Guide to the Assessment
of Rates of Veterans' Pensions
Department of Veterans' Affairs
Canberra
Contents
Introduction ............................................................................................................ 1
How to Use this Guide ............................................................................................ 5
Medical Impairment ........................................................................................... 13
Part A: System Specific Assessment ….................................................................... 15
Chapter 1: Cardiorespiratory Impairment ............................................................ 17
Cardiorespiratory Worksheet ...................................................................... 42
Chapter 2: Hypertension and Non-Cardiac Vascular Conditions ......................... 43
Part 2.1: Hypertension ................................................................................. 43
Part 2.2: Vascular Conditions of the Lower Limb ....................................... 47
Part 2.3: Other Non-Cardiac Vascular Conditions ...................................... 52
Chapter 3: Impairment of Spine and Limbs ......................................................... 53
Part 3.1: Upper Limbs ................................................................................. 53
Part 3.2: Lower Limbs ................................................................................. 65
Part 3.3: Spine ............................................................................................. 77
Part 3.4: Resting Joint Pain ......................................................................... 83
Part 3.5: Ranges of Joint Movement ........................................................... 84
Part 3.6: Spine and Limbs Age Adjustment ................................................ 85
Spine and Limbs Worksheet ........................................................................ 87
Chapter 4: Emotional and Behavioural ................................................................ 89
Emotional and Behavioural Worksheet ..................................................... 100
Chapter 5: Neurological Impairment .................................................................. 103
Chapter 6: Gastrointestinal Impairment ..............................................................115
Part 6.1: Diseases of the Digestive System ................................................115
Part 6.2: Abdominal Wall Hernias and Obesity ........................................ 126
Chapter 7: Ear, Nose, and Throat Impairment .................................................... 127
Part 7.1: Hearing Loss and Tinnitus .......................................................... 127
Part 7.2: Ear, Nose, and Throat ................................................................. 150
Hearing Impairment Worksheets
Index .......................................................................................................... 152
Worksheets ................................................................................................ 153
Chapter 8: Visual Impairment ............................................................................ 159
Part 8.1: Impairment of Visual Function ................................................... 159
Part 8.2: Other Ocular Impairment ........................................................... 167
Visual Impairment Worksheet ................................................................... 168
Chapter 9: Renal and Urinary Tract Function .................................................... 169
Part 9.1: Renal Function ............................................................................ 169
Part 9.2: Lower Urinary Tract Function .................................................... 173
Chapter 10: Sexual Function, Reproduction, and Breasts .................................... 177
Part 10.1: Sexual Function ........................................................................ 178
Part 10.2: Reproduction ............................................................................ 182
Part 10.3: Breasts ....................................................................................... 187
Chapter 11: Skin Impairment .............................................................................. 189
Chapter 12: Endocrine and Haemopoietic Impairment ...................................... 193
Part 12.1: The Endocrine System .............................................................. 193
Part 12.2: The Haemopoietic System ........................................................ 197
Part B: Non-System Specific Assessment ........................................................... 199
Chapter 13: Negligible Impairment .................................................................... 201
Chapter 14: Malignant Conditions ..................................................................... 203
Chapter 15: Intermittent Impairment .................................................................. 209
Intermittent Impairment Worksheets ........................................................ 217
Chapter 16: Activities of Daily Living ............................................................... 219
Chapter 17: Disfigurement and Social Impairment ............................................ 225
Part C: Impairment Ratings: Combining, Apportioning, Partially
Contributing ....................................................................................................... 229
Chapter 18: Combined Values Chart .................................................................. 231
Chapter 19: Partially Contributing Impairment .................................................. 237
Chapter 20: Apportionment ................................................................................ 241
Chapter 21: Paired Organs Policy ....................................................................... 259
Lifestyle Effects ................................................................................................. 261
Chapter 22: Lifestyle Effects .............................................................................. 263
Degree of Incapacity ......................................................................................... 275
Chapter 23: Conversion to Degree of Incapacity ............................................... 277
Chapter 24: Degree of Incapacity for Specific Disabilities ................................ 279
Index ................................................................................................................... 281
Introduction
Purpose
This Guide is to be applied to assess the extent of incapacity from war-caused or defence-caused injury or disease. Its provisions are binding on the Repatriation Commission, the Veterans' Review Board, and the Administrative Appeals Tribunal.
Legal background
The Veterans' Entitlements Act 1986 (the Act) provides for pensions to veterans for incapacity resulting from war or defence-caused injuries and diseases (sections 13 and 70).
The terms "injury" and "disease" are defined in subsection 5D(1) of the Act. A veteran's incapacity is defined by subsection 5D(2) as the effects of that injury or disease.
The Act provides three fundamental rates of pension: a general rate, an intermediate rate, and a special rate.
Section 22 of the Act provides that the percentage of general rate of pension payable is to be determined by reference to the extent of the veteran's incapacity as assessed in accordance with this Guide. Section 29 of the Act provides that the Repatriation Commission prepare the Guide, setting out:
"(a) criteria by reference to which the extent of the incapacity of a veteran resulting
from war-caused injury or war-caused disease, or both, shall be assessed; and
(b) methods by which the extent of that incapacity, as assessed in accordance with those criteria, shall be expressed as a percentage of incapacity from that injury or disease, or both, being a percentage not exceeding one hundred per centum."
Subsection 22(4) of the Act sets out the criteria in accordance with this Guide that must be met in order to qualify for the extreme disablement adjustment.
Definitions
For the purposes of this Guide, and unless a contrary intention appears:
"Act" means the Veterans' Entitlements Act 1986 as amended from time to time;
"accepted condition" means an injury or disease that has been determined under the Act to be war-caused or defence-caused;
"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 Table 18.1 (Combined Values Chart) in Chapter 18 in accordance with that chapter;
"condition" means an injury or a disease;
"defence-caused injury" and "defence-caused disease" have the meaning given in section 70 of the Act;
"disease" has the meaning given by section 5D of the Act;
"Guide" means this Guide to the Assessment of Rates of Veterans' Pensions;
"impairment rating" means a measure of the degree of medical impairment due to accepted conditions, on a scale of 0 to 100;
"incapacity" has the meaning given in subsection 5D(2) of the Act; "injury" has the meaning given by section 5D of the Act;
"non-accepted condition" means an injury or disease that:
+ has not been determined under the Act to be war-caused or defence-caused;
or
+ has been determined under the Act not to be war-caused or defence-caused;
"Statement of Principles" means:
+ a Statement of Principles determined by the Repatriation Medical Authority under section 196B of the Act; or
+ a determination made by the Repatriation Commission under section 180A
of the Act; or
+ a statement of principles concerning a particular kind of injury or disease made available to the Veterans' Review Board by the Repatriation Commission under paragraph 138(2)(a) of the Act;
"veteran" means a person (including a deceased person) in respect of whom an injury or disease has been determined under the Act to be war-caused or defence-caused;
"war-caused injury" and "war-caused disease" have the meaning given in section 9 of the Act;
"worksheet" means a page or pages of this Guide, identified as a "worksheet",
Introduction
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 following published works were found to be useful in the preparation of this edition of the Guide:
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 degree of incapacity from injuries or diseases or both that have been determined to be war-caused or defence-caused.
In making an assessment the clinical features of war-caused or defence-caused injuries or diseases are to be taken into account. Clinical features of sequelae of accepted conditions can only be assessed after the sequelae have been determined to be war- caused or defence-caused.
The elements of assessment
The two elements of the assessment of degree of incapacity are medical impairment and lifestyle effects. Lifestyle effects are dealt with in Chapter 22. Other chapters address medical impairment.
Medical impairment
Medical impairment has two components:
+ physical loss of, or disturbance to, any body part or system; and
+ the resultant functional loss.
Chapters 1 to 16 of the 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 that of 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 only 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.
Whole person impairment
Medical impairment is expressed in impairment points, out of a maximum rating of
100. On this scale, zero points corresponds to no or negligible impairment from accepted conditions, and 100 points corresponds to death. Effectively, impairment points are percentages of the impairment of the whole person.
Functional loss
Medical impairment is measured chiefly by loss of vital functions, addressed in twelve system specific chapters, as follows:
+ Cardiorespiratory Impairment
+ Hypertension and Non-Cardiac Vascular Conditions
+ Impairment of Spine and Limbs
+ Emotional and Behavioural
+ Neurological Impairment
+ Gastrointestinal Impairment
+ Ear, Nose, and Throat Impairment
+ Visual Impairment
+ Renal and Urinary Tract Function
+ Sexual Function, Reproduction, and Breasts
+ Skin Impairment
+ Endocrine and Haemopoietic Impairment
Functional loss is to be rated against criteria in Functional Loss tables. Each functional loss associated with an accepted condition is to be identified and rated individually. In most cases a single condition gives rise to a single functional loss.
If there is a multisystem condition in which a single condition gives rise to multiple functional losses, then such a single condition is to be rated using several Functional Loss tables. The separate ratings are only to be combined with each other in the final combining of all ratings from all accepted conditions. If two or more conditions contribute to the same functional loss, a single rating only is to be given for that functional loss.
Other Impairment
Other Impairment is the physical loss of, or disturbance to, any body part or system. This concept is extended in some chapters to include discomfort, pain, poor prognosis and other, less tangible, effects of accepted conditions. It is to be rated against criteria in Other Impairment tables.
As a general rule, ratings from Other Impairment and Functional Loss tables are not to be combined for the same condition. Exceptions to this rule are expressly indicated in particular chapters. When ratings from both types of table can be applied, the higher rating is to be chosen.
Lifestyle effects
Lifestyle effects are to be assessed by applying Tables 22.1 to 22.5 in Chapter 22 in accordance with that chapter.
The tables
Types of Tables. There are five types of tables in the Guide. They are "Functional Loss", "Other Impairment", "Scale", "Procedural", and "Lifestyle". Each table carries its type identification and number in the top left hand corner.
Some chapters are divided into parts. The tables in these chapters carry a number in three segments (separated by full stops):
Table
7.1.1
Chapter Table
Number
Part
Number
Number
Tables in chapters not divided into parts carry a number in two segments:
Table
1.1
Chapter Table
Number Number
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 may be 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.
Non-system specific assessments
There are five chapters describing alternate methods of assessing certain conditions. They are:
+ Chapter 13 Negligible Impairment
+ Chapter 14 Malignant Conditions
+ Chapter 15 Intermittent Impairment
+ Chapter 16 Activities of Daily Living
+ Chapter 17 Disfigurement and Social Impairment
A condition may be assessable under both system specific chapter(s) and non-system specific chapter(s), for example, carcinoma of the lung or epilepsy.
As a general rule, ratings from Chapters 14, 15, and 16 are not to be combined with any impairment ratings for the same condition derived from one or more system specific chapters. The impairment ratings from the system-specific chapters and the non-system specific chapters are to be compared and the higher impairment rating is to be selected.
Ratings from Chapters 13 and 17 are to be dealt with differently. Any applicable ratings from Chapters 13 and 17 are to be combined with any applicable ratings from other chapters in the final combining of all ratings.
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 themselves been separately determined to be war-caused or defence- caused.
As a general guide, a condition that is the subject of a Statement of Principles in force on 18 April 1998 should be taken as a separate disease entity. For the purposes of the preceding sentence, "Statement of Principles" has the meaning given to it on page 2 of this Guide.
Applying the instructions
To the extent of any inconsistency between an instruction in "How to Use this Guide" and a specific instruction concerning a particular matter in another chapter of this Guide, the specific instruction in that other chapter is to apply to that particular matter.
If assessment of impairment is not possible
If it is impossible to assess the impairment of an accepted condition that has previously been assessed under this or an earlier edition of the Guide, the impairment rating that was last given for that accepted condition (under this or the earlier edition of the Guide, as the case may be) is to be taken to be the impairment rating for that condition.
For example, if the veteran has an accepted visual loss, which at the last assessment had been given a rating of 15 impairment points, and is now afflicted with dementia, which prevents the assessment of that visual loss, the impairment rating for that visual loss would be taken to be 15 impairment points for the purposes of the current assessment.
If the impairment from a particular accepted condition has not previously been assessed (under this or an earlier edition of the Guide) and it is otherwise impossible to assess the impairment of that condition in accordance with this Guide, a best estimate must be made based on what medical and other evidence is available concerning the extent of impairment from that condition. Such assessment of impairment must take into account the contribution to impairment from other conditions and the expected course of the condition, including the effect of aging by reference to age adjustment tables, as appropriate. The impairment rating given by this method must be as consistent as possible with the relevant steps and tables in this Guide.
Pain and suffering
Pain and suffering have been taken into account in this Guide in the following manner:
+ if pain and suffering restrict everyday activities, the functional loss caused is rated in the appropriate table;
+ if pain and suffering occur without restriction to any activity the appropriate
Other Impairment table is used; and
+ allowance for pain and suffering is included in the lifestyle assessment.
Medication or treatment
In some cases, type of medication or treatment has been used as an indicator of the severity of disablement. Such tables contain appropriate criteria about medication. No additional rating is therefore required.
Persistent side effects of long term treatment are to be assessed as part of the condition being treated, using the appropriate system specific tables. Persistent side effects are those side effects of the treatment that persist during therapy but which resolve on (or shortly after) cessation of therapy.
Permanent side effects of long term treatment cannot be assessed as part of the condition being treated. Permanent side effects are those side effects of the treatment that persist during therapy and which do not resolve on (or shortly after) cessation of therapy. Such permanent side effects would generally be covered by a Statement of Principles. The permanent side effects must first be determined to be war-caused or defence-caused, before they can be assessed.
Time reference
The severity of many conditions fluctuates over time and may be better assessed by an averaging process. Therefore, because some criteria refer to the occurrence of symptoms during a period, it will be necessary to assess an averaged severity during that period. Twelve months is usually a suitable period, as it allows any seasonal fluctuation to be observed, but the period may be varied according to circumstances.
For tests done on a particular date, specifically spirometry, audiometry and creatinine clearance calculated from the formula, the veteran's age for the purpose of obtaining an impairment rating shall generally be his or her age on the date of the test.
Duration of assessment period
While the Act requires the assessment of a rate or rates of pension over an "assessment period" (see section 19 of the Act), that assessment can in practice only be made by reference to the available medical and other material that, of necessity, relates to a particular point or period in time. Therefore, the assessment of the impairment and lifestyle ratings during the "assessment period" must be based on the assessor's reasonable satisfaction as to those ratings throughout the assessment period, based on the available material. If there is a significant change in impairment or lifestyle during an assessment period, the assessment period must be divided into appropriate periods to reflect those changes, and separate assessments made of the degree of incapacity.
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.
Paired organs policy
The paired organs policy is described in Chapter 21.
Combining impairment ratings
If all accepted conditions have been given impairment ratings, the ratings are to be combined by applying Table 18.1 (Combined Values Chart).
Details on how to apply Table 18.1 are given in Chapter 18.
The combined impairment rating obtained by applying Table 18.1 (Combined Values Chart) is to be rounded to the nearest five points. If Table 18.1 is not required to be applied because only one impairment rating has been obtained and that rating is not a multiple of five, that rating is to be rounded to the nearest five points (or to zero) to produce the impairment rating for the purposes of applying Table 23.1 in Chapter 23 (Conversion to Degree of Incapacity), and for the purposes of the extreme disablement adjustment.
Degree of incapacity
The combined impairment rating which is obtained by applying Chapter 18 (Combined Values Chart) is to be combined with the lifestyle rating to determine the degree of incapacity, by applying Table 23.1 (Conversion to Degree of Incapacity) in accordance with Chapter 23.
Degree of incapacity for specific disabilities
If a veteran has one or more accepted conditions that are listed in Column 1 of Table 24.1, then the degree of incapacity of the veteran must be determined in accordance with Chapter 24. The veteran’s degree of incapacity from accepted conditions determined by applying Chapters 1-23 of the Guide, is to be compared with the degree of incapacity determined by applying Chapter 24, and the higher degree of incapacity is to be taken. This is the veteran's final degree of incapacity from all accepted conditions.
NOTES
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 26-27). 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 (MEF25-75) 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 "MEF25-75" and "FEF25-75" (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 Establish what cardiorespiratory conditions are Page
1 present. 19
STEP Assess the information that is available and decide Page
2 whether it is reliable and sufficient. 19
STEP Determine the impairment rating based on effort Page
3 tolerance. 21
STEP (Omit this step if no respiratory disease is present.) Page
4 Determine the impairment rating based on measure- 25
ments of lung function.
STEP Determine the total accepted cardiorespiratory Page
5 functional impairment rating. 32
STEP Consider the effects of cardiac failure (if any). Page
6 36
STEP Moderate the total cardiorespiratory functional Page
7 impairment rating to allow for effects of any non- 37
accepted conditions.
STEP Determine whether any ratings from the relevant Other Page
8 Impairment tables apply (Tables 1.7, 1.8, 1.9, 1.10). 37
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).
Page
21
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).
Page
25
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 which 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 following activities are listed for information only.
7-8 METs + Chopping hardwood.
+ Very heavy exercise + Callisthenics.
+ Jogging (8 km/h). + Squash (non
+ Horseback riding (galloping). - competitive).
+ Carrying heavy objects
(30 kg) on level ground. 10+ METs
+ Sawing hardwood with + Running quickly hand tools. (10 km/h).
+ Cycling quickly (25 km/h).
8-9 METs Carrying loads (10 kg)
+ Running (9 km/h). up a gradient.
+ Skiing (cross-country). + Football (any code).
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.
SCALE
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 expended in dressing, washing and performing light house- hold 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.
Ratings derived from METs are age adjusted
(continued next page)
SCALE
1.1 (cont'd)
CARDIORESPIRATORY IMPAIRMENT: ACTIVITY LEVELS (with energy expenditure in METs) continued
· 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.
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
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.
I