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Guide to Determining Impairment and Compensation 2016

Authoritative Version
2016 No. MRCC37 Guides & Guidelines as made
This instrument, as outlined in subsection 67(1) of the Act, is to set out the criteria and methodology used to assess the degree of impairment, and thus compensation payable for entitled persons who have suffered a service related injury or disease.
Administered by: Veterans' Affairs
Made 09 Aug 2016
Registered 16 Aug 2016
Tabled HR 30 Aug 2016
Tabled Senate 30 Aug 2016
Table of contents.

GUIDE TO DETERMINING IMPAIRMENT AND COMPENSATION (GARP M)

INTRODUCTION

Purpose

This Guide is to be applied to assess the degree of impairment from service injury or disease. Its provisions are binding on the Military Rehabilitation and Compensation Commission, the Veterans’ Review Board, and the Administrative Appeals Tribunal.

Legal background

The Military Rehabilitation and Compensation Act 2004 provides for periodic payments to be made to members for impairment resulting from service injuries or diseases as defined in section 5 of the Act.

Part 2 of Chapter 4 of the Act provides that periodic payments are payable only if certain thresholds are reached as determined by reference to the extent of the veteran’s incapacity as assessed in accordance with this Guide. Subsection 67(1) of the Act provides that the Guide prepared by the Military Rehabilitation and Compensation Commission sets out:

       (a)   criteria to be used in deciding the degree of impairment of a person resulting from a service injury or disease; and

       (b)   methods by which the degree of that impairment can be expressed in impairment points on a scale from 0 to 100; and

       (c)   criteria to be used in assessing the effect of a service injury or disease on a person’s lifestyle; and

       (d)   methods by which the effect of a service injury or disease on a person’s lifestyle can be expressed as a numerical rating; and

       (e)   methods by which the impairment points of a person, and the effect on a person’s lifestyle, from a service injury or disease can be used to determine the compensation payable to the person under this Part by reference to the maximum compensation that can be payable to a person under this Part.

In addition the Guide, in accordance with subsection 67(2) of the Act

       (a)   specifies different methods under paragraph (1)(e) for:

              (i)    service injuries or diseases that relate to warlike service or non‑warlike service; and

              (ii)   other service injuries or diseases; and

              (b)   specifies a method for determining the compensation payable to a person who has both:

                     (i)    a service injury or disease that relates to warlike service or non‑warlike service; and

                     (ii)   another service injury or disease.

Definitions

In this Guide, unless a contrary intention appears:

accepted condition means an injury or disease that has been determined to be caused by service.

Act means the Military Rehabilitation and Compensation Act 2004 as amended from time to time.

add means find the arithmetic sum of two or more numbers.

clinical features includes signs and symptoms.

combine means produce a result by combining two or more numbers by applying Chart 18.1 (Combined Values Chart) in Chapter 18 in accordance with that Chapter.

Commission means the Military Rehabilitation and Compensation Commission.

condition means an injury or a disease.

defence-caused injury and defence-caused disease have the meaning given in section 70 of the VEA.

disease means:

       (a)   any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development); or

       (b)   the recurrence of such an ailment, disorder, defect or morbid condition;

but does not include:

         (c)   the aggravation of such an ailment, disorder, defect or morbid condition; or

         (d)   a temporary departure from:

(i)       the normal physiological state; or

(ii)     the accepted ranges of physiological or biochemical measures;

that results from normal physiological stress (for example, the effect of exercise on blood pressure) or the temporary effect of extraneous agents (for example, the effect of alcohol on blood cholesterol levels).

GARP V means the Guide to the Assessment of Rates of Veterans’ Pensions, Fifth Edition (GARP V), instrument No.9 of 1997, as amended or remade from time to time.

Guide means this Guide to Determining Impairment and Compensation.

impairment, in relation to a person, means the loss, the loss of the use, or the damage or malfunction, of any part of the person’s body, of any bodily system or function, or of any part of such a system or function.

impairment rating means a measure of the degree of medical impairment on a scale of 0 to 100.

injury means any physical or mental injury (including the recurrence of a physical or mental injury) but does not include:

            (a)   a disease; or

            (b)   the aggravation of a physical or mental injury.

lifestyle points means the number of points determined using the tables in Chapter 22 of this Guide.

lifestyle averaged points means the total of lifestyle points added together and averaged for each of the tables used.

lump sum means the amount payable after determining the periodic payment for a service injury or disease and converted to a single dollar amount in accordance with the tables provided by the Australian Government Actuary for that purpose.

member or former member means a member or former member of the Defence Force who serves or served on or after 1 July 2004.

non-accepted condition means any injury or disease that has not been determined under the Act to be service related or has been determined under the Act not to be service related.

periodic payment means the amount determined by reference to the tables in this guide for warlike and non-warlike service or for peacetime service and the maximum amount payable under the relevant provision of the Act.

service means service in the Defence Force which is warlike service, non‑warlike service or peacetime service as determined by the Minister for Defence from time to time.

service disease has the meaning given by section 27, subsections 29(1) and (2), and section 30 of the Act.

Note:    A reference to a service disease being contracted includes a reference to a disease being aggravated by defence service (see section 7 of the Act).

service injury has the meaning given by section 27, subsections 29(1) and (2), and section 30 of the Act.

Note:    A reference to a service injury being sustained includes a reference to an injury being aggravated by defence service (see section 7 of the Act).

SRCA means the Safety, Rehabilitation and Compensation Act 1988.

Statement of Principles means:

(a)     a Statement of Principles determined by the Repatriation Medical Authority under section 196B of the VEA and to which section 19 of the Consequential and Transitional Provisions Act 2004 applies; or

(b)    a determination made by the Commission under subsection 340(2) or (3) of the Act.

VEA means the Veterans’ Entitlements Act 1986.

veteran means a member or former member of the Defence Force (including a deceased person) under section 5 of the MRCA in respect of whom an injury or disease has been determined to be caused by that service.

war-caused injury and war-caused disease have the meaning given in section 9 of the VEA.

worksheet means a page or pages of this Guide, identified as such, that gives a structure by which certain calculations may be set out to assist in determining an impairment rating.

Definitions of words and phrases that are used in only one chapter are to be found in that chapter.

 

Acknowledgment of sources

The Guide to the Assessment of Rates of Veterans’ Pensions Fifth Edition, Part A Chapters 1–12 and Part B Chapters 13-17 and Part C Chapters 18-21 are the basic tables for this Guide.

That publication acknowledges that the following published works were found to be useful in the preparation of the VEA Guide (GARP V) and therefore were basic to this Guide as well:

Guides to the Evaluation of Permanent Impairment, 4th edition, American Medical Association, 1993;

International Classification of Impairments, Conditions, and Handicaps, World Health Organisation, Geneva, 1980; and

Publication No 118 of the National Acoustic Laboratories, Improved Procedure for Determining Percentage Loss of Hearing, by J. Macrae, Australian Government Publishing Service, Canberra, 1988.


HOW TO USE THIS GUIDE

The subject of assessment

This Guide is to be applied to assess the impairment points due to injuries or diseases, or both, that are determined to be service related.

In making any determination on the impairment the clinical features of injuries or diseases are to be taken into account. Sequelae of conditions can only be assessed after the sequelae have been determined to be service related.

The elements of whole person impairment and compensation

The two elements required to determine a periodic payment are medical impairment and lifestyle. Impairment is dealt with in Chapters 1 – 21 of this Guide. Lifestyle effects are dealt with separately and are described in Chapter 22 of this Guide.

Chapters 1 to 16 of this Guide contain two principal types of tables. Physical loss is to be rated against criteria in “Other Impairment” tables. Functional loss is to be rated against criteria in “Functional Loss” tables.

Greater emphasis has been given throughout this Guide to functional loss as a basis for assessment. It is measured by reference to an individual’s performance efficiency compared with an average, healthy person of the same age and sex, in a set of defined vital functions. This is a means of compensating for the loss of ability to perform everyday functions.

Each table contains benchmark values, generally at intervals of five points. In some cases the range between nil and five includes a rating of two points. In some other cases intervals are greater than five points because lesser increments of impairment cannot be distinguished.

Each benchmark is a threshold value, that is, the rating applies only if the threshold is achieved or exceeded. Ratings are not to be rounded up to the next benchmark. Similarly, ratings between benchmark values contained in the tables are not to be interpolated.

In some tables more than one criterion is stated opposite a benchmark value. The different criteria are marked by dot points. Where more than one criterion is stated for a particular value, the condition being assessed has to satisfy one of the criteria in order to attract the impairment rating of that value.

Each chapter contains step-by-step instructions to be followed in the use and application of the tables.

Determining compensation payable

This Guide specifies the only way of determining the amount of compensation payable is by reference to the maximum compensation that can be paid. The maximum is specified in the Act as a weekly amount. It becomes payable only when a person’s impairment rating reaches 80 points.

The Guide includes tables that will give a compensation factor for different impairment and lifestyle ratings. Different tables are used for warlike and non-warlike service and for peacetime service. The maximum compensation is multiplied by the compensation factor to give the weekly amount of compensation payable.

Medical impairment

Under this Guide medical impairment has two components:

(a)     physical loss of, or disturbance to, any body part or system; and

(b)    the resultant functional loss.

Whole person impairment

Medical impairment is expressed in impairment points, out of a maximum rating of 100. On this scale, zero corresponds to no impairment or negligible impairment from accepted conditions, and 100 points corresponds to death. Effectively, impairment points are percentages of the impairment of the whole person.

Loss of hearing, loss of taste, loss of smell, loss of a finger or of a toe as impairment for a single condition can be compensated for under this Guide only if a threshold value of 5 impairment points is reached. Any combination of loss from conditions that delivers a combined impairment of 10 or more will attract compensation.

Example

Loss of taste rated at 5 impairment points and mild reflux rated at 2 impairment points.

¨       A payment for loss of taste is permitted but, since 5 plus 2 is 7 and does not reach the threshold of 10 impairment points, no other payment is made.

Loss of taste rated at 5 impairment points and reflux rated at 5 impairment points.

¨       The reflux 5 points when combined with the loss of taste reaches the threshold of 10 impairment points and so payment is made on the basis of 10 impairment points.

Functional loss

Medical impairment is measured chiefly by loss of vital functions and is addressed in the twelve system specific chapters of this Guide, as follows:

Cardio-Respiratory Impairment

Hypertension and Non-Cardio Vascular Conditions

Impairment of Spine and Limbs

Emotional and Behavioural

Neurological Impairment

Gastro-intestinal Impairment

Ear, Nose, and Throat Impairment

Visual Impairment

Renal and Urinary Tract Function

Sexual Function, Reproduction, and Breasts

Skin Impairment

Endocrine and Haemopoietic Impairment

Other Impairment

Other Impairment is the physical loss of, or disturbance to, any body part or system. This concept is extended in some chapters in this Guide to include discomfort, pain, poor prognosis and other, less tangible, effects of accepted conditions.

Lifestyle effects

Lifestyle effects are to be assessed by applying Chapter 22 of this Guide in accordance with that Chapter.

The Tables

Types of Tables

There are several different sorts of tables used in GARP V that remain common to both GARP V and this Guide. Basically these are various impairment tables, the lifestyle tables and the tables to deal with more complex matters.

However the MRCA requires the Commission to specify two particular tables that are not used in GARP V or the VEA. These are tables that arise from the method specified by the Commission to determine compensation payable for warlike and non-warlike as distinct from peacetime service (see Tables 1 and 2 of Chapter 23). In addition the Commission must specify a method for determining compensation payable when a mixture of warlike (or non-warlike) and peacetime service causes the whole person impairment

Gender Use

Some tables are for men only, some for women only, and others (the majority) are not gender specific. Each table is clearly marked in the top right hand corner:

¨      the symbol

means that the table is only to be used for the assessment of female veterans;

¨      the symbol

means that the table is only to be used for the assessment of male veterans;

¨      the symbol

means that the table is used for either male or female veterans.

Age Adjustment

Some tables incorporate age dependent criteria. Some other tables have no such criteria and require subsequent age adjustment by applying tables provided for that purpose.

Each table is clearly marked in the bottom left hand corner with instructions on age adjustment for ratings derived from that table.

Conversion Factor Tables

The Commission is required by paragraph 67(1)(e) to provide methods that enable Lifestyle to be combined with Impairment to give compensation for each type of service by reference to the maximum compensation payable. These are set out as compensation factors in tables in Chapter 23 and include a different set of factors to be used for warlike and non-warlike service and for other service as provided for in the Act (see subsection 67(2)).

Non-system specific assessments

This Guide has chapters describing alternate methods of assessing certain conditions:

Chapter 13 — Negligible Impairment

Chapter 14 — Malignant Conditions

Chapter 15 — Intermittent Impairment

Chapter 16 — Activities of Daily Living

Chapter 17 — Disfigurement

Conditions and their sequelae

Only the clinical features of an accepted condition may be taken into account in making an assessment. If the accepted condition causes some other distinct and diagnosable condition (sequela), the symptoms of the sequela cannot be taken into account when assessing the original accepted condition.

Sequelae can only be assessed when they have been separately determined to be service related.

Applying the instructions

To the extent of any inconsistency between an instruction in this “How to use the Guide” and a specific instruction concerning a particular matter in this Guide, the specific instruction in this “How to use the Guide” is to apply to that particular matter.

Duration of assessment period or date of determination and commencement of periodic payment and permanent impairment and interim payments

Assessment can only be made by reference to the available medical and other material that, of necessity, relates to a particular point or period in time.

The assessment of the impairment and lifestyle ratings must be based on the Commission’s reasonable satisfaction on the available material. If there is a significant change in impairment during the course of an investigation a payment may still be made as an interim payment.  Interim payments are made until the Commission is satisfied that the condition has stabilised at an impairment level.

If the condition worsens after the last payment is made the person may claim additional compensation for the worsening and further periodic payments or lump sums can be made.

Apportionment of impairment ratings

It is sometimes necessary, for an accepted condition, to compare an impairment rating derived from one table with an impairment rating derived from another table. When two or more conditions contribute to the impairment ratings from either or both tables, and comparison is necessary, the method called “apportionment” is to be applied before making the comparison.

Details of the application of apportionment are given in Chapter 20.

Apportionment between tables

If a condition can be rated using both a functional loss table and an “Other Impairment” table, only the higher of the two ratings is to be given to the veteran.

Paired organ policy

The paired organ policy applies to eyes, kidneys etc and is described in detail in Chapter 21 of this Guide.

Impairment for specific disabilities

The Act provides only for impairment and does not convert that rating into a degree of incapacity like the VEA requires.  Instead the impairment and lifestyle ratings determine a factor, not a degree of incapacity.  Incapacity applies to ability to perform military service or a civilian occupation. Therefore, Chapter 24, “Degree of incapacity for specific disabilities” of GARP V, has been omitted.  Instead impairment ratings are based only on the Tables from Chapter 1 to 21 of this Guide.

 


MEDICAL IMPAIRMENT

PART A: SYSTEM SPECIFIC ASSESSMENT

CHAPTER 1

CARDIORESPIRATORY IMPAIRMENT

INTRODUCTION

Cardiorespiratory impairment results from conditions that affect the function of the heart or lungs. The procedures described in this chapter are to be applied in assessing most conditions of the heart and lungs, and will usually also be appropriate for conditions affecting the function of the thorax or diaphragm, lesions of the nerves that supply the muscles of respiration, and conditions such as anaemia. The principal exception is any condition which is predominantly intermittent in nature and which would be better assessed by applying Chapter 15 (Intermittent Impairment).

Different procedures (described in Chapter 2) are to be applied to assess hypertension and non-cardiac vascular conditions (such as aortic aneurysm and varicose veins).

In general, cardiorespiratory impairment is to be measured by reference to exercise tolerance. Exercise tolerance is quantified in terms of METs (see pages 11–12). However, if a respiratory component is present, measurements of lung function, such as forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and maximal expiratory flow (MEF 25–75) are to be used in addition to exercise tolerance. FEV1 and FVC are to be measured by spirometry. For the purposes of assessment in accordance with this Guide, the terms “MEF 25–75” and “FEF 25–75” (forced expiratory flow between 25% and 75% of the vital capacity) are to be taken as equivalent.

The conversion of loss of exercise tolerance and measurements of lung function into an impairment rating is set out in Table 1.2 and Table 1.3.

Certain cardiorespiratory conditions cannot be rated by applying exercise tolerance. These include:

·           conditions that do not decrease exercise tolerance;

·           conditions that do not produce symptoms; and

·           intermittent conditions.

“Exercise tolerance” refers to a person’s ability to exercise from a cardiorespiratory point of view rather than to a person’s total ability to exercise. For example, a veteran who has osteoarthritis of both knees may be greatly limited in walking but may still be able to swim a considerable distance. Such a veteran would still have good exercise tolerance from a cardiorespiratory point of view, though total ability to exercise would be reduced.

A veteran whose ability to exercise has been significantly reduced by other conditions (such as musculoskeletal conditions or being grossly overweight), or who no longer has cardiac or respiratory symptoms on exercise, cannot always be given an appropriate impairment rating for reduced exercise tolerance. However, the need to apply Chapter 19 (Partially Contributing Impairment) should always be considered before disregarding exercise tolerance figures.

Calculation of the impairment rating for accepted cardiorespiratory conditions

Follow the steps below to determine the impairment rating for cardiorespiratory conditions:

(Each step is elaborated in the following pages.)

Step 1

Establish what cardiorespiratory conditions are present.

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Step 2

Assess the information that is available and decide whether it is reliable and sufficient.

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Step 3

Determine the impairment rating based on effort tolerance.

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Step 4

(Omit this step if no respiratory disease is present.)

Determine the impairment rating based on measure­ments of lung function.

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Step 5

Determine the total accepted cardiorespiratory functional impairment rating.

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Step 6

Consider the effects of cardiac failure (if any).

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Step 7

Moderate the total cardiorespiratory functional impairment rating to allow for effects of any non-accepted conditions.

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Step 8

Determine whether any ratings from the relevant Other Impairment tables apply (Tables 1.7, 1.8, 1.9, 1.10).

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Step 1:            Establish what cardiorespiratory conditions are present.

For the purpose of assessing cardiorespiratory impairment, both the accepted and the non-accepted conditions are be taken into account. Both will affect the way in which cardiorespiratory functional impairment is calculated. (Their combined effect is taken into account in the application of Table 1.5 in Step 5.)

Any non-accepted conditions are to be subsequently allowed for by applying Chapter 19 (Partially Contributing Impairment) ­— see Step 7.

When considering the question: ‘What cardiorespiratory conditions are present in this veteran?’, it is not appropriate to rely simply on a list of accepted conditions. Both previously claimed but rejected cardiorespiratory conditions and unclaimed cardiorespiratory conditions may also be present.

Step 2:            Assess the information that is available and decide whether it is reliable and sufficient.

To make a reliable cardiorespiratory assessment, there should be an adequate medical history of the veteran’s cardiorespiratory conditions. In addition, there should be information relating to the veteran’s effort tolerance and, if any respiratory disease is present, there should also be one or more sets of spirometry or other physiological measurements of respiratory function. The criteria by which the evaluation of the information is to be made are set out below.

Medical history

An adequate history of the veteran’s illness and a description of the current symptoms and details of the current treatment should be available.

The history should be reviewed at the start of the cardiorespiratory assessment procedure to establish whether any major cardiorespiratory event (for example a myocardial infarction or bypass surgery) has occurred within the period of assessment.

An examination of the history will indicate whether any Other Impairment ratings (from Tables 1.7, 1.8, 1.9, 1.10) are applicable. For example, in the case of ischaemic heart disease, the history will reveal whether the veteran has had any myocardial infarctions, whether coronary bypass surgery has been performed and the outcome of any such surgery. In other cases, for example when respiratory disease is present, the current treatment will reveal whether any Other Impairment rating for cardiorespiratory conditions is applicable.

In long-standing respiratory conditions, there will often be a disease complex present that is more extensive than that implied by the original diagnostic label. For example, asthma may lead to chronic obstructive respiratory disease and chronic bronchitis may lead to small airways disease. Such extensions of the disease process are to be assessed as part and parcel of the original condition unless there is clear reason why they should not be — for example, they have been determined to be non-accepted conditions.

Effort tolerance

Effort tolerance information should always be obtained except if the veteran has a condition that renders the collection of reliable effort tolerance information impracticable.

Examples of conditions that may render the collection of reliable effort tolerance information impracticable include:

·           hemiparesis following a stroke;

·           quadriplegia or hemiplegia;

·           severe arthritis of the lower limbs; and

·           certain mental conditions such as dementia (in which the veteran’s ability to co-operate or provide useful information may be restricted).

The date of the effort tolerance information used must be appropriate to the period of assessment: the effort tolerance information should be not more than six months older than the relevant time in the assessment period to which the information is to be applied.

Measurements of lung function

Spirometry should always be obtained if any condition affecting the function of the lungs is present unless it is not practicable or appropriate to perform spirometry because:

·           the veteran is very old or frail and cannot reasonably attend a clinic where spirometry can be performed; or

·           the veteran lives in a remote locality and cannot reasonably attend a clinic where spirometry can be performed; or

·           the veteran’s impairment from other accepted conditions is of such a degree that it would result in a combined impairment rating of at least 68 points.

The date of the spirometry used must be appropriate to the period of assessment: the spirometry should be not more than six months older than the relevant time in the assessment period to which the information is to be applied.

The nature of the spirometry should be appropriate: the nature of the spirometric readings should be consistent with the known conditions affecting the veteran and should also be consistent with such other information (eg, old spirometry) as is available or can reasonably be obtained. There should be no unexplained inconsistencies between the various reports.

If the nature of the spirometry cannot be reconciled with other relevant information, the spirometry may need to be repeated or the veteran referred to a respiratory physician for clarification of the situation.

If a veteran has emphysema, as evidenced by diminished carbon monoxide diffusing capacity, and diagnosed by a specialist respiratory physician, assessment can be made on the basis of effort tolerance alone.

Step 3:            Determine the impairment rating based on effort tolerance.

To determine the impairment rating based on effort tolerance follow the substeps below.

(Each step is elaborated in the following pages.)

Substep 3A

Determine the symptomatic activity level by applying Table1.1 — Activity Levels (with energy expenditure in METs).

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Substep 3B

Convert that symptomatic activity level into an impairment rating. This step involves consulting either Table 1.2 — Loss of Cardiorespiratory Function: Exercise Tolerance (Males); or Table 1.3 — Loss of Cardiorespiratory Function: Exercise Tolerance (Females).

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After both substeps have been completed, a single rating will have been obtained. This rating is known as the impairment rating for effort tolerance.

If symptoms do not occur, a rating for the condition may be found in Table 1.6 (Cardiac Failure) if applicable, or in the relevant Other Impairment table.

Substep 3A:        Determine the symptomatic activity level.

The symptomatic activity level is the exercise level (measured in METs) at which symptoms occur. One MET represents the energy expenditure associated with the consumption of 3.5 mL oxygen per kilogram of body weight per minute. Table 1.1 lists various activities grouped according to their energy expenditure in METs.

The symptomatic activity level is the level at which the activities from within any one METs category consistently give rise to symptoms of the accepted cardiorespiratory condition, such as angina, dyspnoea, palpitations, or fatigue. The symptomatic activity level may be determined by reference to a report specifically provided for the purpose as well as by reference to clinical notes and by comparison of the information with the activities listed in Table 1.1. (The symptomatic activity level may be determined by reference to activities other than those contained in Table 1.1 if the energy expenditure (in METs) of those activities is available in the medical or scientific literature.)

In determining the symptomatic activity level, greater reliance is to be placed on activities that involve steady, as opposed to sporadic, expenditure of energy. Such activities are more reliable as indicators of exercise tolerance. Less reliance is to be placed on activities that can be completed in less than a few minutes, as symptoms may take longer than this to occur.

Responses of the type ‘I cannot do such and such’ or ‘I do not do so and so’ are not useful in assessing the symptomatic activity level. What must be established is that level of exercise that the veteran is able to do but which results in angina, breathlessness, or some other cardiorespiratory symptom.

Symptoms that occur while an activity is performed are not necessarily a result of the energy expenditure occasioned by the activity. Many specific activities can be performed in a way that would mean that they were no longer examples of the METs level in which they are placed in Table 1.1. For example, while driving a car sedately is an example of 2–3 METs, driving a car in a Grand Prix is not.

Estimations of exercise tolerance above the 6-7 METs level should only be made using exercise tests. The activities above the 6-7 METs level are listed for information only.


TABLE 1.1                                                                                                                                   

CARDIORESPIRATORY IMPAIRMENT: ACTIVITY LEVELS

(with energy expenditure in METs)

1-2 METs

Energy expended at rest or minimal activity

·      Lying down.

·      Sitting and drinking tea.

·      Using sewing machine (electric).

·      Sitting down.

·      Sitting and talking on telephone.

·      Travelling in car as passenger.

·      Standing.

·      Sitting and knitting.

·      Playing cards.

·      Strolling (slowly).

·      Light sweeping.

·      Clerical work (desk work only).

2–3 METs

Energy expanded in dressing, washing and performing light household duties

·      Light household duties.

·      Walking slowly (3.5 km/h).

·      Playing piano, violin, or organ.

·      Typing.

·      Cooking or preparing meals.

·      Playing billiards.

·      Clerical work which involves moving around.

·      Setting table.

·      Driving power boat.

·      Washing dishes.

·      Playing golf (with power buggy).

·      Bench assembly work (seated).

·      Dressing, showering.

·      Horseback riding at walk.

·      Using self-propelled mower.

·      Light tidying, dusting.

·      Lawn bowls.

·      Polishing silver.

·      Driving car.

3–4 METs

Energy expended in walking at an average pace

·      Walking at average walking pace (5 km/h).

·      Golf (pulling buggy).

·      Machine assembly.

·      Cleaning car (excludes vigorous polishing).

·      Minor car repairs.

·      Tidying house.

·      Welding.

·      Cleaning windows.

·      Table tennis.

·      Pushing light power mower over flat suburban lawn at slow steady pace

·      Vacuuming.

·      Sedate cycling (10 km/h)

·      Shifting chairs.

·      Light gardening (weeding and water).

·      Hanging out washing.

·      Making bed.

4–5 METs

Moderate activity: encompasses more strenuous daily activities with the exclusion of manual labour and vigorous exercise

·      Mopping floors.

·      Golf (carrying bag).

·      Light carpentry (eg, chiselling, hammering).

·      Scrubbing floors.

·      Ballroom dancing.

·      Beating carpets.

·      Tennis doubles (social, non-competitive).

·      Stocking shelves with light objects.

·      Polishing furniture.

·      Wallpapering.

·      Shopping and carrying groceries (10 kg).

·      Gentle swimming.

·      Painting outside of house.

·      Hoeing (soft soil).

·      Stacking firewood.

5–6 METs

Heavy exercise: manual labour or vigorous sports

·      Walking 6.5 km/h (sustained brisk walk, discomfort in talking at the same time).

·      Walking slowly but steadily up stairs.

·      Carpentry (eg. Sawing and planing with hand tools).

·      Swimming laps (non-competitive).

·      Pushing a full wheelbarrow (20 kg).

·      Shovelling dirt (12 throws a minute).

·      Digging in garden.

6–7 METs

·      Badminton (competitive)

·      Tennis (singles, non-competitive).

·      Water skiing.

·      Loading truck with bricks.

·      Using a pick and shovel to dig trenches.

7–8 METs

Very heavy exercise

·      Jogging (8 km/h).

·      Horseback riding (galloping).

·      Carrying heavy objects (30 kg) on level ground.

·      Sawing hardwood with hand tools.

8–9 METs

·      Running (9 km/h).

·      Skiing (cross-country.

·      Chopping hardwood.

·      Callisthenics.

·      Squash (non competitive).

10+ METs

·      Running quickly (10 km/h).

·      Cycling quickly (25 km/h).

·      Carrying loads (10 kg) up a gradient.

·      Football (any code).

The activities listed under each heading are examples. There will be other activities that have the same METs expenditure and hence can be used for reference if their METs level is known.

Ratings derived from METs are age adjusted

Alternate procedures for establishing the symptomatic activity level

1.    The symptomatic activity level may be determined by exercise tests. These tests include:

-          use of treadmills; or

-          cycles; or

-          rowing machines.

Because of their greater objectivity, the results of exercise tests (when available) are to be used in preference to the method of calculating exercise tolerance as described above. Moreover, exercise tests must always be used to make an estimate of exercise tolerance above 6–7 METs.

2.    If certain levels of activity have been prohibited by the treating doctor, because of the adverse effect the prohibited activity is likely to have on the veteran’s health as a result of the accepted condition, then the level of exercise that has been prohibited may be regarded as the symptomatic activity level.

Substep 3B:        Convert the symptomatic activity level into an impairment rating.

The symptomatic activity level is used, in conjunction with the veteran’s age, height, and sex, to obtain an impairment rating.

In the case of a male, Table 1.2 is to be applied.

In the case of a female, Table 1.3 is to be applied.

For the purposes of Tables 1.2 and 1.3, a veteran’s age is taken to be his or her age in whole years at the date of the report relating to the exercise tolerance (unless the report is of a retrospective type and clearly refers to some earlier period, in which case the veteran’s age is taken to be his or her age in whole years at the relevant time).

Step 4:            (Omit this step if no respiratory disease is present.) Determine the impairment rating based on measurements of lung function.

FEVl, FVC, and MEF 25–75 are the usual physiological measurements of lung function. Determinations of FEVl, FVC, and MEF 25–75 should be conducted by an experienced operator without specific administration of a bronchodilator. The best set of results should be selected, that is, the set of results which indicates the greatest degree of health and, consequently, the lowest degree of impairment.

If both pre-bronchodilator and post-bronchodilator results are available the pre-bronchodilator results are to be applied in determining the impairment rating based on measurements of lung function.

To determine the impairment rating based on measurements of lung function, follow the substeps below.

Substep 4A

Obtain the measured FEVl, FVC, and MEF 25–75 from the data.

Substep 4B

Work out the predicted FEVl, FVC, and MEF 25–75 for a person of the same age, height, and gender. This can be done either by applying the nomograms Figure 1a (for males) or Figure 1b (for females) or by applying the formula relating to each nomogram.

Substep 4C

Express the measured FEV1 as a percentage of the predicted FEV1, and Express the measured FVC as a percentage of the predicted FVC, and Express the measured MEF 25–75 (if appropriate) as a percentage of the predicted MEF 25–75.

These conversions are performed by applying the formula: 

Measured value as % of predicted value = Actual value x 100

                                                                      Predicted Value

Substep 4D

Determine an impairment rating from a physiological measurement by using the percentage obtained in substep 4C in conjunction with Table 1.4. Separate impairment ratings can be obtained from each physiological measurement (that is, from the FEV1, FVC, and MEF 25–75).

Substep 4E

The final impairment rating is the highest (or equal highest) of the ratings obtained in substep 4D.


 

Function Loss Table 1.2

LOSS OF CARDIORESPIRATORY FUNCTION: EXERCISE TOLERANCE

 

(Males)

 

Age

Symptomatic Activity Level

Age

Symptomatic Activity Level

 

 

(METs*)

 

(METs*)

 

less than

25

1–2

2–3

3–4

4–5

5–6

6–7

7–8

8–9

10+

 

1–2

2–3

3–4

4–5

5–6

6–7

7–8

8–9

10+

 

90

80

70

60

50

40

30

20

10

55

80

70

55

40

25

15

10

 

 

 

25

90

80

70

60

50

40

30

20

10

56

80

70

54

39

24

15

9

 

 

 

26

90

80

70

60

50

40

30

20

10

57

80

69

53

38

23

14

8

 

 

 

27

89

80

70

59

48

38

28

19

10

58

80

69

52

37

22

14

7

 

 

 

28

89

80

70

59

47

37

27

19

10

59

80

68

51

36

21

13

6

 

 

 

29

88

80

70

58

46

36

26

18

10

60

80

68

50

35

20

13

5

 

 

 

30

88

80

70

58

45

35

25

18

10

61

80

67

49

34

19

12

4

 

 

 

31

87

80

70

57

44

34

24

17

10

62

80

67

48

33

18

12

3

 

 

 

32

87

80

70

57

43

33

23

17

10

63

80

66

47

32

17

11

2

 

 

 

33

86

80

70

56

42

32

22

16

10

64

80

66

46

31

16

11

 

 

 

 

34

86

80

70

56

41

31

21

16

10

65

80

65

45

30

15

10

 

 

 

 

35

85

80

70

55

40

30

20

15

10

66

80

64

44

29

15

9

 

 

 

 

36

85

80

70

55

39

29

20

15

9

67

79

63

43

28

14

8

 

 

 

 

37

85

79

69

54

38

28

19

14

8

68

79

62

42

27

14

7

 

 

 

 

38

85

79

69

54

37

27

19

14

7

69

78

61

41

26

13

6

 

 

 

 

39

85

78

68

53

36

26

18

13

6

70

78

60

40

25

13

5

 

 

 

 

40

85

78

68

53

35

25

18

13

5

71

77

59

39

24

12

4

 

 

 

 

41

85

77

67

52

34

24

17

12

4

72

77

58

38

23

12

3

 

 

 

 

42

85

77

67

52

33

23

17

12

3

73

76

57

37

22

11

2

 

 

 

 

43

85

76

66

51

32

22

16

11

2

74

76

56

36

21

11

1

 

 

 

 

44

85

76

66

51

31

21

16

11

 

75

75

55

35

20

10

 

 

 

 

 

45

85

75

65

50

30

20

15

10

 

76

75

55

35

19

9

 

 

 

 

 

46

85

75

64

49

30

20

15

9

 

77

75

54

34

18

8

 

 

 

 

 

47

84

74

63

48

29

19

14

8

 

78

75

54

34

17

7

 

 

 

 

 

48

84

74

62

47

29

19

14

7

 

79

75

53

33

16

6

 

 

 

 

 

49

83

73

61

46

28

18

13

6

 

80

75

53

33

15

5

 

 

 

 

 

50

83

73

60

45

28

18

13

5

 

81

75

52

32

14

4

 

 

 

 

 

51

82

72

59

44

27

17

12

4

 

82

75

52

32

13

3

 

 

 

 

 

52

82

72

58

43

27

17

12

3

 

83

75

51

31

12

2

 

 

 

 

 

53

81

71

57

42

26

16

11

2

 

84

75

51

31

11

1

 

 

 

 

 

54

81

71

56

41

26

16

11

 

 

85

75

50

30

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

above 85

75

50

30

10

 

 

 

 

 

 

 

*One MET represents the energy expenditure associated with the consumption of 3.5 mL oxygen/kg body Weight/min.

 

Ratings derived from METs are age adjusted


 

Functional Loss Table 1.3

LOSS OF CARDIORESPIRATORY FUNCTION: EXERCISE TOLERANCE

(Females)

Age

Symptomatic Activity Level

Age

Symptomatic Activity Level

 

(METs*)

 

(METs*)

less than

25

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

10+

 

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

10+

 

90

80

70

55

40

30

20

15

10

55

80

65

50

30

20

15

10

 

 

 

25

90

80

70

55

40

30

20

15

10

56

80

65

49

29

20

15

9

 

 

 

26

90

80

69

54

40

30

20

15

10

57

80

64

48

28

19

14

8

 

 

 

27

89

79

68

53

39

29

20

15

10

58

80

64

47

27

19

14

7

 

 

 

28

89

79

67

52

39

29

20

15

10

59

80

63

46

26

18

13

6

 

 

 

29

88

78

66

51

38

28

20

15

10

60

80

63

45

25

18

13

5

 

 

 

30

88

78

65

50

38

28

20

15

10

61

80

62

44

24

17

12

4

 

 

 

31

87

77

64

49

37

27

20

15

10

62

80

62

43

23

17

12

3

 

 

 

32

87

77

63

48

37

27

20

15

10

63

80

61

42

22

16

11

2

 

 

 

33

86

76

62

47

36

26

20

15

10

64

80

61

41

21

16

11

 

 

 

 

34

86

76

61

46

36

26

20

15

10

65

80

60

40

20

15

10

 

 

 

 

35

85

75

60

45

35

25

20

15

10

66

80

59

39

20

15

9

 

 

 

 

36

85

75

60

45

34

25

20

15

9

67

79

58

38

19

14

8

 

 

 

 

37

85

75

60

44

33

24

19

14

8

68

79

57

37

19

14

7

 

 

 

 

38

85

75

60

44

32

24

19

14

7

69

78

56

36

18

13

6

 

 

 

 

39

85

75

60

43

31

23

18

13

6

70

78

55

35

18

13

5

 

 

 

 

40

85

75

60

43

30

23

18

13

5

71

77

54

34

17

12

4

 

 

 

 

41

85

75

60

42

29

22

17

12

4

72

77

53

33

17

12

3

 

 

 

 

42

85

75

60

42

28

22

17

12

3

73

76

52

32

16

11

2

 

 

 

 

43

85

75

60

41

27

21

16

11

2

74

76

51

31

16

11

1

 

 

 

 

44

85

75

60

41

26

21

16

11

 

75

75

50

30

15

10

 

 

 

 

 

45

85

75

60

40

25

20

15

10

 

76

75

49

29

15

9

 

 

 

 

 

46

85

74

59

39

25

20

15

9

 

77

75

48

28

14

8

 

 

 

 

 

47

84

73

58

38

24

19

14

8

 

78

75

47

27

14

7

 

 

 

 

 

48

84

72

57

37

24

19

14

7

 

79

75

46

26

13

6

 

 

 

 

 

49

83

71

56

36

23

18

13

6

 

80

75

45

25

13

5

 

 

 

 

 

50

83

70

55

35

23

18

13

5

 

81

75

44

24

12

4

 

 

 

 

 

51

82

69

54

34

22

17

12

4

 

82

75

43

23

12

3

 

 

 

 

 

52

82

68

53

33

22

17

12

3

 

83

75

42

22

11

2

 

 

 

 

 

53

81

67

52

32

21

16

11

2

 

84

75

41

21

11

1

 

 

 

 

 

54

81

66

51

31

21

16

11

 

 

85

75

40

20

10

 

 

 

 

 

 

above 85

75

40

20

10

 

 

 

 

 

 

 

*One MET represents the energy expenditure associated with the consumption of 3.5mL oxygen/kg body weight/min.

Ratings derived from METs are age adjusted

FIGURE 1a ‑ PREDICTION NOMOGRAM: MALE (BTPS)

FIGURE 1b ‑ PREDICTION NOMOGRAM: FEMALE (BTPS)


 

Functional Loss Table 1.4

LOSS OF CARDIORESPIRATORY FUNCTION: PHYSIOLOGICAL MEASUREMENTS

 

Impairment

Rating

FEV1 as a

percentage

of predicted

FVC as a

percentage

of predicted

MEF 2575 as a

percentage

of predicted

NIL

85

85

85

TWO

 

84

 

SIX

84

 

84

SEVEN

 

83

 

EIGHT

83

 

83

TEN

82

 

82

ELEVEN

81

82

81

TWELVE

 

 

 

THIRTEEN

80

 

80

FOURTEEN

79

81

79

FIFTEEN

 

 

 

SIXTEEN

78

80

78

SEVENTEEN

77

 

77

EIGHTEEN

76

79

76

NINETEEN

 

 

 

TWENTY

75

78

75

TWENTY-ONE

74

 

74

TWENTY-TWO

73

77

73

TWENTY-THREE

72

 

72

TWENTY-FOUR

71

76

71

TWENTY-FIVE

 

 

 

TWENTY-SIX

70

75

70

TWENTY-SEVEN

69

74

69

TWENTY-EIGHT

68

 

68

TWENTY-NINE

67

73

67

THIRTY

66

72

66

THIRTY-ONE

65

71

65

THIRTY-TWO

64

 

64

THIRTY-THREE

63

70

63

THIRTY-FOUR

62

69

62

THIRTY-FIVE

61

68

61

THIRTY-SIX

60

67

60

THIRTY-SEVEN

59

 

59

 


 

Functional Loss Table 1.4 (continued)

LOSS OF CARDIORESPIRATORY FUNCTION: PHYSIOLOGICAL MEASUREMENTS

 

Impairment

Rating

FEV1 as a

percentage

of predicted

FVC as a

percentage

of predicted

MEF 2575 as a

percentage

of predicted

THIRTY-EIGHT

58

66

58

THIRTY-NINE

57

65

57

FORTY

 

64

 

FORTY-ONE

56

63

56

FORTY-TWO

55

62

55

FORTY-THREE

54

61

54

FORTY-FOUR

53

60

53

FORTY-FIVE

52

 

52

FORTY-SIX

51

59

51

FORTY-SEVEN

50

58

50

FORTY-EIGHT

49

57

49

FORTY-NINE

48

56

48

FIFTY

47

55

47

FIFTY-ONE

46

54

46

FIFTY-TWO

45

53

45

FIFTY-THREE

44

52

44

FIFTY-FOUR

43

51

43

FIFTY-FIVE

42

50

42

FIFTY-SIX

41

49

41

FIFTY-SEVEN

40

 

40

FIFTY-EIGHT

39

48

39

FIFTY-NINE

38

47

38

SIXTY

37

46

37

SIXTY-ONE

36

45

36

SIXTY-TWO

35

44

35

SIXTY-THREE

34

43

34

SIXTY-FOUR

33

42

33

SIXTY-FIVE

32

41

32

SIXTY-SIX

31

40

31

SIXTY-SEVEN

30

39

30

SIXTY-EIGHT

29

38

29

SIXTY-NINE

28

37

28

SEVENTY

27

36

27

Ratings derived from this table are age adjusted


Whenever the measured parameter is less than 85% of the predicted, Table 1.4 corresponds to the following formulas:

Impairment rating based on FEV1

=

98 - % FEV1 +

50

(% FEV1-90)

Impairment rating based on FVC

=

108 - % FVC +

100

(%FVC-88.5)

Impairment rating based on MEF 25–75

=

98 - % MEF +

50

(% MEF-90)

When the measured parameter is 85% or more of the predicted, then the impairment rating is defined as NIL

“%FEV1” means measured  FEV1 expressed as a percentage of predicted  FEV1.

“%FVC” means measured  FVC  expressed as a percentage of predicted   FVC. “%MEF” means measured MEF 25‑75 expressed as a percentage of predicted MEF 25–75.

In each case the percentage is to be rounded to the nearest integer before the formula is applied.

If these formulas are applied the resulting impairment rating is always to be rounded to the nearest integer.

Step 5:            Calculate the total accepted cardiorespiratory functional impairment rating.

At this stage there will usually be an impairment rating derived from effort tolerance information and there may also be an impairment rating derived from measurements of lung function. These must be combined into a single cardiorespiratory functional impairment rating. The method by which that is to be done is set out in Table 1.5.

For the purposes of Table 1.5, the following abbreviations have been used:

Abbreviation

Meaning

“FI”

means cardiorespiratory functional impairment rating.

“No FI”

means a cardiorespiratory functional impairment rating cannot be calculated from either effort tolerance information or measurements of lung function.

“METs”

means the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from METs alone.

“Spirometry”

means the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from measurements of respiratory function.

“average of METs and Spirometry”

means the average of the cardiorespiratory functional impairment rating derived from METs alone and the cardiorespiratory functional impairment rating derived from measurements of respiratory function alone — using the ordinary formula for averaging two quantities or by use of the nomogram in Figure 1c. In either case, the result is to be rounded to the nearest integer.

 


 

Procedural Table 1.5

CARDIORESPIRATORY FUNCTIONAL IMPAIRMENT

 

 

Respiratory disease present

No respiratory disease

 

 

Spirometry obtainable

Spirometry not obtainable

 

Cardiac disease present

METs data obtainable

FI = higher of METs and Spirometry

FI = METs

FI = METs

METs data not obtainable

FI = Spirometry

No FI

No FI

No cardiac disease

METs data obtainable

FI = average of METs and Spirometry

FI = METs

 

METs data not obtainable

FI = Spirometry

No FI

 

In applying this table, both accepted and non-accepted conditions are to be taken into account.

No age adjustment permitted for this table

From Table 1.5 it will be seen that:

·           if cardiac conditions exist in the absence of respiratory disease, cardiorespiratory functional impairment should be measured by effort tolerance alone;

·           if respiratory conditions exist in the absence of cardiac disease, the cardiorespiratory functional impairment rating is the rounded average of (i) impairment as measured by effort tolerance, and (ii) impairment as measured by spirometry;

·           if both cardiac and respiratory conditions co-exist, the cardiorespiratory functional impairment rating is the greater of (i) the impairment rating as measured by effort tolerance, and (ii) the impairment rating  as measured by spirometry.

In applying these rules, both accepted and non-accepted cardiac and respiratory conditions are to be taken into account.

Only one rating for effort tolerance is to be given irrespective of the number of conditions that contribute to the relevant impairment.

Only one rating is to be given for physiological measurements of lung function irrespective of the number of conditions that contribute to the relevant impairment.

This single “total cardiorespiratory functional impairment” is due to the combined effect of all cardiorespiratory conditions whether accepted or not.

FIGURE 1c ‑ LOSS OF REPIRATORY FUNCTION RESPIRATORY NOMOGRAM

This nomogram is to be used in accordance with the instructions in Step 5 and the procedural Table 1.5.

Results from this nomogram are to be rounded to the nearest five points. 2.5 is to be rounded up to 5 and 7.5 is to be rounded up to 10.

This nomogram corresponds to the formula:

Impairment Rating =

METs Impairment Rating + Impairment Rating of Physiological Measurement

2

Step 6:            Consider the effects of cardiac failure (if any).

For the purposes of assessment under this Guide, cardiac failure is considered to be a surrogate measure of cardiorespiratory impairment. When cardiac failure is present, the impairment rating calculated using effort tolerance will usually exceed any possible impairment rating from Table 1.6. Table 1.6 is of particular importance in assessing a veteran who is unable to be rated using effort tolerance because of significant conditions such as hemiplegia.

 

Functional Loss Table 1.6

CARDIAC FAILURE

Impairment Ratings

Criteria

NIL

No cardiac failure; that is,  neither symptoms nor X-ray evidence of cardiac failure.

TEN

·         No symptoms, but X-ray evidence of early cardiac failure.

·         Evidence of right ventricular failure.

FIFTEEN

Left or biventricular cardiac failure demonstrated by ejection fraction of between 40% and 60% and persisting despite therapy.

TWENTY

Left or biventricular cardiac failure demonstrated on X-ray or by ejection fraction of less than or equal to 40% and persisting despite therapy.

Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.

No age adjustment allowed for this table

A rating from Table 1.6 is to be compared with the total cardiorespiratory functional impairment rating (obtained in Step 5) and the higher of the two is to be chosen.

Step 7:            Moderate the total cardiorespiratory functional impairment rating to allow for effects of any non-accepted conditions.

Partially contributing impairment

If non-accepted conditions contribute to the impairment, Chapter 19 (Partially Contributing Impairment) is to be applied to determine impairment from the accepted conditions.

If cardiac conditions exist in the absence of respiratory disease: if there is more than one cardiac condition present (for example ischaemic heart disease and a valvular heart disease) and some are accepted and some are not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition.

If a respiratory condition exists in the absence of cardiac disease, the symptomatic activity level will generally be the exercise level (in METs) at which dyspnoea occurs. If there is more than one respiratory condition present and at least one is accepted and at least one is not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition or conditions.

If cardiac and respiratory conditions co-exist, and at least one is accepted and at least one is not accepted, it is necessary to determine the total cardiorespiratory functional impairment rating (as set out in the previous steps), and then to moderate that rating by applying Chapter 19 to determine the impairment due to the accepted condition.

The result that is then derived is the “total accepted cardiorespiratory functional impairment rating”.

Step 8:            Determine whether any ratings from the cardiorespiratory Other Impairment tables apply.

Cardiorespiratory Other Impairment tables

Once the total accepted cardiorespiratory functional impairment rating has been determined, it must be compared with the relevant cardiorespiratory Other Impairment tables. For assessment purposes, four categories of cardiorespiratory condition are recognised. These categories are:

·           ischaemic heart disease;

·           valvular heart disease;

·           miscellaneous heart disease; and

·           lower respiratory tract conditions.

There are four cardiorespiratory Other Impairment tables — corresponding to each of the above categories. These tables are:

Table 1.7         —        Cardiorespiratory Impairment: Ischaemic;

Table 1.8         —        Cardiorespiratory Impairment: Valvular;

Table 1.9         —        Cardiorespiratory Impairment: Miscellaneous; and

Table 1.10       —        Cardiorespiratory Impairment: Respiratory.

Only one rating is to be selected from each of these cardiorespiratory Other Impairment tables (Tables 1.7, 1.8, 1.9, and 1.10) for any condition or combination of conditions.

If accepted conditions belonging to more than one of the four categories of cardiorespiratory disease above are present, then the relative contribution of their effect on the total accepted cardiorespiratory functional impairment must be estimated by applying Chapter 20 (Apportionment). The rating for each condition will be the higher of the cardiorespiratory functional impairment rating attributed to it and its cardiorespiratory Other Impairment rating.

The cardiorespiratory worksheet (at page 29) should also be consulted.

Other Impairment Table 1.7

CARDIORESPIRATORY IMPAIRMENT: ISCHAEMIC HEART DISEASE

Impairment Ratings

Criteria

NIL

No history of symptoms but evidence of transient ischaemia on exercise ECG testing.

TEN

·         Coronary artery disease, characterised by typical history of angina pectoris.

·         Coronary artery disease, characterised by history of uncomplicated myocardial infarct, with no subsequent evidence of cardiac failure and infrequent or no angina.

·         Coronary artery disease, with single vessel disease (other than left main coronary) demonstrated on angiogram.

·         Coronary artery disease with successful coronary artery surgery, followed by no angina or only infrequent angina but no further infarcts or cardiac failure.

FIFTEEN

Coronary artery disease with multi-vessel disease (not successfully corrected) demonstrated on angiogram.

TWENTY

·         Coronary artery disease characterised by a history of myocardial infarct followed, immediately or after a lapse of time, by continuing angina or further infarcts.

·         Coronary artery disease characterised by left main coronary artery disease (not successfully corrected) demonstrated on angiogram.

·         Coronary artery disease with successful coronary artery surgery, followed, after a lapse of time, by frequent angina or further infarcts or cardiac failure.

 

Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.

No age adjustment permitted for this table

 

Other Impairment Table 1.8

CARDIORESPIRATORY IMPAIRMENT: VALVULAR HEART DISEASE

Impairment Ratings

 

Criteria

NIL

·         Mitral valve prolapse with no or minimal symptoms.

·         Aortic sclerosis with no or minimal symptoms.

FIVE

Diagnosed valvular heart disease (other than mitral valve prolapse or aortic sclerosis) with no symptoms and no X-ray evidence of cardiac failure.

TEN

Valvular heart disease with successful valve replace­ment, not requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.

FIFTEEN

Valvular heart disease with successful valve replace­ment, requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.

 

Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.

No age adjustment permitted for this table


 

Other Impairment Table 1.9

CARDIORESPIRATORY IMPAIRMENT: MISCELLANEOUS

Impairment Ratings

 

Criteria

NIL

Flow murmurs.

TWO

Chronic asymptomatic arrhythmia, eg. atrial fibril­lation, atrial or ventricular ectopic beats.

FIVE

Need for a permanent pacemaker.

 

Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.

No age adjustment permitted for this table

Arrhythmias are usually to be rated by applying Chapter 15 (Intermittent Impairment) unless they cause a permanent restriction of exercise tolerance, in which case they are to be assessed by their effect on effort tolerance.

 

Other Impairment Table 1.10

CARDIORESPIRATORY IMPAIRMENT: LOWER RESPIRATORY TRACT

Impairment Ratings

 

Criteria

NIL

Asymptomatic pleural plaques

TWO

·         Recurrent lower respiratory infections (at least 6 per year)

·         Intermittent use of bronchodilator medication.

FIVE

·         Daily use of inhaled steroids required.

·         Regular, daily use of bronchodilator medication.

·         Chronic cough, with production of at least 50mL sputum/day.

TEN

·         Regular, daily use of bronchodilator medication required in addition to daily inhaled steroids.

·         Chronic cough, with production of at least 100 mL sputum/day.

TWENTY

Repeated courses (at least several courses per year) or permanent use of oral steroids required.

 

Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.

No age adjustment permitted for this table

Peripheral Vascular Conditions

Tables 1.2 and 1.3 are to be applied to assess those conditions that affect exercise tolerance from a cardiorespiratory point of view. Peripheral vascular conditions typically cause loss of function of the lower limbs only and therefore are to be assessed under lower limb impairment (using Chapter 3).

Atherosclerosis frequently causes both a cardiorespiratory condition and a peripheral vascular condition. In such cases, if both types of conditions are accepted conditions, then both conditions are to be rated using the appropriate assessment procedure.


 

The rating of asthma depends on the clinical circumstances. If asthma has caused chronic airways obstruction the method of assessment described in this chapter is to be applied. If there is little fixed obstruction and a large reversible component, the rating is to be based on the occurrence of attacks using the method of intermittent impairment (Chapter 15). Asthma can also be rated, if there is minimal loss of function, from Table 1.10.

 

CHAPTER 2

HYPERTENSION AND NON-CARDIAC VASCULAR CONDITIONS

This Chapter contains three parts:

Part 2.1           —        Hypertension

Part 2.2           —        Vascular Conditions of the Lower Limbs

Part 2.3           —        Other Non-Cardiac Vascular Conditions

INTRODUCTION

This chapter is to be applied in determining impairment ratings for hypertension and non-cardiac vascular conditions. For conditions affecting the heart itself refer to Chapter 1 (Cardiorespiratory Impairment).

PART 2.1:     HYPERTENSION

Hypertension, of itself, does not affect effort tolerance. Therefore, uncomplicated hypertension is not to be assessed under Chapter 1 (Cardiorespiratory Impairment) but in the manner set out below.

Calculation of the impairment rating for hypertension

Follow the steps below to calculate the impairment rating for hypertension.

STEP 1

Establish whether any target organ damage is present.

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STEP 2

(Omit this step if  there is no target organ damage.)

Calculate the total functional impairment for any accepted target organ damage

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STEP 3

Calculate the Other Impairment rating for the accepted hypertension by applying Table 2.1.1.

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STEP 4

(Omit this step if  there is no target organ damage.)

Compare the rating obtained in Step 2 with the rating obtained in Step 3. Take the higher of these two ratings

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Step 1:            Establish whether any target organ damage is present.

For the purposes of this chapter, “target organ damage” means any of the following:

·           hypertensive retinopathy, grade III or IV;

·           hypertensive cardiac disease, with ECG or X-ray evidence of left ventricular hypertrophy;

·           hypertensive nephropathy demonstrated at biopsy, or by presence of proteinuria or elevated serum creatinine level; or

·           hypertensive cerebral haemorrhage.

Certain other conditions have hypertension as a contributing factor in their aetiology (for example: ischaemic heart disease and peripheral vascular disease). Such conditions are not to be regarded as being target organ damage when applying Part 2.1.

Step 2:            Calculate the total functional impairment due to any accepted target organ damage.

Accepted hypertensive retinopathy is to be assessed by applying Chapter 8.

If other ophthalmic conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.

Accepted hypertensive cardiac disease is to be assessed by applying Chapter 1.

If other cardiorespiratory conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.

Accepted hypertensive nephropathy is to be assessed by applying Chapter 9.

If other renal conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.

Accepted hypertensive cerebral haemorrhage is to be assessed according to the specific effects of the haemorrhage.

The impairment ratings attributable to the accepted target organ damage are to be combined by applying Chapter 18 (Combined Values Chart) to obtain the total impairment rating for accepted target organ damage.

Target organ damage that is not an accepted condition cannot be assessed under this Guide. Target organ damage can be assessed under this Guide only after it has been claimed and has become an accepted condition.

The criterion in Table 2.1.1 which refers to “hypertension of such a degree that target organ damage is present” is not an assessment of the target organ damage itself but is a measure of the severity of the hypertension.


Step 3:            Determine an impairment rating for hypertension from Table 2.1.1.

Other Impairment Table 2.1.1

HYPERTENSION

Impairment Ratings

 

Criteria

NIL

Hypertension adequately controlled by diet and weight loss without long-term medication.

TWO

Hypertension requiring long-term medication but without side-effects of the medication and with no evidence of target organ damage.

FIVE

·         Hypertension with diastolic pressure consistently at or greater than 90 mm Hg despite treatment.

·         Hypertension: controlled but frequent minor side effects of medication which cause no loss of function.

TEN

·         Hypertension: diastolic pressure consistently greater than 100 mm Hg.

·         Hypertension of such a degree that target organ damage is present.

·         Hypertension: controlled but with side effects of medication causing a significant and persistent loss of function.

 

Only one rating is to be selected from this table.

No age adjustment permitted for this table

For the purpose of determining a rating of 10 impairment points from Table 2.1.1  (dot point 2) target organ damage has to be present either as an accepted condition or as a non-accepted condition.

Step 4:            (Omit this step if is there is no target organ damage.) Compare the rating obtained in Step 2 with the rating obtained in Step 3. Take the higher rating.

The total impairment rating for accepted target organ damage is to be compared with any applicable rating from Table 2.1.1, and the higher of the two is to be taken as the impairment rating for the accepted hypertension.

Substep 4A

If the impairment rating from Table 2.1.1 is higher than the total rating for accepted target organ damage, the latter rating is to be discarded and its components are not to be used in any further calculations.

Substep 4B

If the impairment rating for accepted target organ damage is higher than the rating from Table 2.1.1, the rating from Table 2.1.1 is to be discarded and each of the components of the rating for accepted target organ damage is to be included in the final combining of all impairment ratings.

Impairment ratings from Table 2.1.1 are not routinely compared with ratings from the functional loss tables in Chapter 1 (Cardiorespiratory Impairment) except if hypertensive cardiomyopathy is present. Instead, they are to be compared with the impairment rating for the total loss of function due to target organ damage.

The total impairment rating for target organ damage is not to be combined with the impairment rating obtained from Table 2.1.1.


PART 2.2:     VASCULAR CONDITIONS OF THE LOWER LIMBS

Each vascular condition of the lower limbs is characterised as belonging to one or more of three categories. These categories are:

·           (arterial) peripheral vascular disease;

·           varicose veins and vascular leg ulcers; and

·           oedema.

Each category is to be assessed by applying a specific table from this part of the Guide. Depending on their effects, vascular conditions of the lower limbs may be rated under one or more of these tables.

Determination of the impairment rating for vascular conditions of the lower limbs

Follow the steps below to determine the impairment rating for each type of accepted vascular condition of the lower limbs.

(Each step is elaborated in the following pages.)

Step 1

Establish whether any effect on lower limb function is present.

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Step 2

Establish whether any effect on the skin is present.

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Step 3

(Omit this step if there is no effect on lower limb function)

Determine the impairment rating for the effects on lower limb function.

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Step 4

(Omit this step if there is no effect on skin)

Determine the impairment rating for the effects on the skin.

Page 34

Step 5

Determine the Other Impairment rating for the vascular conditions of the lower limbs by applying Tables 2.2.1, 2.2.2, and 2.2.3.

Page 34

Step 6

Combine the impairment ratings obtained in Steps 3 and 4.

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Step 7

Combine the impairment ratings obtained in Step 5.

Page 36

Step 8

Compare the impairment ratings obtained in Steps 6 and 7.

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Step 9

If the comparison made in Step 8 shows that the impairment rating obtained in Step 6 is greater than the impairment rating obtained in Step 7, then the ratings obtained in Steps 3 and 4 are the final impairment ratings for the vascular condition.

Page 36

Step 10

If the comparison made in Step 8 shows that the impairment rating obtained in Step 7 is greater than the impairment rating obtained in Step 6, then the separate ratings that have been combined in Step 5 are the final impairment rating(s) for the vascular condition.

Page 37

Step 1:            Establish whether any effect on lower limb function is present.

Lower limb function may be affected by peripheral vascular disease. If  peripheral vascular disease is present, the veteran’s walking distance is likely to be reduced as a result of intermittent claudication (cramplike pain in the calves of the legs).

Step 2:            Establish whether any effect on the skin is present.

Varicose veins can affect the skin of the lower limbs. They may cause discolouration or pruritus (itching). Excoriations (scratch marks) may be present.

Step 3:            (Omit this step if there is no effect on lower limb function.) Determine the impairment rating for the effects on lower limb function.

Lower Limb Function is to be assessed by applying Chapter 3 (Impairment of Spine And Limbs) ­— Part 3.2. If other conditions affecting lower limb function are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.

The effects of vascular conditions of the lower limbs on lower limb function are taken to be symptoms or manifestations of the condition. Hence, they are to be assessed as part of the vascular condition of the lower limbs.

Step 4:            (Omit this step if there is no effect on the skin.) Determine the impairment rating for the effects on the skin.

Skin conditions are to be assessed by applying Chapter 11 (Skin Impairment). If other conditions affecting the skin are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.

The effects of vascular conditions of the lower limbs on the skin of the lower limbs are taken to be symptoms or manifestations of the condition. Hence, they are to be assessed as part of the vascular condition of the lower limb.

Step 5:            Determine the Other Impairment rating for the vascular conditions of the lower limbs by applying Tables 2.2.1, 2.2.2, and 2.2.3.

There are three Other Impairment tables relating to the effects of vascular conditions of the lower limbs. A condition may be rated under more than one table if appropriate. However, only one rating may be taken from each table irrespective of how many conditions contribute to the type of impairment to which that table relates.

The three Other Impairment tables are:

Table 2.2.1        —        (Arterial) Peripheral Vascular Disease

Table 2.2.2        —        Varicose Veins

Table 2.2.3        —        Oedema.

Amputations arising from peripheral vascular disease cannot be assessed unless they have been separately accepted.  They can then be assessed under Chapter 3 (Impairment of Spine and Limbs).

Other Impairment Table 2.2.1

(ARTERIAL) PERIPHERAL VASCULAR DISEASE

Impairment Ratings

 

Criteria

NIL

No peripheral vascular disease is present.

TWO

Minor peripheral vascular disease or peripheral vascular disease that has been successfully treated.

FIVE

Moderate peripheral vascular disease is present but causes little restriction of activities.

TEN

Severe peripheral vascular disease, the expected effects of which are masked by a non-accepted condition (eg, masked by restriction on walking due to a musculo­skeletal disorder).

 

Irrespective of whether one or two legs are affected, only one rating may be selected from this table.

No age adjustment permitted for this table

Other Impairment Table 2.2.2

VARICOSE VEINS

Impairment Ratings

 

Criteria

NIL

·         Varicose veins which are not greatly disfiguring, which cause only trivial symptoms, and which impose no significant restriction on activities.

·         Superficial, small or transient ulceration.

TWO

Varicose veins which are unsightly or even gross but which impose no significant restriction on activities.

FIVE

Varicose veins, varicose ulcers — causing constant or almost constant symptoms which are not easily tolerated and require medication or therapy.

TEN

Very severe varicose veins or ulceration — difficult to control and requiring periodic confinement or hospital admissions.

 

Irrespective of whether one or two legs are affected, only one rating may be selected from this table.

No age adjustment permitted for this table

Other Impairment Table 2.2.3

OEDEMA

Impairment Ratings

 

Criteria

NIL

Mild or transient oedema.

FIVE

Moderate and persistent oedema.

TEN

Marked oedema, that is only partly controlled by treatment or therapy.

 

Irrespective of whether one or two legs are affected, only one rating may be selected from this table.

No age adjustment permitted for this table

An impairment rating from this table may be given in addition to an impairment rating from Chapter 1 even when both arise from the same condition (eg, heart failure). 

Step 6:            Combine the impairment ratings obtained in Steps 3 and 4.

If ratings were obtained both in Step 3 and in Step 4, then the ratings are to be combined. This combining is for the purpose of the comparison to be made in Step 8. If only one rating has been given in Steps 3 and 4, then the result to be obtained in Step 6 is to be the same as the one rating given in either Step 3 or Step 4.

Step 7:            Combine the impairment ratings obtained in Step 5.

If more than one rating has been given in Step 5 then the ratings are to be combined. This combining is for the purpose of the comparison to be made in Step 8. If only one rating has been given in Step 5, then the result to be obtained in Step 7 is to be the same as the result obtained in Step 5.

Step 8:            Compare the impairment ratings obtained in Steps 6 and 7.

 

Step 9:            If the comparison made in Step 8 shows that the impairment rating obtained in Step 6 is higher than the impairment rating obtained in Step 7, then the ratings obtained in Steps 3 and 4 are the final impairment ratings for the vascular condition.

If more than one rating was obtained in Steps 3 and 4 those ratings are not to be combined at this stage, but each is to be included in the final combining of all ratings.

Step 10:          If the comparison made in Step 8 shows that the impairment rating obtained in Step 7 is higher than the impairment rating obtained in Step 6, then the rating(s) obtained in Step 5 are the final impairment rating(s) for the vascular condition.

If more than one rating was obtained in Step 5 those ratings are not to be combined at this stage, but each is to be included in the final combining of all ratings.


PART 2.3:  OTHER NON-CARDIAC VASCULAR CONDITIONS

This Part is to be applied for a variety of vascular conditions not covered elsewhere in the Guide.

Other Impairment Table 2.3.1

ANEURYSMS AND INTRA-VASCULAR CONDITIONS

Impairment Ratings

 

Criteria

NIL

No aneurysms or intra-vascular conditions present.

TWO

·         Aortic aneurysm of diameter less than 6 cm.

·         Renal artery stenosis.

·         Iliac or femoral or carotid aneurysms.

FIVE

·         Embolus requiring anticoagulant medication.

·         Non-valvular vascular conditions requiring anti-coagulant medication.

·         Aortic aneurysm of 6 cm diameter or more.

·         Aortic aneurysm surgically corrected.

TEN

Other vascular conditions (eg. severe deep venous thrombosis) that are difficult to control.

 

The impairment from any single condition can only receive one rating from this table. If the impairment from a given condition (eg, an aortic aneurysm) satisfies more than one criterion, it is to be given only the highest applicable rating.

No age adjustment permitted for this table

Aneurysms, atherosclerosis, and cerebrovascular disease

Impairment from atherosclerosis is to be rated by applying the appropriate tables in Chapter 1, Part 2.2 of Chapter 2, and Chapter 5 (Neurological Impairment) according to the losses of function or other impairments which it causes.

Impairment from cerebral aneurysms and cerebrovascular disease is to be rated by applying Chapter 5 (Neurological Impairment) and any other applicable chapter, according to the other effects of the cerebrovascular disease.


 

CHAPTER 3

IMPAIRMENT OF SPINE AND LIMBS

 

This chapter contains six parts:

Part 3.1           —        Upper Limbs

Part 3.2           —        Lower Limbs

Part 3.3           —        Spine

Part 3.4           —        Resting Joint Pain

Part 3.5           —        Ranges of Joint Movement

Part 3.6           —        Spine and Limbs Age Adjustment

INTRODUCTION

This chapter is used to assess the motor function of the spine and limbs. Sensory loss is to be assessed under Chapter 5 (Neurological Impairment).

Impairment of limbs

When a previously-accepted condition is later removed by an amputation that is also an accepted condition, the rating is to be based on the amputation or the resulting functional deficit, whichever results in the higher impairment rating. The previously accepted condition is not to be given an impairment rating.

PART 3.1:     UPPER LIMBS

Functional impairment is to be calculated separately for each upper limb. Thus one functional impairment rating may be calculated for the right upper limb and another for the left upper limb.

Calculation of the impairment rating for conditions of each upper limb

Follow the steps below to calculate the impairment rating for accepted conditions of each upper limb:

(Steps 2–8 are elaborated in the following pages.)

STEP 1

If accepted condition(s) affect only the right upper limb, follow steps 2–8.

If accepted condition(s) affect only the left upper limb, follow steps 2–8 substituting “left” for “right” in the instructions.

If accepted condition(s) affect both upper limbs, follow steps 2–8 to assess the right upper limb, and then, to assess the left upper limb, repeat steps 2–8 substituting “left” for “right” in the instructions.

 

STEP 2

Establish which joints in the right upper limb, if any, have some restriction of movement as a result of accepted conditions affecting the right upper limb.

Page 40

STEP 3

(Omit this step if is there is no restriction of joint movement in the right upper limb.)

Calculate the functional impairment due to restriction of range of movement of joints in the right upper limb as a result of accepted conditions of the right upper limb.

Page 41

STEP 4

Calculate the functional impairment rating for the right upper limb as a whole using Table 3.1.2.

Page 43

STEP 5

Compare the functional impairment rating for the right upper limb as a whole with the functional impairment rating from any restricted range of movement. Take the higher of these two as the final functional impairment rating for the right upper limb.

Page 43

STEP 6

Make any applicable age adjustment to the final functional impairment rating for the right upper limb by applying Table 3.6.1 in Part 3.6 of this chapter.

Page 43

STEP 7

Determine if any Other Impairment rating applies to the right upper limb.

Page 44

STEP 8

(Omit this step if no Other Impairment rating applies to the right upper limb.)

Compare the final functional impairment rating for the right upper limb with any Other Impairment rating applicable to the right upper limb. Take the higher of these ratings.

Page 45

 

Step 2:            Establish which joints in the right upper limb have some restriction of movement as a result of accepted conditions of the right upper limb.

For the purposes of assessment under the Guide, the major joints of the upper limb are the shoulder, the elbow and the wrist.  

In addition, the joints of the thumb and fingers are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the thumb and fingers considered together.

Conditions such as painful arc syndrome and fractured neck of radius may affect the range of movement (ROM) of the shoulder. A condition such as fractured scaphoid will be likely to affect the ROM of the wrist. In cases of fractures, the ranges of movements of the joints proximal to and distal to the fracture site should generally be considered as joints the ROM of which may be affected.

Hence, it must be determined which, if any, of

·           shoulder;

·           elbow;

·           wrist; and

·           thumb and fingers,

potentially have loss of range of movement due to accepted conditions.

Certain vascular conditions or neurological conditions of the upper limb, such as muscle weakness, tremor, apraxia, and loss of co-ordination, may have an effect on the function of the upper limb without restricting the range of movement of any joint of the limb. The assessment of such conditions is to be made under Step 4 of this Part.

Step 3:            Calculate the functional impairment due to restriction of range of movement of joints in the right upper limb as a result of accepted conditions of the right upper limb.

Single functional impairment ratings may be obtained for each of the following four joints or sets of joints based on restriction of range of movement due to accepted conditions:

·      shoulder;

·      elbow;

·      wrist; and

·      thumb and fingers.

These impairment ratings are to be obtained by applying Table 3.1.1. Such functional impairment ratings are referred to as the functional impairment rating of the upper limb based on restriction of range of movement of the shoulder, elbow, wrist, or thumb and fingers respectively.

The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.

The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non-affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right elbow in the normal fashion, by use of the right biceps, but can use the left hand to bend the right elbow, the right elbow should be assessed as having “loss of almost all movement”.)

The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.1.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement must be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.

The average ranges of movement of various normal joints of the upper limb may be obtained from Table 3.5.1 in Part 3.5. These values are to be used in arriving at the fractional loss of range of movement when the actual movements of a joint are known in degrees.

If non-accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.1.

For the purposes of this chapter:

“position of function” means the position that interferes least with the total  function of the limb or the spine; and

“unfavourable position” means a position that is significantly different from the position of function; and

“flail joint” means a joint that is completely unstable in all directions.


 

Functional Loss Table 3.1.1

 

LOSS OF MUSCULOSKELETAL FUNCTION: UPPER LIMB JOINTS

 

 

Impairment Ratings

Shoulder

Elbow

Wrist

Thumb and Fingers

 

NIL

·              No abnormality.

·       X-ray changes only with normal range of movement.

·              No abnormality.

·       X-ray changes only with normal range of movement.

·              No abnormality.

·       X-ray changes only with normal range of movement.

·                   No abnormality.

·         X-ray changes only with normal range of movement.           

 

FIVE

 

 

Loss of about one-quarter normal range of movement.

 

·                   Ankylosis in any position of joints of 4th or 5th finger.

·         Ankylosis in any position of function of any joints of 2nd or 3rd finger.

 

TEN

Loss of about one-quarter normal range of movement.

Loss of about one-quarter normal range of movement.

Loss of about one-half normal range of movement.

 

·                   Ankylosis in an unfavourable position of any or all joints of 2nd and 3rd finger.

·         Thumb: loss of almost all movement or complete ankylosis of any or all joints (in position of function).

 

FIFTEEN

 

 

Loss of about three-quarters normal range of movement.

 

Thumb: ankylosis of any or all joints in an unfavourable position.

 

 

TWENTY

Loss of about one-half normal range of movement.

Loss of about one-half normal range of movement.

 

Loss of almost all movement, or complete ankylosis in position of function.

 

 

 

THIRTY

Loss of about three-quarters normal range of movement.

Loss of about three-quarters normal range of movement.

Ankylosis in an unfavourable position, or a flail joint.

 

 

 

FORTY

Loss of almost all movement, or complete ankylosis in position of function.

Loss of almost all movement, or complete ankylosis in position of function.

 

 

 

FIFTY

Ankylosis in an unfavourable position, or a flail joint.

Ankylosis in an unfavourable position, or a flail joint.

 

 

 

 

Only one rating is to be selected from this table fro each shoulder, elbow, or wrist; and only one rating is to be selected from this table for the thumb and fingers together.  Of these ratings only the highest is to be taken for each side.

Ratings from this table are age adjusted (see Table 3.6.1)


Step 4:            Calculate the functional impairment rating for the right upper limb as a whole using Table 3.1.2.

Table 3.1.2 measures the loss of function relating to the upper limb as a whole. Only one rating is to be given from this table, for the right upper limb, for any condition or combination of conditions. To attract a particular rating, the degree of impairment must be greater than that described at all lower levels.

Table 3.1.2 is the only relevant table if the use of an upper limb is restricted by vascular conditions or neurological conditions, such as muscle weakness, tremor, apraxia, loss of co-ordination, fatigue or pain, and when no condition affecting the range of movement of a joint is present.

If non-accepted conditions contribute to the loss of function, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.2.

Step 5:            Compare the impairment rating for loss of function of the right upper limb with the impairment rating from any restricted range of movement. Take the higher of these two as the final functional impairment rating for the right upper limb.

After the application of Chapter 19 (Partially Contributing Impairment) in Step 3, the functional impairment rating from loss of range of movement is to be compared with the functional impairment for the use of the limb as whole.

The higher of these two ratings is then taken as the final functional impairment rating for the right upper limb.

Step 6:            Make any applicable age adjustment to the final functional impairment rating for the right upper limb by applying Table 3.6.1 in Part 3.6 of this chapter.

The functional impairment rating obtained in Step 4 is to be age adjusted by applying Table 3.6.1.

Total loss of function of each upper limb is considered to be 60 per cent impairment of the whole person. Amputation of an arm at the shoulder joint, or total loss of use of an arm is equivalent to 60 impairment points.

With the exception of a forequarter amputation, no condition or combination of conditions affecting an arm shall receive an impairment rating exceeding 60 points.

In the case of a veteran aged 45 years or less, if the application of age adjustment to the functional impairment rating of an accepted condition affecting the right upper limb results in an impairment rating higher than 60 impairment points, the functional impairment rating for the right upper limb is to be taken as 60 impairment points and not at the higher rating obtained by applying Table 3.6.1.

 


 

Functional Loss Table 3.1.2

LOSS OF MUSCULOSKELETAL FUNCTION: (BASED ON USE OF LIMB AS A WHOLE)

Impairment Ratings

 

Criteria

NIL

Can use limb efficiently for normal tasks and without undue fatigue.

TWO

Can use limb efficiently for normal tasks but with excessive fatigue towards the end of the day.

FIVE

Can use limb efficiently for normal tasks without excessive fatigue for no more than half an hour.

TEN

·       Can use limb reasonably well in most circumstances, but frequent difficulties are manifested by:

-     minor loss of digital dexterity causing handwriting changes, or difficulty in manipulation of small or fine objects, or

-     minor loss of grip strength causing difficulty in gripping moderately heavy to heavy objects.

·       Can use limb efficiently for normal tasks without excessive fatigue for no more than ten minutes.

FIFTEEN

Can use limb reasonably well in most circumstances, but frequent difficulties are manifested by:

-     minor loss of digital dexterity causing handwriting changes, or difficulty in manipulation of small or fine objects, and 

-     minor loss of grip strength causing difficulty in gripping moderately heavy to heavy objects.

TWENTY

Can use limb reasonably well in some circumstances, but with more noticeable difficulty manifested by either or both of:

-     minor loss of digital dexterity and reduced grip strength causing difficulty in manipulation of larger objects, or

-     major loss of digital dexterity causing marked difficulty in handwriting or manipulation of everyday domestic objects.

THIRTY

Can use limb reasonably well in a few circumstances only. Use of limb is otherwise inefficient, with increasing difficulty for self-care activities. Poor digital co-ordination and markedly reduced grip strength in, eg, lifting light objects. Problems with dressing, feeding or writing.

FORTY

Uses limb inefficiently in all circumstances. Use of limb subject to major limitations, capable of light grip only. Aids, eg, splints, required for everyday activities such as writing and eating.

FIFTY

Has only some movement against gravity at elbow, shoulder or wrist.

SIXTY

Unable to use upper limb at all.

 

Only one rating is to be selected from this table for each upper limb, for any condition or combination of conditions.

Ratings from this table are age adjusted (see Table 3.6.1)

Step 7:            Determine if any Other Impairment rating applies to the right upper limb.

There are three Other Impairment tables relating to the upper limb. These are:

Table 3.1.3        —        Amputations of Fingers and Thumb; and

Table 3.1.4        —        Amputations of Upper Limb; and

Table 3.1.5        —        Dislocation of Shoulder.

Not more than one rating may be selected from either Table 3.1.3 or Table 3.1.4, if the veteran has an amputation affecting the right upper limb.

An additional rating may be selected from Table 3.1.5 if it is applicable to the right shoulder.

If no ratings from Tables 3.1.3 or 3.1.4 or 3.1.5 apply to the right upper limb, then the functional impairment rating obtained under Step 6 is the final functional impairment rating for the right upper limb.

Step 8:            Compare the final functional impairment rating for the right upper limb with any Other Impairment rating applicable to the right upper limb. Take the higher of these ratings.

The final functional impairment rating obtained in Step 6 is to be compared with the impairment rating for that limb obtained in Step 7 (if any).

The higher of the two ratings is then to be taken as the total final impairment rating for the right upper limb.

If multiple accepted conditions are responsible for the impairment of an upper limb, the situation will be more complicated and may require applying Chapter 20 (Apportionment).

If the veteran has received a rating from either Table 3.1.3 or Table 3.1.4 and also a rating from Table 3.1.5 the substeps below are to be followed.

 

Substep 8A

The functional impairment rating for the right upper limb, obtained in Step 6, is to be apportioned into two or three parts, as appropriate, by applying Chapter 20 (Apportionment). The parts are:

·         one part corresponding to the impairment due to amputations affecting the right upper limb;

·         one part corresponding to the impairment due to dislocation of the right shoulder;

·         one part corresponding to the impairment (if any) of the right upper limb due to all causes other than dislocation of shoulder and amputations.

 

 

Other Impairment Table 3.1.3

AMPUTATIONS OF FINGERS AND THUMB

Impairment Ratings

 

Criteria

NIL

No amputation of fingers or thumb.

TWO

Amputation of little finger of one hand.

FIVE

Amputation of ring finger of one hand.

TEN

·                   Amputation of index finger of one hand

·                   Amputation of middle finger of one hand.

·                   Amputation of ring and little fingers of one hand.

FIFTEEN

·                   Amputation of index and little fingers of one hand.

·                   Amputation of middle and little fingers of one hand.

·                   Amputation of index and ring fingers of one hand.

·                   Amputation of middle and ring  fingers of one hand.

TWENTY

·                   Amputation of thumb of one hand.

·                   Amputation of index and middle fingers of one hand

·                   Amputation of index, ring, and little fingers of one hand.

·                   Amputation of middle, ring, and little fingers of one hand.

TWENTY-FIVE

·                   Amputation of thumb and ring finger of one hand.

·                   Amputation of thumb and little finger of one hand.

·                   Amputation of index, middle, and ring fingers of one hand.

·                   Amputation of index, middle, and little fingers of one hand.

THIRTY

·                   Amputation of thumb and index finger of one hand.

·                   Amputation of thumb and middle finger of one hand.

·                   Amputation of thumb, index and little fingers of one hand.

·                   Amputation of thumb, middle and little fingers of one hand.

·                   Amputation of thumb, ring, and little fingers of one hand.

·                   Amputation of index, middle, ring and little finger, but not thumb, of one hand.

THIRTY-FIVE

·                   Amputation of thumb, index, and middle fingers of one hand.

·                   Amputation of thumb, index and ring fingers of one hand.

·                   Amputation of thumb, middle and ring fingers of one hand.

·                   Amputation of thumb, index, ring, and little fingers of one hand.

·                   Amputation of thumb, middle, ring, and little fingers of one hand.

FORTY

·                   Amputation of thumb, index, middle, and ring fingers of one hand.

·                   Amputation of thumb, index, middle, and little fingers of one hand.

FORTY-FIVE

Amputation of index, middle, ring, and little fingers, and thumb, of one hand.

 

One rating may be given from this table for each side, as applicable.

No age adjustment permitted for this table

 


 

Other Impairment Table 3.1.4

AMPUTATIONS OF UPPER LIMB

Impairment Ratings

 

Criteria

NIL

No amputations involving the upper limb.

FIFTY

·         Mid-carpal amputation of one hand.

·         Mid-metacarpal amputation of one hand.

·         Disarticulation at wrist joint.

·         Amputation of forearm distal to biceps tendon insertion.

SIXTY

·         Amputation of forearm proximal to biceps tendon insertion.

·         Disarticulation at elbow.

·         Amputation between deltoid insertion and elbow.

·         Amputation above deltoid insertion.

·         Disarticulation at shoulder.

SEVENTY

Forequarter amputation.

 

One rating may be given from this table for each upper limb, as applicable.

No age adjustment permitted for this table

Other Impairment Table 3.1.5

DISLOCATION OF SHOULDER

Impairment Ratings

 

Criteria

NIL

·       No recurrent dislocation of shoulder.

·       Dislocation of shoulder on a single occasion.

TWO

Recurrent dislocation of shoulder surgically corrected.

FIVE

Recurrent dislocation of shoulder not surgically corrected.

TEN

Dislocation of shoulder resulting in prophylactic restriction of movement.

 

Only one rating is to be selected from this table for each shoulder.

No age adjustment permitted for this table


 

Substep 8B

Compare the apportioned functional impairment rating corresponding to the impairment due to amputations affecting the right upper limb (obtained in substep 8A) with the Other Impairment rating from either Table 3.1.3 or Table 3.1.4 (obtained in Step 7). The higher of these two ratings is to be selected.

Substep 8C

Compare the apportioned functional impairment rating corresponding to the impairment due to dislocations of the right shoulder (obtained in substep 8A) with the Other Impairment rating from Table 3.1.5 (obtained in Step 7). The higher of these two ratings is to be selected.

Substep 8D

The veteran’s accepted right upper limb condition(s) will receive (up to) three impairment ratings:

·      The functional impairment rating corresponding to the impairment of the right upper limb due to all causes other than amputations and dislocation of shoulder (if such a rating is obtained in substep 8A);

·      The impairment rating obtained in substep 8B; and

·      The impairment rating obtained in substep 8C.

These ratings are not to be combined at this stage but are to be included in the final combining of all ratings.

Examples

Example 1

A veteran has an amputation of the right thumb as the only accepted disability of the right upper limb.

By following steps 1 to 7 inclusive, a rating will have been selected

from Table 3.1.2:

probably 20 to 40 impairment points (depending on the severity of the effect on the hand)

from Table 3.1.3:

20 impairment points.

These two ratings are compared and the veteran receives the higher as the final impairment rating for the right upper limb.

Example 2

A veteran has an amputation of his right thumb and dislocation of the right shoulder as the only accepted conditions of the right upper limb.

By following steps 1 to 7 inclusive, a rating will have been selected

from Table 3.1.2:

say, 40 impairment points (the veteran can use the right upper limb reasonably well in a few circumstances only)

from Table 3.1.3:

20 impairment points; and

from Table 3.1.5:

10 impairment points.

Medical evidence shows that the incapacity of the veteran’s right upper limb is due 80% to the shoulder condition and 20% to the amputated thumb. Apportioning the 40 impairment points in the ratio of 4:1, 34 points are obtained for the shoulder, and 9 points for the thumb (Table 20.1).

After comparing the apportioned functional impairment rating of 34 for the right shoulder with the Other Impairment rating of 10 from Table 3.1.5, the veteran gets 34 points for the shoulder. After comparing the apportioned functional impairment rating of 9 for the amputated right thumb with the Other Impairment rating of 20 from Table 3.1.3, the veteran gets 20 points for the amputation of the right thumb.

In this case the final impairment ratings for the right upper limb are 34 points and 20 points. These are to be included in the final combining of all ratings.

 

An Upper Limb Worksheet is provided on page 70.

 

A separate Upper Limb Worksheet is to be used for each upper limb. If, for either upper limb, two Other Impairment ratings are applicable the Functional Impairment rating (E) is to be compared with the Other Impairment ratings in accordance with Step 8.

 


 

PART 3.2:     LOWER LIMBS

Because the two lower limbs constitute a functional unit, a single functional impairment rating is calculated for both lower limbs together.

Calculation of the impairment rating for conditions of the lower limbs

Follow the steps below to calculate the impairment rating due to accepted conditions of the lower limbs:

(Each step is elaborated in the following pages.)

Step 1

Establish which joints in the lower limbs, if any, have some restriction of movement as a result of accepted conditions affecting the lower limbs.

Page 50

Step 2

(Omit this step if there is no restriction of joint movement in the limbs.)

Calculate the functional impairment due to restriction of the range of movement of joints in the lower limbs as a result of accepted conditions of the lower limbs.

Page 51

Step 3

Make any applicable age adjustment to the final functional impairment rating for the limbs by applying Table 3.6.1 in Part 3.6 of this chapter.

Page 53

Step 4

Calculate the functional impairment rating for the lower limbs as a whole by applying Table 3.2.2.

Page 54

Step 5

Compare the functional impairment rating for the lower limbs as a whole with the functional impairment rating due to any restricted range of movement. Take the higher of these two ratings as the final functional impairment rating for the limb.

Page 56

Step 6

Determine if any Other Impairment rating applies to the lower limbs.

Page 56

Step 7

(Omit this step if no Other Impairment rating applies to the limbs.)

Compare the final functional impairment rating for the limbs with any Other Impairment rating applicable to the limbs. Take the higher of these ratings.

Page 56

Step 1:            Establish which joints in the lower limbs, if any, have some restriction of movement as a result of accepted conditions affecting the lower limbs.

For the purposes of assessment under this Guide, the major joints of the lower limbs are the hip, the knee and the ankle.  

In addition, the joints of the toes are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the toes of one foot considered together.

Conditions such as chondromalacia patellae and torn medial meniscus may affect the range of movement of the knee. A condition such as fractured neck of femur will be likely to affect the range of movement of the hip. In cases of a fracture, the ranges of movements of the joints both proximal to and distal to the fracture site should generally be considered as joints the range of movement of which may be affected. The closer a fracture site is to a joint, the more likely it is that it will have some effect on the range of movement of that joint.

Hence, it must be determined which, if any, of both right and left:

·           hip;

·           knee;

·           ankle; and

·           toes;

potentially have loss of range of movement due to accepted conditions.

Certain vascular conditions or neurological conditions of the lower limb, such as muscle weakness, tremor, apraxia, or loss of co-ordination may have an effect on the function of the lower limb without restricting the range of movement of any joint of the limbs. The assessment of such conditions is made under Step 4 of this Part.

Step 2:            Calculate the functional impairment due to restriction of the range of movement of joints in the lower limbs as a result of accepted conditions of the lower limbs.

Single functional impairment ratings may be obtained for each of the following eight joints or sets of joints based on restriction of range of movement due to accepted conditions:

·           Right hip;

·           Left hip;

·           Right knee;

·           Left knee;

·           Right ankle;

·           Left ankle; and

·           Right toes;

·           Left toes.

These impairment ratings are obtained by applying Table 3.2.1. Such functional impairment ratings are referred to as the functional impairment rating of the relevant lower limbs based on restriction or range of movement of the right or left hip, knee, ankle, or toes respectively.

The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.

The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non-affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right knee in the normal fashion, by use of the hamstring muscles, but can use a hand to bend the right knee, the right knee should be assessed as having “loss of almost all movement”.)

“Unfavourable position” and “position of function” and “flail joint” are defined at page 41.

The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.2.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement is to be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.

The average ranges of movement of various normal joints of the lower limbs may be obtained from Table 3.5.1 in Part 3.5 of this Chapter. These values are to be used in arriving at the fractional loss of range of movement when the movements of a joint are known in degrees.

If non-accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be used in conjunction with Table 3.2.1.

If various impairment ratings have been obtained for lower limb joints, and Chapter 19 has been applied to them, take the highest resultant rating. This is the final functional impairment rating for the lower limbs based on loss of range of movement. If Chapter 19 did not have to be applied, then take the highest of the various impairment ratings that have been obtained for each lower limb joint. In that case, this is the final functional impairment rating for the lower limbs.