathy, Falls and Traumatic Injuries (Balance Impairment), Falls-Related Fractures / Orthopedic Injury. Each secondary requires medical nexus evidence linking it to the primary, documented in treatment records or a private nexus letter.

“Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.”
— 38 CFR § 3.310(a), Disabilities that are proximately due to, or aggravated by, service-connected disease or injury
Evidence Strength:STRONGMODERATEEMERGING

Which secondary conditions are most common after Paralysis of?

MODERATE

Medical Rationale

Gabapentin and pregabalin, widely prescribed for service-connected neuropathic pain, produce cognitive impairment through GABAergic and calcium channel modulation in the central nervous system. These medications bind voltage-gated calcium channels (alpha-2-delta subunit), reducing excitatory neurotransmitter release in the hippocampus and prefrontal cortex — regions critical for memory and executive function. Studies demonstrate dose-dependent cognitive impairment: at standard neuropathic pain doses (gabapentin 1800-3600mg/day, pregabalin 300-600mg/day), patients show measurable deficits in verbal memory, processing speed, and attention. The "gabapentin fog" is well-recognized clinically and can impair occupational functioning independently of the underlying pain condition.

Key Studies

Salinsky MC et al. (2005) Epilepsia (gabapentin cognitive effects); Hindmarch I et al. (2005) Psychopharmacology (pregabalin cognitive and psychomotor effects); Zaccara G et al. (2008) Epilepsia (antiepileptic drug cognitive side effects).

Filing Tips

Neuropsychological testing showing cognitive deficits correlating with medication initiation. Prescribing records showing gabapentin/pregabalin prescribed for service-connected pain condition. Neurology or psychiatry nexus letter connecting medication side effects to cognitive impairment. Document impact on work performance — inability to concentrate, memory lapses, word-finding difficulty. VA rates cognitive impairment under DC 9326 or as a medication side effect claim.

MODERATE

Medical Rationale

Peripheral neuropathy produces restless legs syndrome through sensory deafferentation that disrupts normal spinal cord inhibitory circuits. The loss of large-fiber afferent input from damaged peripheral nerves disinhibits spinal interneurons, producing the uncomfortable crawling, tingling, and pulling sensations that characterize RLS. Additionally, small-fiber neuropathy (which preferentially affects the legs) reduces dopaminergic signaling in the A11 hypothalamic-spinal pathway that normally suppresses involuntary leg movements during rest. EMG studies demonstrate that RLS patients with neuropathy have increased periodic limb movements in sleep (PLMS index >15/hour) compared to RLS without neuropathy. Studies show RLS prevalence of 25-40% in peripheral neuropathy patients versus 5-10% in the general population.

Key Studies

Gemignani F et al. (2006) J Neurol Neurosurg Psychiatry (neuropathy and RLS); Polydefkis M et al. (2000) Neurology (small-fiber neuropathy and RLS); Hattan E et al. (2009) J Clin Sleep Med (neuropathy-associated RLS).

Filing Tips

Sleep study documenting elevated PLMS index. Neurology evaluation diagnosing RLS with onset after peripheral neuropathy diagnosis. Document RLS symptoms (evening/nighttime leg discomfort relieved by movement) and sleep disruption. Neurology nexus letter connecting sensory deafferentation from neuropathy to RLS pathophysiology. VA does not have a specific DC for RLS — it is typically rated analogously under DC 8103 (convulsive tic) or as a sleep disorder.

STRONG

Medical Rationale

Peripheral neuropathy ablates protective sensation in the feet, allowing repetitive microtrauma and abnormal loading to produce progressive joint destruction without pain-mediated protection. The neuroarthropathic cascade (Charcot foot) begins with loss of proprioception and pain sensation, followed by repetitive unrecognized injuries to midfoot joints, inflammatory bone resorption, and progressive joint dislocation and collapse. The midfoot is most commonly affected, producing the "rocker-bottom" deformity. Autonomic neuropathy simultaneously increases pedal blood flow (arteriovenous shunting), which promotes bone resorption and weakens the skeletal architecture. The end result is severe foot deformity requiring custom footwear, bracing, or surgical reconstruction.

Key Studies

Rogers LC et al. (2011) Diabetes Care (Charcot neuroarthropathy management); Frykberg RG & Belczyk R (2008) Clin Podiatr Med Surg (Charcot pathophysiology); Jeffcoate WJ et al. (2005) Lancet (Charcot foot in diabetic neuropathy).

Filing Tips

Weight-bearing foot X-rays or MRI showing Charcot changes (fragmentation, subluxation, collapse). Podiatry or orthopedic records documenting neuropathic arthropathy. Document custom footwear, bracing, or surgical intervention. Podiatrist or orthopedic nexus letter connecting loss of protective sensation from peripheral neuropathy to Charcot joint destruction. VA rates foot conditions under DC 5284 — severe foot injury is rated 30%.

STRONG

Medical Rationale

Peripheral neuropathy impairs proprioception and balance through loss of large-fiber sensory input from mechanoreceptors in the feet and ankles. Normal postural control requires intact somatosensory feedback from plantar pressure receptors and ankle joint position sensors — both of which are degraded in peripheral neuropathy. Quantitative balance testing shows neuropathy patients have 3-5x higher postural sway and significantly impaired balance recovery from perturbations. This increases fall risk by 15-25 fold compared to age-matched controls. Falls in neuropathic patients frequently produce fractures (wrist, hip, vertebral compression), traumatic brain injury, and soft tissue injuries that would not occur in individuals with intact protective reflexes.

Key Studies

Richardson JK et al. (1996) J Am Geriatr Soc (peripheral neuropathy and fall risk); Cavanagh PR et al. (1992) J Rehabil Res Dev (balance deficits in neuropathy); DeMott TK et al. (2007) Phys Ther (sensory impairment and fall risk).

Filing Tips

Document fall history with dates and injuries sustained. Emergency room records, orthopedic records, or imaging from fall-related injuries. Physical therapy balance assessment documenting impaired proprioception. Neurology nexus letter connecting peripheral neuropathy sensory loss to balance impairment and fall risk. Each fall-related injury may be rated separately as a secondary condition — fractures, joint injuries, and TBI from falls all qualify.

STRONG

Medical Rationale

Peripheral neuropathy causes falls and resultant fractures through three converging mechanisms. First, sensory neuropathy ablates the cutaneous and proprioceptive afferent signals from the feet that are essential for postural stability — without accurate ground contact and joint position information, balance is profoundly impaired. Second, motor neuropathy weakens intrinsic foot muscles and ankle dorsiflexors (foot drop), causing tripping, stumbling, and inability to catch oneself. Third, autonomic neuropathy causes orthostatic hypotension — the sudden blood pressure drop upon standing that produces pre-syncopal lightheadedness and sudden falls. Studies of diabetic peripheral neuropathy patients document 15–25% annual fall rates (3-fold higher than non-neuropathic controls) and hip fracture rates 2–3-fold above the general population. Each fracture is a direct physical consequence of the underlying neuropathy.

Key Studies

Cavanagh PR et al. (2007) J Rehabil Res Dev (falls in diabetic neuropathy); Maurer MS et al. (2005) Diabetes Care (orthostatic hypotension and falls); Schwartz AV et al. (2002) Diabetes Care (hip fractures and diabetes/neuropathy); Tanaka S et al. (2007) J Bone Miner Metab.

Filing Tips

Neurology records documenting peripheral neuropathy and its severity (sensory loss, proprioception deficit, motor weakness, autonomous dysfunction). Fracture records (emergency department visits, orthopedic surgeon records, X-ray/CT documenting fracture location and treatment). A nexus letter from your neurologist or physiatrist explicitly attributing the fall leading to fracture to neuropathic sensory and motor deficits is the critical evidence. Consider fracture residuals (post-fracture arthritis, hardware complications, malunion) as tertiary conditions. Note: Specific rating depends on fracture site — hip fracture (DC 5054/5255), wrist fracture (DC 5215), vertebral fracture (DC 5285). Consider each fracture site under its most appropriate diagnostic code for maximum rating accuracy.

How do I file a secondary service connection claim?

File VA Form 21-526EZ and list the secondary condition as a new claimed disability, noting it is secondary to Paralysis of. Submit a nexus letter at the time of filing — the VA does not request nexus evidence on your behalf. An effective date of Intent to File (VA Form 21-0966) protects your start date for up to 12 months while you gather medical evidence.

Common Questions About Secondary Service Connection

What is a secondary service-connected condition?

A secondary service-connected condition is a disability that is proximately caused or chronically worsened by an already service-connected condition. The VA rates secondary conditions separately and combines them with the primary rating using the combined ratings table under 38 CFR § 4.25.

What legal standard applies to secondary service connection?

38 CFR § 3.310(a) governs secondary service connection. It states: "Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." Aggravation claims — where the primary condition worsens a pre-existing disability — are covered under § 3.310(b).

Which secondary conditions are most common after Paralysis of?

The 5 secondary conditions documented for Paralysis of vary by evidence strength. The most strongly supported include: Charcot Foot / Neuropathic Arthropathy, Falls and Traumatic Injuries (Balance Impairment), Falls-Related Fractures / Orthopedic Injury. Evidence strength reflects the volume and quality of medical literature linking each secondary to the primary condition.

What evidence proves a secondary condition is caused by the primary?

The most reliable evidence is a private nexus letter from a treating physician or independent medical examiner that: (1) acknowledges the service-connected primary condition, (2) diagnoses the secondary condition, and (3) states to at least a 50% probability ("as likely as not") that the primary caused or aggravated the secondary. Treatment records documenting the progression are supporting evidence, not a substitute.

How does the VA rate secondary conditions?

Secondary conditions are rated under the same 38 CFR Part 4 diagnostic codes as any other condition. The VA then combines the primary and all secondary ratings using the combined ratings formula under § 4.25 — not simple addition. For example, a 50% primary and a 30% secondary combine to 65% (rounded to 70%), not 80%.

How do I file a secondary service connection claim?

File VA Form 21-526EZ and list the secondary condition as a new claimed disability, specifically noting it is secondary to your already service-connected primary condition. Submit a nexus letter and all relevant treatment records at the time of filing. If your primary claim is already decided, you can file for the secondary as a new claim at any time — the effective date will be the date of the new claim.

Can I add secondary conditions to an existing claim after it has been decided?

Yes. Secondary conditions can be added at any time as a new claim. The effective date for the secondary will generally be the date VA receives your new claim (or the date of an Intent to File, if filed within the preceding 12 months). If the secondary was improperly denied in an earlier rating decision, a Supplemental Claim or Higher-Level Review may allow an earlier effective date.

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