SAFETY, REHABILITATION AND COMPENSATION ACT 1988 –

GUIDE TO THE ASSESSMENT OF THE DEGREE OF PERMANENT
IMPAIRMENT EDITION 2.1 (CONSOLIDATION 1)

This consolidation incorporates the Safety, Rehabilitation and Compensation Act 1988 – Guide to the Assessment of the Degree of Permanent Impairment Edition 2.1 (‘Edition 2.1’) as prepared by Comcare and approved by the Minister for Tertiary Education, Skills, Jobs and Workplace Relations on 2 November 2011 with effect from 1 December 2011 and as varied by the Safety, Rehabilitation and Compensation Act 1988 – Guide to the Assessment of the Degree of Permanent Impairment Edition 2.1 – Variation No.1 of 2011 (‘Variation 1 of 2011’) as approved by Comcare and approved by the Minister for Tertiary Education, Skills, Jobs and Workplace Relations on 29 November 2011 with effect from 1 December 2011.

NOTES:

1. Edition 2.1 and Variation 1 of 2011 were each prepared by Comcare under subsection 28(1) of the Safety, Rehabilitation and Compensation Act 1988 and approved by the Minister under subsection 28(3) of that Act.

2. Edition 2.1 was registered on the Federal Register of Legislative Instruments as F2011L02375 and Variation 1 of 2011 was registered as F2011L02519.

3. This compilation was prepared on 30 November 2011 in accordance with section 34 of the Legislative Instruments Act 2003 substituting paragraph 3 (Application of this Guide) to Edition 2.1 as in force on 1 December 2011.

Guide to the assessment of the degree of permanent impairment

Edition 2.1

Introduction to Edition 2.1 of the Guide

1. Authority

2. Structure of this guide

3. Application of this guide

4. Whole person impairment (WPI)

5. Entitlements under the SRC Act

6. Non-economic loss

7. Compensation Payable

8. Interim and final assessments

9. Increase in degree of whole person impairment

Contents

List of tables and figures

List of references

Principles of assessment

1. Impairment and non-economic loss

2. Employability and incapacity

3. Permanent impairment

4. Pre-existing conditions and aggravation

5. The impairment tables

6. Malignancies and conditions resulting in major systemic failure..............

7. Percentages of impairment

8. Comparing assessments under alternative tables

9. Combined values

10. Calculating the assessment

11. Ordering of additional investigations

12. Exceptions to use of Part 1 of this guide

Glossary

Division 1

Assessment of the degree of an employee’s

permanent impairment resulting from an injury

1.0 Introduction

1.1 Coronary artery disease

1.2 Hypertension

1.2.1 Diastolic hypertension

1.2.2 Systolic hypertension

1.3 Arrhythmias

1.4 Peripheral vascular disease of the lower extremities

1.5 Peripheral vascular disease of the upper extremities

1.6 Raynaud’s disease

2.0 Introduction

2.1 Assessing impairment of respiratory function

2.1.1 Measurements

2.1.2 Methods of measurement

2.1.3 Impairment rating

2.2 Asthma and other hyper-reactive airways diseases

2.3 Lung cancer and mesothelioma

2.4 Breathing disorders associated with sleep

3.0 Introduction

3.1 Thyroid and parathyroid glands

3.2 Adrenal cortex and medulla

3.3 Pancreas (diabetes mellitus)

3.4 Gonads and mammary glands

4.0 Introduction

4.1 Skin disorders

4.2 Facial disfigurement

4.3 Bodily disfigurement

5.0 Introduction

5.1 Psychiatric conditions

6.3 Abnormal ocular motility and binocular diplopia

6.0 Introduction

6.1 Central visual acuity

6.1.1 Determining the loss of central vision in one eye

6.2 Determining loss of monocular visual fields

6.3 Abnormal ocular motility and binocular diplopia

6.4 Other ocular abnormalities

6.5 Other conditions involving permanent deformities causing up to 10% impairment of the whole person

6.6 Calculation of visual system impairment for both eyes

Figure 6-F: Calculation of Visual System Impairment for Both Eyes

7.0 Introduction

7.1 Hearing loss

7.2 Tinnitus

7.3 Olfaction and taste

7.4 Speech

7.5 Air passage defects

7.6 Nasal passage defects

7.7 Chewing and swallowing

8.0 Introduction

8.1 Upper digestive tract—oesophagus, stomach, duodenum, small intestine and pancreas

8.2 Lower gastrointestinal tract—colon and rectum

8.3 Lower gastrointestinal tract—anus

8.4 Surgically created stomas

8.5 Liver—chronic hepatitis and parenchymal liver disease

8.6 Biliary tract

8.7 Hernias of the abdominal wall

9.5 Lower extremity amputations

9.6 Spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities

9.6.1 Spinal nerve root impairment affecting the lower extremity

9.6.2 Peripheral nerve injuries affecting the lower extremities

9.11 Shoulders

Part III—Introduction

Part III—Definitions of clinical findings for diagnosis-related estimates in assessing spinal impairment

Part III—Multi-level fractures involving the spinal canal

9.15 Cervical spine—diagnosis-related estimates

9.16 Thoracic spine—diagnosis-related estimates

9.17 Lumbar spine—diagnosis-related estimates

Notes to Table 9.17

9.18 Fractures of the pelvis

10.0 Introduction

10.1 The Upper Urinary Tract

11.0 Introduction

11.1 Male reproductive system

11.1.1 Male reproductive organs—penis

11.1.2 Male reproductive organs—scrotum

11.1.3 Male reproductive organs—testes, epididymes and spermatic cords

11.1.4 Male reproductive organs—prostate and seminal vesicles

11.2 Female reproductive system

11.2.1 Female reproductive organs—vulva and vagina

11.2.2 Female reproductive organs—cervix and uterus

11.2.3 Female reproductive organs—fallopian tubes and ovaries

12.0 Introduction

12.1 Disturbances of levels of consciousness and awareness

12.1.1 Permanent disturbances of levels of consciousness and awareness

12.1.2 Epilepsy, seizures and convulsive disorders

12.1.3 Sleep and arousal disorders

12.2 Impairment of memory, learning, abstract reasoning and problem solving ability

12.3 Communication impairments—dysphasia and aphasia

12.4 Emotional or behavioural impairments

12.5 Cranial nerves

12.5.1 The olfactory nerve (I)

12.5.2 The optic nerve, the oculomotor and trochlear nerves and the abducens (II, III, IV and VI)

12.5.3 The trigeminal nerve (V)

12.5.4 The facial nerve (VII)

12.5.5 The auditory nerve (VIII)

12.5.6 The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)

12.6 Neurological impairment of the respiratory system

12.7 Neurological impairment of the urinary system

12.8 Neurological impairment of the anorectal system

12.9 Neurological impairment affecting sexual function

13.0 Introduction

13.1 Anaemia

13.2 Leukocyte abnormalities or disease

13.3 Haemorrhagic disorders and platelet disorders

13.4: Thrombotic disorders

Division 2

Guide to the assessment of non-economic loss

Introduction

B1. Pain

B2. Suffering

B3. Loss of amenities

B4. Other loss

B5. Loss of expectation of life

B6. Calculation of non-economic loss

Division 3

Calculation of total entitlement under Section 24 and Section 27

Appendix 1

Combined values chart

Part 1 Appendix 1: Combined values chart

Contents

List of references

List of tables and figures

List of references

Principles of assessment

1. Impairment and non-economic loss

2. Employability and incapacity

3. Permanent

4. The impairment tables

5. Gradations of impairment

6. Combined impairments

7. Double assessment

8. Fingers and toes

9. Inapplicability of Part 2 of this guide

10. Interim assessments

11. Application of Part 2 of the guide

12. Likelihood of reduction in degree of impairment

13. Aggravation

Glossary

Glossary (continued)

Division 1—Impairment

1. Cardio-vascular system

2. Respiratory system

3. Endocrine system

4. Skin disorders

Table 4.2: Facial disfigurement

5. Psychiatric conditions

6. Visual system

7. Ear, nose and throat disorders

8. Digestive system

9. Musculo-skeletal system

10. Urinary system

11. Reproductive system

12. Neurological function

13. Miscellaneous

Appendix 1

14. Combined values chart

Part 2—Appendix 1: Combined values chart

Division 2—Non-economic loss

1. Authority

Division 4 of Part II (sections 24 to 28) of the Commonwealth’s Safety, Rehabilitation and Compensation Act 1988 (the SRC Act) provides for payment of lump sum compensation for permanent impairment and non-economic loss resulting from a work related injury.

The amount of compensation payable (if any) is to be assessed by reference to the degree of permanent impairment and the degree of non-economic loss determined by Comcare under the provisions of the approved guide:

‘approved guide’ is defined by section 4 of the SRC Act as meaning:

(a) the document, prepared by Comcare in accordance with section 28 under the title ‘Guide to the Assessment of the Degree of Permanent Impairment’, that has been approved by the Minister and is for the time being in force; and

(b) if an instrument varying the document has been approved by the Minister—that document as so varied.

Authority for this document rests therefore in subsections 28(1), 28(2) and 28(3) of the SRC Act, which provide that:

(1) Comcare may, from time to time, prepare a written document, to be called the ‘Guide to the Assessment of the Degree of Permanent Impairment’, setting out:

(a) criteria by reference to which the degree of the permanent impairment of an

employee resulting from an injury shall be determined

(b) criteria by reference to which the degree of non-economic loss suffered by an

employee as a result of an injury or impairment shall be determined; and

(c) methods by which the degree of permanent impairment and the degree of non economic loss, as determined under those criteria, shall be expressed as a percentage.

(2) Comcare may, from time to time, by instrument in writing, vary or revoke the approved Guide.

(3) A document prepared by Comcare under subsection (1), and an instrument under subsection (2), have no force or effect unless and until approved by the Minister.

This document is the new Guide to the Assessment of the Degree of Permanent Impairment. It may be referred to as ‘this guide’ or ‘Edition 2.1 of the guide’. This guide is binding on Comcare, licensed authorities and corporations, and the Administrative Appeals Tribunal (subsection 29(4) of the SRC Act).

2. Structure of this guide

This guide is divided into two parts:

Part 1—Claims for Permanent Impairment other than Defence-related claims

This part deals with the assessment of claims other than defence-related claims as defined in Part XI of the SRC Act. That is, claims made under the SRC Act by employees who are not members of the Australian Defence Force.

Part 2—Defence-related claims for permanent impairment

This part deals with the assessment of defence-related claims as defined in Part XI of the SRC Act. That is, claims made under the SRC Act by members of the Australian Defence Force in relation to injuries which occurred during defence service before 1 July 2004.

The responsibility for development of any guide that applies to members of the Australian Defence Force in respect of injuries incurred after the commencement of the Military Rehabilitation and Compensation Act 2004 (MRC Act) will fall to the Military Rehabilitation and Compensation Commission (MRCC).

Part 1 of this guide has three divisions:

DIVISION 1—Division 1 is used to assess the degree of an employee’s permanent impairment resulting from an injury.

DIVISION 2—Division 2 is used to assess the degree of an employee’s non-economic loss resulting from impairment.

DIVISION 3—Division 3 is used to calculate the total entitlement based on the assessments completed in Divisions 1 and 2.

The Principles of Assessment and Glossary in Part 1 of this guide contain information relevant to the interpretation and application of Part 1, Divisions 1 and 2.

Part 2 of this guide has two divisions:

DIVISION 1—Division 1 is used to assess the degree of an employee’s permanent impairment resulting from an injury.

DIVISION 2—Division 2 is used to assess the degree of an employee’s non-economic loss resulting from impairment.

The Principles of Assessment and Glossary in Part 2 of this guide contain information relevant to the interpretation and application of Part 2, Divisions 1 and 2.

3. Application of this guide

The Guide to the Assessment of the Degree of Impairment prepared by the Commission for the Safety, Rehabilitation and Compensation of Commonwealth Employees under section 28(1) of the Commonwealth Employees’ Rehabilitation and Compensation Act 1988 and approved by the Minister of State for Industrial Relations by notice in writing dated 27 July 1989 is referred to as the ‘first edition of the guide’.

The first edition of the guide was revoked and the second edition of the guide applied in relation to permanent impairment claims made under sections 24, 25 or 27 of the SRC Act on and from 1 March 2006. Claims under those sections received on or before 28 February 2006 continue to be determined under the provisions of the first edition of the guide.

The second edition of the guide is revoked on and from 1 December 2011 and edition 2.1 of the guide applies from that date. This edition varies the second edition by addressing medical ambiguities identified by medical practitioners using the second edition of the guide, addressing various errata and providing a 10% impairment rating for all tables within the guide. Edition 2.1 of the Guide does not change the structure of the second edition of the guide or the composition of benefits payable.

Except as provided below, Part 1 of Edition 2.1 of the guide applies to permanent impairment claims under sections 24, 25 or 27 of the SRC Act received by the relevant authority on and from 1 December 2011.

Part 2 of this Guide applies to defence-related claims for permanent impairment under sections 24, 25 or 27 of the SRC Act received by the relevant authority on and from 1 December 2011 for injuries related to defence service rendered before 1 July 2004.

Where a request by an employee pursuant to subsection 25(1) of the SRC Act (in respect of interim payment of permanent impairment compensation) is received by the relevant authority on or after 1 December 2011, but relates to a claim under section 24 of the SRC Act that was received by the relevant authority on or before 28 February 2006, that request must be determined under the provisions of the first edition of the guide.

Where a request by an employee pursuant to subsection 25(1) of the SRC Act (in respect of interim payment of permanent impairment compensation) is received by the relevant authority on or after 1 December 2011, but relates to a claim under section 24 of the SRC Act that was received by the relevant authority on or after 1 March 2006 but before 1 December 2011, that request must be determined under the provisions of the second edition of the guide.

Where a claim for compensation pursuant to subsections 25(4) or 25(5) of the SRC Act (in respect of a subsequent increase in the degree of permanent impairment) is received by the relevant authority on or after 1 December 20112, that claim must be determined under the provisions of this edition of the guide, notwithstanding that the initial claim for compensation for permanent impairment may have been determined under the provisions of the previous editions of this guide.

However, where the initial claim for compensation for permanent impairment was determined under the provisions of the first or second edition of the guide, in determining whether or not there has been any subsequent increase in the degree of permanent impairment under this edition of the guide, the degree of permanent impairment or the degree on non-economic loss shall not be less than the degree of permanent impairment or degree of non-economic loss that was determined under the provisions of first or second edition of the guide unless that determination would not have been made but for a false statement or misrepresentation of a person.

In this guide, ‘relevant authority’ and ‘defence-related claims’ have the same meaning as defined in section 4 and Part XI of the SRC Act.

4. Whole person impairment (WPI)

Prior to 1988, the Compensation (Commonwealth Government Employees) Act 1971 (repealed with the coming into effect of the SRC Act) provided for the payment of lump sum compensation where an employee suffered the loss of, or loss of efficient use of, a part of the body or faculty, as specified in a table of maims. The range of conditions compensated was exclusive and did not reflect the broad range of work-related injuries and diseases.

This guide, like the previous editions, is, for the purposes of expressing the degree of impairment as a percentage, based on the concept of ‘whole person impairment’. Subsection 24(5) of the SRC Act provides for the determination of the degree of permanent impairment of the employee resulting from an injury, that is, the employee as a whole person. The whole person impairment concept, therefore, provides for compensation for the permanent impairment of any body part, system or function to the extent to which it permanently impairs the employee as a whole person.

Whole person impairment is assessed under Division 1 of Parts 1 and 2 of this guide.

5. Entitlements under the SRC Act

Where the degree of permanent impairment of the employee (other than a hearing loss) determined under subsection 24(5) of the SRC Act is less than 10 per cent, paragraph 24(7)(b) of the SRC Act provides that compensation is not payable to the employee under section 24 of that Act.

Subsection 24(8) of the SRC Act excludes the operation of subsection 24(7) in relation to impairment resulting from the loss, or the loss of the use, of a finger or toe, or the loss of the sense of taste or smell.

For injuries suffered by employees after 1 October 2001, subsection 24(7A) of the SRC Act provides that, if the injury results in a permanent impairment that is a hearing loss, the 10% threshold does not apply. In those cases, subsection 24(7A) provides that there is no compensation payable if the permanent impairment that is binaural hearing loss is less than 5%.

6. Non-economic loss

Subsection 27(1) of the SRC Act provides that where there is liability to pay compensation in respect of a permanent impairment, additional compensation for non-economic loss is payable in accordance with section 27.

Non-economic loss is assessed under Division 2 of Parts 1 and 2 of this guide.

7. Compensation Payable

The maximum level of payment is prescribed in the legislation and indexed annually on 1 July in accordance with the Consumer Price Index. Compensation is calculated at the rate applicable at the time of the assessment (In Part 1 of this guide, see Division 3 for calculation of total entitlement).

8. Interim and final assessments

On the written request of the employee under subsection 25(1) of the SRC Act, an interim determination must be made of the degree of permanent impairment suffered and an assessment made of an amount of compensation payable to the employee, where:

a determination has been made that an employee has suffered a permanent impairment as a result of an injury
the degree of that impairment is equal to or more than 10%
a final determination of the degree of permanent impairment has not been made.

When a final determination of the degree of permanent impairment is made, there is payable to the employee, under subsection 25(3) of the SRC Act, an amount equal to the difference, if any, between the final determination and the interim assessment.

9. Increase in degree of whole person impairment

Where a final assessment of the degree of permanent impairment has been made and the level of whole person permanent impairment subsequently increases by 10% or more in respect of the same injury, the employee may request, pursuant to subsection 25(4) of the SRC Act, another assessment for compensation for permanent impairment and non-economic loss. Additional compensation is payable for the increased level of impairment only.

For injuries suffered by employees after 1 October 2001, pursuant to subsection 25(5) of the SRC Act, if the injury results in a permanent impairment that is a hearing loss, there may be a further amount of compensation payable if there is a subsequent increase in the binaural hearing loss of 5% or more.

See section 3 above (Application of this guide) as to assessments of the degree of permanent impairment made under the previous editions of the guide.

PART 1

Principles of assessment

1. Impairment and non-economic loss

2. Employability and incapacity

3. Permanent impairment

4. Pre-existing conditions and aggravation

5. The impairment tables

6. Malignancies and conditions resulting in major systemic failure

7. Percentages of impairment

8. Comparing assessments under alternative tables

9. Combined values

10. Calculating the assessment

11. Ordering of additional investigations

12. Exceptions to use of Part 1 of this guide

1. Impairment and non-economic loss

Under subsection 4(1) of the SRC Act, impairment means ‘the loss, the loss of the use, or the damage or malfunction, of any part of the body or of any bodily system or function or part of such system or function’. It relates to the health status of an individual and includes anatomical loss, anatomical abnormality, physiological abnormality, and psychological abnormality. The degree of impairment is assessed by reference to the impact of that loss by reference to the functional capacities of a normal healthy person.

Non-economic loss is assessed in accordance with Part 1, Division 2 (see page 221) of this guide, and deals with the effects of the impairment on the employee’s life. Under subsection 4(1) of the SRC Act, for an employee who has suffered an injury resulting in a permanent impairment, it means:

‘loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware’.

Non-economic loss may be characterised as the ‘lifestyle effects’ of an impairment. ‘Lifestyle effects’ are a measure of an individual’s mobility and enjoyment of, and participation in, social relationships, and recreation and leisure activities. The employee must be aware of the losses suffered. While employees may have equal ratings of whole person impairment it would not be unusual for them to receive different ratings for non-economic loss because of their different lifestyles.

2. Employability and incapacity

The concepts of ‘employability’ and ‘incapacity’ are not the tests for the assessment of impairment and non-economic loss. Incapacity is influenced by factors other than the degree of impairment and is compensated by weekly payments which are separate and independent to permanent impairment entitlements.

3. Permanent impairment

Compensation is only payable for impairments which are permanent. Under subsection 4(1) of the SRC Act ‘permanent’ means ‘likely to continue indefinitely’. Subsection 24(2) of the SRC Act provides that for the purposes of determining whether an impairment is permanent, the following matters shall be considered:

(a) the duration of the impairment

(b) the likelihood of improvement in the employee’s condition

impairment

(d) any other relevant matters.

Thus, a loss, loss of the use, damage, or malfunction, will be permanent if it is likely, in some degree, to continue indefinitely. For this purpose, regard shall be had to any medical opinion concerning the nature and effect (including possible effect) of the impairment, and the extent, if any, to which it may reasonably be capable of being reduced or removed.

4. Pre-existing conditions and aggravation

Where a pre-existing or underlying condition is aggravated by a work-related injury, only the impairment resulting from the aggravation is to be assessed. However, an assessment should not be made unless the effects of the aggravation of the underlying or pre-existing condition are considered permanent. In these situations, the pre-existing or underlying condition would usually have been symptomatic prior to the work-related injury and the degree of permanent impairment resulting from that condition is able to be accurately assessed.

If the employee’s impairment is entirely attributable to the pre-existing or underlying condition, or to the natural progression of such a condition, the assessment for permanent impairment is nil.

Where the pre-existing or underlying condition was previously asymptomatic, all the permanent impairment arising from the work-related injury is compensable.

5. The impairment tables

Part 1, Division 1 of this guide is based on the concept of whole person impairment which is drawn from the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

Division 1 assembles into groups, according to body system, detailed descriptions of impairments. The extent of each impairment is expressed as a percentage value of the whole, normal, healthy person. Thus, a percentage value can be assigned to an employee’s impairment by reference to the relevant description in this guide.

It may be necessary in some cases to have regard to a number of chapters within Part 1 of this guide when assessing the degree of whole person impairment which results from compensable injury.

Where a table specifies a degree of impairment because of a surgical procedure, the same degree of impairment applies if the same loss of function has occurred due to a different medical procedure or treatment.

6. Malignancies and conditions resulting in major systemic failure

Conditions such as cancer, HIV infection, diabetes, asbestosis, mesothelioma and others, often with terminal consequences, may result in failure or impairment of multiple body parts or systems.

Assessments should be made of the impairment suffered in each of the affected body parts and systems and combined using the combined values chart in Part 1, Appendix 1.

7. Percentages of impairment

Most tables in Part 1, Division 1 provide impairment values expressed as fixed percentages. Where such a table is applicable in respect of a particular impairment, there is no discretion to choose an impairment value not specified in that table. For example, where 10% and 20% are the specified values, there is no discretion to determine the degree of impairment as 15%.

Where a table provides for impairment values within a range, consideration will need to be given to all criteria applicable to the condition, which includes performing activities of daily living and an estimate of the degree to which the medical impairment interferes with these activities. In some cases, additional information may be required to determine where to place an individual within the range. The person conducting the assessment must provide written reason why he or she considers the selected point within the range as clinically justifiable.

For further information relating to the application of this guide, please contact the Comcare Permanent Impairment Guide Helpdesk on 1300 366 979 or email PI.Guide@comcare.gov.au.

8. Comparing assessments under alternative tables

Unless there are instructions to the contrary, where two or more tables (or combinations of tables) are equally applicable to an impairment, the decision-maker must assess the degree of permanent impairment under the table or tables which yields or yield the most favourable result to the employee.

9. Combined values

Impairment is system or function based. A single injury may give rise to multiple losses of function and, therefore, multiple impairments. When more than one table applies in respect of that injury, separate scores should be allocated to each functional impairment. To obtain the whole person impairment in respect of that injury, those scores are then combined using the combined values chart (see Part 1, Appendix 1) unless the notes in the relevant section specifically stipulate that the scores are to be added. (For instance, see table 9.8.1).

Where there is an initial injury (or pre-existing condition) which results in impairment, and a second injury which results in impairment to the same bodily part, system or function the pre-existing impairment must be disregarded when assessing the degree of impairment of the second injury. The second injury should be assessed by reference to the functional capacities of a normal healthy person. The final scores are then added together.

Where two or more injuries give rise to different whole person impairments, each injury is to be assessed separately and the final scores for each injury (including any combined score for a particular injury) added together.

It is important to note that whenever the notes in the relevant section refer to combined ratings, the combined values chart must be used, even if no reference is made to the use of that chart.

10. Calculating the assessment

Where relevant, a statement is included in the chapters of Part 1, Division 1 which indicates:

the manner in which tables within that chapter may (or may not) be combined
whether an assessment made in that chapter can be combined with an assessment made in another chapter in assessing the degree of whole person impairment.

There are some special circumstances where addition of scores rather than combination is required. These circumstances are specified in the relevant sections and tables in Part 1 of this guide.

11. Ordering of additional investigations

As a general principle, the assessing medical practitioner should not order additional radiographic or other investigations solely for impairment evaluation purposes, unless the investigations are specifically required in the relevant chapter of Part 1 of this guide.

12. Exceptions to use of Part 1 of this guide

In the event that an employee’s impairment is of a kind that cannot be assessed in accordance with the provisions of Part 1 of this guide, the assessment is to be made under the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

An assessment is not to be made using the American Medical Association’s Guides to the Evaluation of Permanent Impairment for:

mental and behavioural impairments (psychiatric conditions)
impairments of the visual system
hearing impairment
chronic pain conditions, except in the case of migraine or tension headaches. (For complex regional pain syndromes affecting the upper extremities, see Part 1, Chapter 9 – 9.13.3 Complex Regional Pain Syndrome).

Any reference in this guide to the American Medical Association’s Guides to the Evaluation of Permanent Impairment is a reference to the 5th edition 2001.

Glossary

Definitions in italics are from subsection 4(1) and 5A(1) and 5B(1) of the SRC Act.

Activities of daily living are those activities that an employee needs to perform to function in a non-specific environment (that is, to live). Performance of Activities of Daily Living is measured by reference to primary biological and psychosocial function.

Ailment means any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development).

Disease means:

(a) an ailment suffered by an employee

(b) an aggravation of such an ailment

that was contributed to, to a significant degree, by the employee’s employment by the Commonwealth or a licensee.

Impairment means the loss, the loss of the use, or the damage or malfunction, of any part of the body or of any bodily system or function or part of such system or function.

Injury means:

(a) a disease suffered by an employee

(b) an injury (other than a disease) suffered by an employee, that is a physical or mental injury arising out of, or in the course of, the employee’s employment

(c) an aggravation of a physical or mental injury (other than a disease) suffered by an employee (whether or not that injury arose out of, or in the course of, the employee’s employment), that is an aggravation that arose out of, or in the course of, that employment

but does not include a disease, injury or aggravation suffered as a result of reasonable administrative action taken in a reasonable manner in respect of the employee’s employment.

Loss of amenities means the effects on mobility, social relationships and recreation and leisure activities.

Non-economic loss in relation to an employee who has suffered an injury resulting in a permanent impairment, means loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware.

Pain means physical pain.

Suffering means the mental distress resulting from the accepted conditions or impairment.

Whole person impairment (or WPI) is the methodology used for expressing the degree of impairment of a person, resulting from an injury, as a percentage. WPI is based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment. WPI is a medical quantification of the nature and extent of the effect of an injury or disease on a person’s functional capacity including Activities of Daily Living. This guide presents descriptions of impairments in chapters and tables according to body system. The extent of each impairment is expressed as a percentage value of the functional capacity of a normal healthy person.

PART 1

Division 1

Assessment of the degree of an employee’s

permanent impairment resulting from an injury

Chapter 1—The Cardiovascular System

1.0 Introduction

1.1 Coronary artery disease

1.2 Hypertension

1.2.1 Diastolic hypertension

1.2.2 Systolic hypertension

1.3 Arrhythmias

1.4 Peripheral vascular disease of the lower extremities

1.5 Peripheral vascular disease of the upper extremities

1.6 Raynaud’s disease

1.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

WPI ratings derived from tables in this chapter may be combined with WPI ratings from other tables where there is co-existent disease (for example, cardiomyopathy, ischaemic heart disease, congenital heart disease, valvular heart disease).

‘Activities of daily living’ are activities which an employee needs to perform to function in a non-specific environment (that is, to live). Performance of activities of daily living is measured by reference to primary biological and psychosocial function.

For the purposes of Chapter 1, activities of daily living are those in Figure 1-A (see below).

Figure 1-A: Activities of daily living

Activity	Examples
Self care, personal hygiene	Bathing, grooming, dressing, eating, eliminating.
Communication	Hearing, speaking, reading, writing, using keyboard.
Physical activity	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function	Tactile feeling.
Hand functions	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel	Driving or travelling as a passenger.
Sexual function	Participating in desired sexual activity.
Sleep	Having a restful sleep pattern.
Social and recreational	Participating in individual or group activities, sports activities, hobbies.

Chapter 1 does not cover impairments arising from cardiomyopathy, congenital heart disease, valvular heart disease, and pericardial heart disease. Where relevant, the degree of impairment arising from these conditions should be assessed in accordance with the appropriate table from the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

For post-thrombotic syndrome, assessments under Tables 1.4 and 1.5 (peripheral vascular disease, see page 26) are an alternative to Table 13.4: Thrombotic Disorders (see Chapter 13 – The Haematopoietic System). WPI ratings from Tables 1.4 and 1.5 must not be combined with a WPI rating from Table 13.4. Tables 1.4 and 1.5 should be used as the primary guide for assessing peripheral complications of thrombosis.

Employees who have permanent cardiac limitation secondary to massive pulmonary embolism should be assessed under Chapter 1. A WPI rating assessed in these circumstances may not be combined with a rating from Table 13.4.

1.1 Coronary artery disease

Steps for assessment are as follows.

Step 1	Using Figure 1-B (see below), determine the symptomatic level of activity in METS according to age and gender. Figure 1-B may be used to assess conditions affecting left ventricular function (LVF) (including ischaemic heart disease, rheumatic heart disease, and hypertension).
Step 2	Using Table 1.1 (see below), refer to any one of pathology (column 3), drug therapy (column 4), or intervention (column 5), to identify the degree of impairment within the range of impairments for that symptomatic level of activity.

Figure 1-B (see below) may be used for the assessment of symptomatic impairment caused by ischaemic heart disease, hypertension, cardiomyopathy, or rheumatic heart disease.

Figure 1-B: Symptomatic level of activity in METS according to age and gender

Age and gender	Symptomatic level of activity in METS
Age and gender	1	1-2	2-3	3-4	4-5	5-6	6-7	7-8	8-9	10+
18-30 M	D	D	D	C	C	B	B	B	A	A
18-30 F	D	D	C	C	B	B	A	A	A
31-40 M	D	D	D	C	C	B	B	A	A
31-40 F	D	D	C	B	B	B	A
41-50 M	D	D	C	C	B	B	A	A
41-50 F	D	D	C	B	B	A	A
51-60 M	D	D	C	B	B	A	A	A
51-60 F	D	D	C	B	B	A	A
61-70 M	D	D	C	B	B	A	A
61-70 F	D	D	B	B	A	A
70+ M	D	C	B	B	A
70+ F	D	C	B	A	A

Table 1.1: Coronary artery disease

See notes immediately following Table 1.1 for further details regarding abbreviations and symbols used in columns 3, 4 and 5.

Column 1 % WPI	Column 2 Level of activity in METS for age and gender	Column 3 Pathology	Column 4 Drug therapy	Column 5 Intervention
5	A	Not applicable	Not applicable	Not applicable
10	A	+	+	Not applicable
15	A	++	++	PTCA
20	A	+++	+++	CABG/Tx
25	B	+	+	Not applicable
30	B	++	++	PTCA
40	B	+++	+++	CABG/Tx
50	C	+	+	Not applicable
60	C	++	++	PTCA
65	C	+++	+++	CABG/Tx
75	D	+	+	Not applicable
85	D	++	++	PTCA
95	D	+++	+++	CABG/Tx

Notes to Table 1.1

In Table 1.1, not applicable means the criterion is not applicable to the specified level of impairment.
Pathology—column 3.

(i) Coronary artery disease:

+ either <50% stenosis in one or more coronary arteries, or single vessel disease > 50% stenosis (except proximal left anterior descending [LAD] and left main coronary artery [LMCA])

++ either >50% stenosis in two vessels, or >50% stenosis in proximal LAD, or <50% stenosis in LMCA

+++ either >50% stenosis in 3 vessels, or LMCA >50% stenosis, or severe diffuse end organ disease.

(ii) Ischaemic left ventricular dysfunction:

+ left ventricular ejection fraction (LVEF) 40-50%

++ LVEF 30-40%

+++ either LVEF < 30%, or LV aneurysm.

(iii) Myocardial infarction (MI):

+ no previous MI

++ previous possible MI (equivocal changes in ECG/cardiac enzymes)

+++ previous definite MI (unequivocal changes in ECG/cardiac enzymes: typical evolution of ST/T segments, or development of significant Q waves, or enzyme rise > 3 times upper limit of normal).

(iv) Arrhythmias

Assessed under Table 1.3—Arrhythmias (see page 38).

3. Drug therapy (continuous) —Column 4.

+ one or two drugs

++ three or four drugs

+++ five or more drugs.

4. Intervention—column 5.

PTCA means percutaneous transluminal coronary angioplasty and/or stenting.

CABG means coronary artery bypass grafting.

Tx means heart transplant.

1.2 Hypertension

Either diastolic hypertension (section 1.2.1 below) or systolic hypertension (section 1.2.2 on the following page) may be assessed, whichever provides the higher WPI rating.

1.2.1 Diastolic hypertension

Hypertensive cardiomyopathy can be assessed using the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

Functional class (determined in accordance with Figure 1-B, see page 32) is the primary criterion for assessment. Level of diastolic blood pressure (DBP) and therapy (see Table 1.2.1 below) are secondary criteria for assessment.

For assessment use either usual DBP, or therapy, for a given functional class, whichever provides the greater WPI rating. If DBP is consistently >120 on optimal therapy, one higher functional class may be assigned.

Table 1.2.1: Diastolic hypertension

See note immediately following Table 1.2.1 for explanation of symbols used in the final column (drug therapy).

% WPI	Level of activity in METS for age and gender	Usual DBP	Drug therapy
5	A	>90	+
10	A	>100	++
15	A	>110	+++
20	B	>90	+
25	B	>100	++
30	B	>110	+++
35	C	>90	+
40	C	>100	++
45	C	>110	+++
50	D	>90	+
55	D	>100	++
60	D	>110	+++

Note to Table 1.2.1

Drug therapy (continuous)—final column of Table 1.2.1:

+ one drug

++ two drugs

+++ three or more drugs.

1.2.2 Systolic hypertension

Hypertensive cardiomyopathy can be assessed using the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

Functional class (determined in accordance with Figure 1-B, see page 32) is the primary criterion for assessment. Level of systolic blood pressure (SBP) and therapy (see Table 1.2.2 below) are secondary criteria for assessment.

Table 1.2.2: Systolic hypertension

See note immediately following Table 1.2.2 for explanation of symbols used in the final column (drug therapy).

% WPI	Symptomatic level of activity in METS for age and gender	Usual SBP	Drug therapy
5	A	>160	+
10	A	>160	++
15	A	>160	+++
20	B	>170	+
25	B	>170	++
30	B	>170	+++
35	C	>180	+
40	C	>180	++
45	C	>180	+++
50	D	>190	+
55	D	>190	++
60	D	>190	+++

Note to Table 1.2.2

Drug therapy (continuous):

+ one drug

++ two drugs

+++ three or more drugs.

1.3 Arrhythmias

Underlying cardiac disease can be assessed using other tables in Chapter 1.

Functional class (determined under Figure 1-C below), and therapy (see Table 1.3 below), are used to determine the WPI rating.

Figure 1-C: Definitions of functional class

Functional class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light Activities of Daily Living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

Table 1.3: Arrhythmias

See note immediately following Table 1.3 for explanation of symbols used in the final column (therapy).

% WPI	Functional class	Therapy
5	I	Nil
10	I	Drug(s)
15	I	Surgery/cath/PPM/Device
20	II	Nil
30	II	Drug(s)
40	II	Surgery/cath/PPM/Device
45	III	Nil
50	III	Drug(s)
55	III	Surgery/cath/PPM/Device
60	IV	Not applicable

Note to Table 1.3

Therapy—column 3:

‘cath’ means either catheter ablation or catheter-associated therapy for arrhythmia

‘PPM’ means permanent pacemaker

‘Device’ means implanted defibrillator.

1.4 Peripheral vascular disease of the lower extremities

Amputatees should not be assessed under Table 1.4. They should be assessed under Table 9.5: Lower extremity amputations (see Chapter 9—The musculoskeletal system).

A WPI rating from Table 1.4 must not be combined with a WPI rating from Table 13.4: Thrombotic disorders (see Chapter 13—The haematopoietic system).

Table 1.4: Peripheral vascular disease of the lower extremities

% WPI	Signs and symptoms
0	The employee experiences neither intermittent claudication nor ischaemic pain at rest.
5	The employee has no difficulty with distances but experiences ischaemic pain on climbing either steps or gradients.
10	The employee experiences claudication on walking 200 metres or more at an average pace on level ground.
20	The employee experiences claudication on walking more than 100 but less than 200 metres at average pace on level ground.
30	The employee experiences claudication on walking more than 75 but less than 100 metres at average pace on level ground.
40	The employee experiences claudication on walking more than 50 but less than 75 metres at average pace on level ground.
50	The employee experiences claudication on walking more than 25 but less than 50 metres at average pace on level ground.
60	The employee experiences claudication on walking less than 25 metres at average pace on level ground.
70	The employee experiences ischaemic pain at rest.

1.5 Peripheral vascular disease of the upper extremities

Amputees should not be assessed under Table 1.5. They should be assessed under Table 9.12.1: Upper extremity amputations, or Table 9.12.2: Amputation of digits (see Chapter 9—The musculoskeletal system).

A WPI rating from Table 1.5 must not be combined with a WPI rating from Table 13.4: Thrombotic disorders (see Chapter 13—The haematopoietic system).

Table 1.5 Peripheral vascular disease of the upper extremities

% WPI	Symptoms	Signs
5	Either no claudication or transient oedema.	Calcification of arteries on X-ray.
10	Either no claudication or persistent oedema controlled by support.	Dilatation of either arteries or veins.
15	As above.	Either loss of pulse or healed ulcer or surgery.
20	Either claudication on strenuous exercise or persistent oedema uncontrolled by support.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
30	As above.	Superficial ulcer.
40	As above.	Either deep or widespread ulcer or surgery.
45	Claudication on mild-moderate exertion.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
50	As above.	Superficial ulcer.
55	As above.	Either deep or widespread ulcer or surgery.
60	Rest pain/unable to exercise.	Not applicable

1.6 Raynaud’s disease

Functional class (determined according to Figure 1-C below) is the primary criterion for assessment. Signs of vasospastic disease and therapy (see Table 1.6 on the following page) are secondary criteria for assessment.

Figure 1-C: Definitions of functional class

See note to immediately following Figure 1-C.

Functional Class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light activities of daily living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

Note to Figure 1-C

Figure 1-C also appears in Section 1.3—Arrhythmias, see page 37. It is repeated here for ease of reference

Table 1.6: Raynaud’s disease

See note immediately following Table 1.6.

% WPI	Functional class	Signs	Therapy
5	I	Nil.	Nil.
10	I	Nil.	Drug(s).
15	I	Nil.	Surgery.
20	II	Neither ulceration nor trophic changes.	Drug(s).
25	II	Either ulceration or trophic changes.	Drug(s).
30	II	not applicable	Surgery.
35	III	Neither ulceration nor trophic changes.	Drug(s).
40	III	Either ulceration or trophic changes.	Drug(s).
45	III	Not applicable	Surgery.
50	IV	Not applicable	Not applicable

Note to Table 1.6

Therapy—final column of Table 1.6:

Surgery includes sympathectomy and local debridement.

Drug(s) means continuous therapy with one or more drugs.

Chapter 2—The Respiratory System

2.0 Introduction

2.1 Assessing impairment to respiratory function

2.1.1 Measurements

2.1.2 Methods of measurement

2.1.3 Impairment rating

2.2 Asthma and other hyper-reactive airways diseases

2.3 Lung cancer and mesothelioma

2.4 Breathing disorders associated with sleep

2.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

The measure of impairment is the reduction in physiological function below that found in health.

Respiratory impairment is quantified by the degree to which measurements of respiratory function are changed by the compensable injury or injuries, relative to values obtained in a healthy reference population of similar individuals.

Conditions such as chronic obstructive airways disease and chronic bronchitis are to be assessed according to the methods used to measure loss of respiratory function.

Employees who have permanent respiratory limitation secondary to massive pulmonary embolism should be assessed under Chapter 2. Any WPI rating awarded in these circumstances must not be combined with a WPI rating from Table 13.4: Thrombotic disorders (see Chapter 13—The haematopoietic system).

2.1 Assessing impairment of respiratory function

2.1.1 Measurements

The most commonly recommended measurements for determining respiratory impairment are:

spirometry with measurement of the forced expiratory volume at 1 second (FEV1) and forced vital capacity (FVC)
the transfer factor, or diffusing capacity of the lung, for carbon monoxide (TlCO), measured by the single breath method.

However, the measurements used must be derived from either:

the tests prescribed below where relevant (for example, in assessing asthma)
where a test is not prescribed, from tests appropriate to assessing the impairments caused by the particular compensable condition or conditions.

Other measurements commonly used to assess impairment include:

the lung volumes
total lung capacity (TLC) and residual volume (RV)
the response to a maximum exercise test including measurement of the oxygen consumption at the maximum workload able to be achieved (vO2max), and the degree of arterial oxygen desaturation during exercise.

On occasion, other measurements may be needed to define impairment accurately. For example:

the elastic and flow resistive properties of the lungs
respiratory muscle strength
arterial blood gases
polysomnography (sleep studies)
echocardiography with estimation of pulmonary artery pressure
quantitative ventilation-perfusion scans of the lung.

Measurement of the partial pressures of oxygen and carbon dioxide in arterial blood (PaO2 and PaCO2 respectively) are not usually required to assign impairment ratings accurately. However, individual variation may result in severe impairment in gas exchange when other measures of function indicate only moderate impairment. Arterial PaO2 of <55 mm Hg and/or PaCO2 >50 mm Hg, despite optimal treatment, is evidence of severe impairment and attracts a WPI rating of 70%.

Measurements of arterial blood gases should be performed on two occasions, with the employee seated.

2.1.2 Methods of measurement

Measurements must be performed in a manner consistent with the methods used by a respiratory function laboratory accredited by one or more of the following bodies:

the Thoracic Society of Australia and New Zealand
the Australian Sleep Society
the Australian Council on Health Care Standards.

Methods of measurement should conform to internationally recognised standards in relation to the equipment used, the procedure, and analysis of the data. Reference values (‘predicted’ normal values) should be representative of the healthy population and be appropriate for ethnicity where possible. Laboratories providing measurements used to assess impairment should state the method(s) of measurement used, and the source of the reference values used.

2.1.3 Impairment rating

Several professional groups have published criteria for rating the severity of impairment based on spirometry, gas transfer and vO2max. These professional groups include the Thoracic Society of Australia and New Zealand (Abramson, 1996), the American Thoracic Society (American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria, 1986), and the American Medical Association (2001). In general, measurements are expressed as a percentage of the predicted value (%P) and, where several measurements are performed, the most abnormal result is used to classify the degree of impairment.

Severity of impairment is rated as shown in Table 2.1 below. This generic table can be used to assign WPI ratings using any valid measurement for which there are predicted normal data.

Table 2.1: Conversion of respiratory function values to impairment

See note immediately following Table 2.1.

% WPI	Respiratory function %P
0	>85
10	85 to 76
20	75 to 66
30	65 to 56
40	55 to 51
50	50 to 44
60	45 to 41
70	40 to 36
80	35

Note to Table 2.1

%P = percentage of mean value for healthy individuals of the same age, height and sex.

2.2 Asthma and other hyper-reactive airways diseases

Assessment of impairment due to asthma can be confounded by the natural history of occupational asthma, by variably severe airflow obstruction, and therefore variable FEV1, and by response to treatment.

For hyper-reactivity of airways due to occupational exposures, assessment of impairment is made after:

the diagnosis and cause are established
exposure to the provoking factors is eliminated
appropriate treatment of asthma is implemented.

Appropriate treatment follows the guidelines in the Asthma Management Handbook 2002 (National Asthma Council, 2002, 5th edition, Melbourne: National Asthma Council of Australia), a later edition of those guidelines, or later guidelines widely accepted by the medical profession as representing best practice.

Permanent impairment should not be assessed until 2 years after cessation of exposure to provoking factors as severity may decrease during this period.

An impairment rating scale is set out in Figure 2-A and Table 2.2 (both on following page). The scale used in Figure 2-A and Table 2.2 is modified to account for frequency of increased impairment from asthma despite optimal treatment.

A score reflecting impairment from asthma is calculated by:

adding the points scored for reduction in FEV1 %P

and either

change in FEV1 with bronchodilator (reversibility)

degree of bronchial hyperreactivity defined by the cumulative dose of metacholine, or histamine, required to decrease baseline FEV1 by at least 20%

and

measurement of FEV1, or peak flow (PF) rate, measured by the employee morning and evening, before and after aerosol bronchodilator, for at least 30 days.

The number of days on which any valid measurement of FEV1 or PF is less than 0.85 x the mean of the six highest values of FEV1 or PF during the monitoring period is to be expressed as a percentage of total days in the monitoring period.

The maximum impairment score from Figure 2-A is 11. One additional point is given, yielding a score of 12, if asthma cannot be controlled adequately with maximal treatment. The score from Figure 2-A is converted to a WPI rating using Table 2.2.

Figure 2-A: Calculating asthma impairment score

See notes immediately following Figure 2-A.

Score	FEV1, % P After bronchodilator	FEV1, % change in FEV1 with bronchodilator	PD20 or mol	% of Days lowest FEV1* is 0.85 highest FEV1
0	>85	<10	>4.0	<6
1	76 to 85	10 to 19	0.26 to 4.0	6 to 24
2	66 to 75	20 to 29	0.063 to 0.25	25 to 34
3	56 to 65	30	0.062	35 to 44
4	55			45

Notes to Figure 2-A

Figure 2-A is based on scales proposed by: the American Thoracic Society (1993), as adapted in Tables 5-9 and 5-10 of American Medical Association’s Guides to the Evaluation of Permanent Impairment (5th edition, 2001); and the Thoracic Society of Australia and New Zealand (Abramson, 1996).
%P = percent predicted normal value.
PD20 = cumulative dose of inhaled metacholine aerosol causing a 20% decrease in FEV1.
* monitored twice daily before and after aerosol bronchodilator for at least 30 days during adequate treatment.
% of days = proportion of days any value of FEV1 (or of peak flow rate) is less than highest repeatable FEV1

(or peak flow rate) x 0.85.

Table 2.2: WPI derived from asthma impairment score

% WPI	Asthma impairment score
0	0
10	1
20	2
30	3
40	4
45	5
50	6
55	7
60	8
65	9
70	10
75	11
80	12

2.3 Lung cancer and mesothelioma

Employees with lung cancers (other than mesothelioma) are considered severely impaired at the time of diagnosis and are given a WPI rating of 70%.

If there is evidence of tumour, or if tumour recurs one year after diagnosis is established, then the employee remains severely impaired and the WPI rating is increased to 80%.

Employees with mesothelioma are considered severely impaired and a WPI rating of 85 % is awarded upon diagnosis.

2.4 Breathing disorders associated with sleep

Some disorders such as obstructive sleep apnoea, central sleep apnoea, and hypoventilation during sleep, can cause impairment which is not quantifiable by standard measurements of respiratory function such as spirometry, diffusing capacity, or response to exercise.

Obstructive sleep apnoea should be assessed using Table 2.4 below. Central sleep apnoea should be assessed using Table 12.1.3: Sleep and arousal disorders (see Chapter 12—The neurological system).

An overnight sleep study is used to define the severity of sleep-related disorders of breathing and can be used to define impairment after appropriate treatment has been implemented. During the overnight sleep study there is continuous monitoring of breathing pattern, respiratory effort, arterial oxygen saturation, electrocardiogram, and sleep state. Results of sleep studies cannot readily be expressed in terms of a percentage of predicted values. Consequently, impairment is rated by assigning scores to the degree of abnormality at sleep study (Figure 2-B below and Table 2.4 on the following page). These ratings are based on frequency of disordered breathing, frequency of sleep disturbance, degree of hypoxaemia and, as appropriate, hypercapnoea during sleep. In addition, degree of daytime sleepiness is assessed using the Epworth sleepiness scale (Johns, 1991).

Where vascular morbidity is present (for example, high blood pressure or myocardial infarction) and is attributable to sleep apnoea, impairment should be assessed using the relevant table in Chapter 1—The cardiovascular system.

The total score derived from Figure 2-B below is the sum of the scores from each column: the maximum score is 12. This score is converted to a WPI rating using Table 2.4.

Figure 2-B: Calculating obstructive sleep apnoea score

See notes immediately following Figure 2-B.

Score	Epworth sleepiness score	Apnoeas + hypopnoeas/hr of sleep	Respiratory arousals*/hr of sleep	Cumulative sleep time, mins, with SaO2 <90% #
0	<5	<5	<5	0
1	5 to 10	5 to 15	5 to 15	<15
2	11 to 17	16 to 30	16 to 30	15 to 45
3	>17	>30	>30	>45

Notes to Figure 2-B

1 *An arousal within 3 seconds of a sequence of breaths which meet the criteria for an apnoea, an hypopnoea, or a respiratory effort related arousal, as defined by the American Academy of Sleep Medicine (1999).

2 #SaO2 = arterial oxygen saturation measured with a pulse oximeter.

Table 2.4: WPI derived from obstructive sleep apnoea score

% WPI	Sleep apnoea score
0	0
10	1
20	2
30	3
40	4
45	5
50	6
55	7
60	8
65	9
70	10
75	11
80	12

Chapter 3—The Endocrine System

3.0 Introduction

3.1 Thyroid and parathyroid glands

3.2 Adrenal cortex and medulla

3.3 Pancreas (diabetes mellitus)

3.4 Gonads and mammary glands

3.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

The degree of impairment caused by secondary conditions (such as peripheral neuropathy, or peripheral vascular disease) accompanying an endocrine system condition must also be assessed under the relevant tables in other chapters, including tables in Chapter 10—The urinary system.

In this circumstance, using the combined values chart (Appendix 1), WPI ratings derived from the relevant tables in other chapters are combined with WPI ratings from tables in Chapter 3.

3.1 Thyroid and parathyroid glands

Hyperthyroidism is not considered to cause permanent impairment because the condition is usually amenable to treatment. Where visual and/or cosmetic effects resulting from exophthalmos persist following correction of the hyperthyroidism, a WPI rating may be derived from:

Chapter 4—Disfigurement and skin disorders
Chapter 6—The visual system (see section 6.5—Other conditions causing permanent deformities causing up to 10% impairment of the whole person).

Hyperparathyroidism is usually amenable to correction by surgery. If surgery fails, or the employee cannot undergo surgery for sound medical reasons, long-term therapy may be needed. If so, permanent impairment can be assessed after stabilisation of the condition with medication, in accordance with the criteria in Table 3.1 below.

Where an employee has more than one of the conditions in Table 3.1 below, combine the WPI ratings using the combined values chart (see Appendix 1).

Permanent secondary impairment resulting from persistent hyperparathyroidism (such as renal calculi or renal failure) should be assessed under the relevant system (for example, Chapter 10—The urinary system).

Table 3.1 Thyroid and parathyroid glands

% WPI	Criteria
0	Hyperparathyroidism—symptoms and signs readily controlled by medication or other treatment such as surgery. Hyperparathyroidism—symptoms and signs readily controlled by medication. Hyperparathyroidism adequately controlled by replacement therapy.
10-15	Hypothyroidism where the presence of a disease in another body system prevents adequate replacement therapy. Hyperparathyroidism—persisting mild hypocalcaemia, despite medication. Hyperparathyroidism—symptoms and signs such as intermittent hyper or hypocalcaemia not readily controlled by medication.
30	Hyperparathyroidism—persisting severe hypocalcaemia with serum calcium above 3.0mmol/l, despite medication.

Notes to Table 3.1

Assessors should refer to the Principles of Assessment for guidance on awarding an impairment value within a range.

3.2 Adrenal cortex and medulla

Where Cushing’s syndrome is present, Table 3.2 below should be used to evaluate impairment from the general effects of hypersecretion of adrenal steroids (for example, myopathy, easy bruising, and obesity).

Using the combined values chart (see Appendix 1), WPI ratings derived from Table 3.2 may be combined with WPI ratings for specific associated secondary impairments (for example, fractures or diabetes mellitus).

Table 3.2 Adrenal cortex and medulla

% WPI	Criteria
0	Cushing’s syndrome—surgically corrected by removal of adrenal adenoma or removal of the source of ectopic ACTH secretion. Phaeochromocytoma—benign tumour, surgically removed or removable where hypertension has not led to the development of permanent cardiovascular disease.
5	Hypoadrenalism—symptoms and signs readily controlled with replacement therapy. Cushing’s syndrome due to moderate doses of glucocorticoids (for example, less than equivalent of 15mg of prednisolone per day) where glucocorticoids will be required long-term.
10	Cushing’s syndrome—surgically corrected by removal of pituitary adenoma or adrenal carcinoma.
15	Cushing’s syndrome—due to: bilateral adrenal hyperplasia treated by adrenalectomy large doses of glucocorticoids (for example, equivalent of at least 15 mg of prednisolone per day) where glucocorticoids will be required long-term inadequate removal of source of ectopic ACTH secretion. Phaeochromocytoma—malignant tumour where signs and symptoms of catecholamine excess can be controlled by blocking agents. Hypoadrenalism—recurrent episodes of adrenal crisis during acute illness or in response to significant stress.
70	Phaeochromocytoma—metastatic malignant tumour where signs and symptoms of catecholamine excess cannot be controlled by blocking agents or other treatment.

3.3 Pancreas (diabetes mellitus)

Where diabetic retinopathy has led to visual impairment, the visual impairment should be assessed using Chapter 6—The visual system.

Where diabetes has led to secondary impairment of renal function, that impairment should be assessed using Chapter 10—The urinary system.

Using the combined values chart (see Appendix 1), WPI ratings derived under Table 3.1 and Table 3.2 may be combined with WPI ratings from Table 3.3 below.

Microangiopathy may be manifest as retinopathy (background, proliferative, or maculopathy) and/or albuminuria measured with a timed specimen of urine. Where there is an overnight collection, the upper limit of normal is 20 g/minute. Where a 24 hour specimen is collected, the upper limit of normal is 30mg/day. Albuminuria must be documented in at least two out of three consecutive urine specimens collected.
Table 3.3: Pancreas (diabetes mellitus)

See notes to Table 3.3 on the following page.

% WPI	Type	Therapy	Microvascular complications
5	Type 2 (NIDDM)	Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control.	Microangiopathy is not present.
10	Type 2 (NIDDM)	Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control.	Microangiopathy and/or significant neuropathy are present.
15	Type 1 (IDDM)	Dietary restrictions and insulin give satisfactory control.	Microangiopathy is not present.
20	Type 1 (IDDM) Type 2 (NIDDM)	Dietary restrictions and insulin give satisfactory control Type 2 (NIDDM) where dietary restrictions & insulin and/or oral hypoglycaemic agents give satisfactory control.	Microangiopathy and/or significant neuropathy are present.
25	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is not present.
30	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is present.
40	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is present as well as significant neuropathy.
50		Symptomatic hypoglycaemia due to metastatic tumour (usually insulinoma), uncontrolled by medication (such as diazoxide).

Notes to Table 3.3

For the purposes of Table 3.3, the degree of control is defined by reference to the glycated haemoglobin measurement (HbA1c) where:

4%-6% is the non-diabetic range
<8% is indicative of satisfactory control for the purposes of this table.

2. ‘Significant neuropathy’ means persistent symptoms of peripheral or autonomic neuropathy which interfere with quality of life to a considerable degree.

3. ‘NIDDM’ means non-insulin dependent diabetes mellitus.

4. ‘IDDM’ means insulin dependent diabetes mellitus.

3.4 Gonads and mammary glands

Impairments resulting from inability to reproduce, and other impairments associated with gonadal dysfunction, are assessed under Chapter 11—The reproductive system.

Loss of one or both breasts in females should also be assessed using Table 4.3: Bodily disfigurement (see Chapter 4—Disfigurement and skin disorders). Using the combined values chart (see Appendix 1), a WPI rating derived from Table 4.3 may be combined with a WPI rating derived from Table 3.4 below.

Table 3.4: Gonads and mammary glands

% WPI	Criteria
0	Diminished or absent level of gonadal hormones in either sex. Abnormally high level of gonadal hormones in either sex.
5	Loss of one or both breasts in male. Loss of whole or part of one breast in female. Gynaecomastia in male where pain interferes with everyday activities—not controlled by medication.
10	Loss of whole or part of both breasts in female.

Chapter 4—Disfigurement and Skin Disorders

4.0 Introduction

4.1 Skin disorders

4.2 Facial disfigurement

4.3 Bodily disfigurement

4.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

Impairments assessed under Chapter 4 include those caused by secondary conditions accompanying an endocrine system condition. A WPI rating from a table in Chapter 3—The endocrine system should be combined with WPI ratings resulting from the secondary conditions assessed under Chapter 4.

Loss of one or both breasts in females should be assessed under both:

Table 3.4: Gonads and mammary glands (see Chapter 3—The endocrine system)
Table 4.3: Bodily disfigurement
and the resulting WPI ratings combined.

In cases where two or three of Tables 4.1, 4.2 and 4.3 apply, WPI ratings from each table can be combined using the combined values chart (see Appendix 1).

WPI ratings awarded under Table 4.2 cannot be combined with WPI ratings arising under section 6.4—Other ocular abnormalities, or section 6.5—Other conditions causing permanent deformities causing up to 10% impairment of the whole person (see Chapter 6—The visual system).

4.1 Skin disorders

For the purposes of Table 4.1: Skin disorders:

‘intermittent treatment’ means a course of treatment leading to a break, treatment alternately ceasing and beginning again

‘constant treatment’ means treatment that continues on a regular basis without interruption

‘complex treatment’ means treatment that requires regular and close supervision, usually by a dermatologist. Such supervision could involve regular blood tests and relevant regular physical examinations, such as blood pressure measurement. Complex treatments would be expected to have potential adverse side effects. Categories of drugs forming a part of, or the whole of, complex treatment would include high doses of systemic corticosteroids, or immunosuppressive medications such as azathioprine, methotrexate and cyclosporin. Phototherapy, photochemotherapy, or photophoresis, would also be considered complex treatments.

Column 4 in Table 4.1 is referenced to Figure 4-A: Activities of daily living, immediately below the table.

Table 4.1: Skin disorders

% WPI	Signs and symptoms	Requirement for treatment	Column 4 Activities of daily living affected
0	Absent	None, intermittent	up to 2
5	Absent	Constant	up to 2
5	Intermittent	Intermittent or constant	up to 2
10	Present on a daily basis for periods aggregating three or more months per year, but less than six months per year.	Intermittent or constant	1 or more
15	Present on a daily basis for period aggregating six or more months per year, but less than nine months per year.	Intermittent or constant	1 or more
20	Present on a daily basis for periods aggregating nine months per year or more.	Intermittent or constant	1 or more
25	Present on a daily basis for periods aggregating nine months per year or more.	Constant	4 or more
30	Present on a daily basis for period aggregating nine months per year or more.	Constant and complex	6 or more

Figure 4-A: Activities of daily living—See Column 4 in Table 4.1

No.	Activities	Examples
1	Self care, personal hygiene	Bathing, grooming, dressing, eating, eliminating.
2	Communication	Hearing, speaking, reading, writing, using keyboard.
3	Physical activity	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
4	Sensory function	Tactile feeling.
5	Hand functions	Grasping, holding, pinching, percussive movements, sensory discrimination.
6	Travel	Driving or travelling as a passenger.
7	Sexual function	Participating in desired sexual activity.
8	Sleep	Having a restful sleep pattern.
9	Social and recreational	Participating in individual or group activities, sports activities, hobbies.

4.2 Facial disfigurement

Table 4.2: Facial disfigurement

% WPI	Criteria
0	No structural changes. Normal facial appearance. Hyperpigmentation, depigmentation, redness or telangiectasis occupying less than 10% of facial area (excluding actinic damage). Scarring that does not significantly alter the appearance of the face.
5	Hyperpigmentation, depigmentation, redness or telangiectasis occupying 10% or more of the facial area (excluding actinic damage) or Scars and/or skin grafts occupying less than 5% of facial area that significantly alter the appearance of the face or Depressed cheek, nasal or frontal bones. Total or partial loss of one external ear.
10	Scars and/or skin grafts occupying 5-15% of facial area that significantly alter the appearance of the face or Total or partial loss of both external ears or Loss of less than 50% of the nose.
15	Scars and/or skin grafts occupying 15-25% of facial area that significantly alter the appearance of the face or Loss of 50-75% of the nose.
20	Scars and/or skin grafts occupying more than 25% of facial area that significantly alter the appearance of the face or Loss of more than 75% of the nose.

4.3 Bodily disfigurement

Table 4.3: Bodily disfigurement

% WPI	Criteria
0	Normal body appearance. Scars and/or skin grafts occupying less than 10% of body area.
5	Scars and/or skin grafts occupying 11% to 20% of body surface.
10	Scars and/or skin grafts occupying 21% to 40% of body area or Tissue loss causing noticeable unilateral alteration of body silhouette.
15	Scars and/or skin grafts occupying 41% to 60% of body area.
20	Scars and/or skin grafts occupying 61% to 80% of body area or Tissue loss causing noticeable bilateral alteration of body silhouette.
25	Scars and/or skin grafts occupying more than 80% of body surface area.

Chapter 5—Psychiatric Conditions

5.0 Introduction

5.1 Psychiatric conditions

5.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

For the purposes of Chapter 5, activities of daily living are those in Figure 5-A (see below). The examples provided below are not exhaustive and should not be seen as a substitute for assessor discretion when making decisions about impairment ratings.

Figure 5-A: Activities of daily living

Activity	Examples
Self care, personal hygiene	Bathing, grooming, dressing, eating, eliminating.
Communication	Hearing, speaking, reading, writing, using keyboard.
Physical activity	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function	Tactile feeling.
Hand functions	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel	Driving or travelling as a passenger.
Sexual function	Participating in desired sexual activity.
Sleep	Having a restful sleep pattern.
Social and recreational	Participating in individual or group activities, sports activities, hobbies.

5.1 Psychiatric conditions

Table 5.1: Psychiatric conditions

See note to Table 5.1 on following page.

% WPI	Description of level of impairment
0	Reactions to stresses of daily living without loss of personal or social efficiency and Capable of performing activities of daily living without supervision or assistance.
5	Despite the presence of one of the following employee is capable of performing activities of daily living without supervision or assistance: reactions to stresses of daily living with minor loss of personal or social efficiency lack of conscience directed behaviour without harm to community or self minor distortions of thinking.
10	Despite the presence of more than one of the following employee is capable of performing activities of daily living without supervision or assistance: reactions to stresses of daily living with minor loss of personal or social efficiency lack of conscience directed behaviour without harm to community or self minor distortions of thinking.
15	Any one of the following accompanied by a need for some supervision and direction in activities of daily living: reactions to stresses of daily living which cause modification to daily living patterns marked disturbances in thinking definite disturbance in behaviour.

Table 5.1 continued on following page

Table 5.1 (continued)

% WPI	Description of level of impairment
20	Any two of the following accompanied by a need for some supervision and direction in activities of daily living: reactions to stresses of daily living which cause modification of daily living patterns marked disturbance in thinking definite disturbance in behaviour.
25	All of the following accompanied by a need for some supervision and direction in activities of daily living: reactions to stresses of daily living which cause modification of daily living patterns marked disturbances in thinking definite disturbances in behaviour.
30	Any one of the following accompanied by a need for supervision and direction in activities of daily living: hospital dischargees who require daily medication or regular therapy to avoid readmission loss of self-control and/or inability to learn from experience resulting in potential for considerable damage to self or community.
40	More than one of the following accompanied by a need for supervision and direction in activities of daily living: hospital dischargees who require daily medication or regular therapy to avoid readmission loss of self-control and/or inability to learn from experience resulting in potential for considerable damage to self or community.
50	One of the following: severe disturbances of thinking and/or behaviour entailing potential or actual harm to self and/or others need for supervision and direction in a confined environment.
60	Both of the following: severe disturbances of thinking and/or behaviour which entail potential or actual harm to self and/or others need for supervision and direction in a confined environment.
90	Very severe disturbance in all aspects of thinking and behaviour requiring constant supervision and care in a confined environment, and assistance with all activities of daily living

Notes to Table 5.1

2. Table 5.1 includes psychoses, neuroses, personality disorders and other diagnosable conditions. The assessment should be made on optimum medication at a stage where the condition is reasonably stable.

3. Supervision means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.

4. Assistance means the provision of assistance to the employee in performing the activities of daily living by a suitable person, responsible in whole or in part for the care of the employee

5. Direction means the provision of direction to the employee by a suitably qualified person, responsible in whole or in part for the care of the employee

6. Suitable person means a person capable of responsibly caring for the employee in an appropriate way

7. Suitably qualified person means a person with the necessary qualifications, experience and skills to provide appropriate direction to the employee. Such persons include medical practitioners, nursing staff and clinical psychologists.

Chapter 6—The Visual System

6.0 Introduction

Steps in determining whole person impairment

6.1 Central visual acuity

6.1.1 Determining the loss of central vision in one eye

6.2 Determining loss of monocular visual fields

6.3 Abnormal ocular motility and binocular diplopia

6.4 Other ocular abnormalities

6.5 Other conditions causing permanent deformities causing up to 10% impairment of the whole person

6.6 Calculation of visual system impairment for both eyes

6.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

Chapter 6 provides a standard method for examining the visual system, and for calculating the extent of any visual impairment. Impairment is any loss or abnormality in the anatomy or function of the visual system. The visual system includes the eyes, the ocular adnexa, and the visual pathways.

All visual tests are standardised and impairment assessment follows a strict protocol in order to ensure that different ophthalmologists can closely reproduce results. Wherever possible, impairment assessment should be performed by an ophthalmologist.

Visual impairment exists when there is deviation from any of the normal functions of the eye.

Among the types of visual impairment listed below, the first three (6.1-6.3) contribute the most to the overall impairment (numbers correspond to sections in Chapter 6):

6.1 Central visual acuity for near and far objects

6.2 Monocular visual field

6.3 Ocular motility

6.4 Other ocular abnormalities

6.5 Other conditions involving permanent deformities causing up to 10% impairment of the whole person.

Impairments assessed under Chapter 6 include those caused by secondary conditions accompanying an endocrine system condition. An impairment assessed under Chapter 3 —The endocrine system should be combined with those resulting from the secondary conditions assessed under Chapter 6.

WPI ratings from Table 4.2: Facial disfigurement (see Chapter 4—Disfigurement and skin disorders), cannot be combined with WPI ratings arising from either:

section 6.4—Other ocular abnormalities
section 6.5—Other conditions causing permanent deformities causing up to 10% impairment of the whole person.

Facial nerve injury complicated by visual changes, such as occurs with corneal desiccation and scarring, rates as a significant impairment. Such an impairment is assessed under Chapter 6 and a resulting WPI rating may be combined with a WPI rating from Table 12.5.4: The Facial Nerve (VII) (see Chapter 12—The neurological system).

Steps in determining whole person impairment

See Figure 6-A on the following page for steps in deriving a visual system impairment rating. Use Table 6.1 (following Figure 6-A) to convert a visual system impairment rating to a WPI rating.

Figure 6-A: Steps for calculating impairment of the visual system

Step 1	Determine and record the percentage loss of central vision for each eye separately, combining the losses of near and distance vision. Refer to Figure 6-C.
Step 2	Determine and record the percentage loss of visual fields for each eye separately (monocular) or for both eyes together (binocular).
Step 3	Using the combined values chart (see Appendix 1), combine the results from Step 1 and Step 2 for each eye if any central vision and visual field impairment is present.
Step 4	Determine and record the percentage loss of ocular motility.
Step 5	Using the combined values chart (see Appendix 1), combine the result of Step 3 with Step 4 if there is any ocular motility impairment.
Step 6	Determine and record the percentage loss if other ocular impairments are present.
Step 7	Using the combined values chart (see Appendix 1), combine the result of Step 5 with Step 6 if any other ocular impairment is present.
Step 8	Determine the visual impairment for both eyes. The visual impairment for both eyes is calculated by the formula: 3 x (impairment of better eye) + (impairment of worse eye) = visual system 4 impairment Alternatively use Figure 6-F.
Step 9	Convert the visual impairment for both eyes to a WPI rating using Table 6.1 below.
Step 10	Using the combined values chart (see Appendix 1), combine the result of Step 9 with any impairment (up to 10% maximum) arising from other conditions causing permanent deformities (see section 6.5).

Table 6.1: Conversion of the visual system to whole person impairment rating

Source: American Medical Association Guides to the Evaluation of Permanent Impairment (4th edition, 1995, Table 6, Chapter 8, page 218).

Visual system	Whole person	Visual system	Whole person	Visual System	Whole person	Visual system	Whole person
0	0
1	1	26	25	51	48	76	72
2	2	27	25	52	49	77	73
3	3	28	26	53	50	78	74
4	4	29	27	54	51	79	75
5	5	30	28	55	52	80	76
6	6	31	29	56	53	81	76
7	7	32	30	57	54	82	77
8	8	33	31	58	55	83	78
9	8	34	32	59	56	84	79
10	9	35	33	60	57	85	80
11	10	36	34	61	58	86	81
12	11	37	35	62	59	87	82
13	12	38	36	63	59	88	83
14	13	39	37	64	60	89	84
15	14	40	38	65	61	90	85
16	15	41	39	66	62	91	85
17	16	42	40	67	63	92	85
18	17	43	41	68	64	93	85
19	18	44	42	69	65	94	85
20	19	45	42	70	66	95	85
21	20	46	43	71	67	96	85
22	21	47	44	72	68	97	85
23	22	48	45	73	69	98	85
24	23	49	46	74	70	99	85
25	24	50	47	75	71	100	85

6.1 Central visual acuity

A Snellen test chart is used to measure the distance of visual acuity. The test distance is six metres.

The near vision is measured using a LogMar reading card. If Near Snellen, Jaeger, Sloan or Roman reading cards are used the results need to be converted to LogMar (see Figure 6-B below). The distance in the near reading test is not fixed: the reading distance should be recorded by the ophthalmologist.

Central vision should be tested and recorded for distant and near objects. The employee should be refracted and tested with loose lenses, phoropter, or with his / her own glasses, provided their correction is accurate.

If an employee wears contact lenses each day and wishes to wear them for the test, this is acceptable for measuring acuity. In certain ocular conditions (particularly in the presence of corneal abnormalities) contact lens-corrected vision may be better than that obtained with spectacle correction. However, if an employee does not already wear contact lenses, they should not be fitted for an impairment assessment.

Figure 6-B: Revised LogMar equivalent for different reading cards

LogMar	Near Snellen	Equivalent to Snellen	N.	Points Roman	Revised Jaeger standard
0.3	14/14	6/6	N5	3	1
0.4	14/18	6/7.5	N6	4	2
0.5	14/21	6/9	N7	5	3
0.6	14/24	6/12	N8	6	4
0.65	14/28	6/15	N9	7	5
0.7	14/35	6/18	N10	8	6
0.725	14/40	6/24	N12	9	7
0.75	14/45	6/30	N15	10	8
0.8	14/60	6/36	N17	11	9
0.9	14/70	6/48	N18	12	10
1.0	14/80	6/60	N20	13	11
1.1	14/88	6/90	N24	14	12
1.3	14/112	6/120	N40	21	13
1.6	14/140	6/240	N80	23	14

6.1.1 Determining the loss of central vision in one eye

The following steps are taken to determine loss of central vision in one eye.

Step 1	Measure the central acuity for distance and near, correcting for any refractive errors and presbyopia, and record the result.
Step 2	Consult Figure 6-C below to derive the overall loss, combining the values for corrected near and distance acuities.
Step 3	If monocular aphakia or pseudoaphakia is present then add 50% to the percentage loss of Central Vision obtained from Figure 6-C.

Figure 6-C: Percentage loss of central vision in one eye

	Revised LogMar standard for near vision
Distance vision (metric 6)	0.3	0.4	0.4	0.5	0.6	0.7	0.7	0.7	0.8	0.9	1.0	1.1	1.3	1.6
6/5	0	0	3	4	5	25	27	30	40	43	44	45	48	49
6/6	0	0	3	4	5	25	27	30	40	43	44	46	48	49
6/7.5	3	3	5	6	8	28	30	33	43	45	46	48	50	52
6/10	5	5	8	9	10	30	32	35	45	48	49	50	53	54
6/12	8	8	10	11	13	33	35	38	48	50	5	53	55	57
6/15	13	13	15	16	18	38	40	43	53	55	56	58	60	62
6/20	16	16	18	20	22	41	44	46	56	59	60	61	64	65
6/22	18	18	21	22	23	43	46	48	58	61	62	63	66	67
6/24	20	20	23	24	25	45	47	50	60	63	64	65	68	69
6/30	25	25	28	29	30	50	52	55	58	68	69	70	73	74
6/38	30	30	33	34	35	55	57	60	70	73	74	75	78	79
6/50	34	34	37	38	39	59	61	64	74	77	78	79	82	83
6/60	40	40	43	44	45	65	67	70	80	83	84	85	88	89
6/90	43	43	45	46	48	68	70	73	83	85	86	88	90	92
6/120	45	45	48	49	50	70	72	75	85	88	89	90	93	94
6/240	48	48	50	51	53	73	75	78	88	90	91	93	95	97

6.2 Determining loss of monocular visual fields

There are many ways of measuring the visual field. The most common are the manual Goldman Field and the Humphrey, Octopus and Medmont computerised field analysers. If using a computerised field it is necessary to test at least a 30-2 threshold.

An Esterman Binocular Field is suitable for the majority of visual field impairment assessments. The field is tested with the employee wearing spectacles and both eyes open. The binocular field result is determined by using the Esterman 120-unit binocular grid, and the dot count is multiplied by 5/6 to obtain the percentage of retained or lost field. Note that binocular field-testing is not recommended when diplopia is present.

If the automated 30-2 Threshold Field is normal, and the ocular history and examination do not suggest lesions that would affect the outer part of the field, it is acceptable to conclude that the entire field is normal. Whatever technique is used to measure the visual field, the test should be performed by an ophthalmologist.

The normal visual field meridians in each of eight principal meridians are given in Figure 6-D below. The total, summed over 8 meridians is 500.

Figure 6-D: Normal extent of the visual field

Direction of vision	Degrees of field
Temporally	85
Down temporally	85
Direct down	65
Down nasally	50
Nasally	60
Up nasally	55
Direct up	45
Up temporally	55
Total	500

The percentage of retained vision is calculated using the following steps.

Step 1	Add the extent of the visual field along each of the 8 meridians (while considering the maximum normal values for the meridians given in Figure 6-D).
Step 2	Divide by 5 to determine the percentage of visual field perception that remains.
Step 3	To obtain the percentage of visual field loss, subtract the percentage of visual field remaining from 100%.

These steps are based upon the following formulae:

Total visual field = % of remaining visual field

100 - (% of remaining visual field) = % of visual field lost

6.3 Abnormal ocular motility and binocular diplopia

Diplopia within the central 30 is measured by an ophthalmologist with a tangent screen. Unless there is diplopia within 30 of the centre of fixation, the diplopia does not cause significant visual impairment. The exception is when looking downwards. Double vision within the central 20 signifies the maximum loss of ocular motility (that is, a 50% loss of ocular motility in one eye).

If the diplopia is not within the central 20º, the presence of diplopia is then plotted along the 8 meridians (see Figure 6-E below). The largest percentage on any of the meridians in which there is double vision is the impairment percentage for loss of ocular motility.

Figure 6-E: Percentage loss of ocular motility of one eye in diplopia fields

Adapted from American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1995,Chapter 8, page 217.

6.4 Other ocular abnormalities

If an ocular adnexal disturbance or deformity interferes with visual function and is not reflected in diminished visual acuity, decreased visual fields, or ocular motility abnormalities with diplopia, then the significance of the disturbance or deformity should be evaluated by an examining ophthalmologist. In that situation, using the combined values chart (see Appendix 1), an ophthalmologist may combine up to an additional 10% impairment for each affected eye.

Problems in the visual system should also be taken into account where they result in symptoms such as epiphora, photophobia, metamorphopsia, and convergence insufficiency.

6.5 Other conditions involving permanent deformities causing up to 10% impairment of the whole person

Using the combined values chart (see Appendix 1), an additional WPI of up to 10% may be combined with WPI ratings for conditions such as permanent deformities of the orbit, scars, and other cosmetic deformities that do not otherwise alter ocular function.

6.6 Calculation of visual system impairment for both eyes

Figure 6-F (from the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Chapter 8, page 219, 4th edition, 1995) is on the three following pages.

Figure 6-F was established using the equation:

3 x (impairment value of better eye) + (impairment value of worse eye) = impairment of
4 visual system

Percentages for the worse eye are read from the side of the table.

Percentages for the better eye are read from the bottom of the table.

The impairment of the visual system is at the intersection of the column for the worse eye and the row for the better eye.

For example, for a 40% impairment of one eye and 10% impairment of the other eye, read down the table until you come to the large value (40%). Follow across the row until it is intersected with the column designated by 10% at the bottom of the page (18%). Thus, the impairment to the visual system is 18%.

Chapter 7—Ear, Nose and Throat Disorders

7.0 Introduction

7.1 Hearing loss

7.2 Tinnitus

7.3 Olfaction and taste

7.4 Speech

7.5 Air passage defects

7.6 Nasal passage defects

7.7 Chewing and swallowing

7.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

Table 12.5.5: The auditory nerve (see Chapter 12 —The neurological system) should be used to assess both Menière’s disease, and true vertigo consequent upon a disturbance of vestibular function.

Unless they cause interference with balance, speech, respiration or hearing, the following conditions attract a WPI rating of 0:

rhinitis
sinusitis
laryngitis
pharyngitis
otitis media or externa (whether permanent or intermittent).

If interference with balance, speech, respiration or hearing is present, these conditions attract WPI ratings based on the degree of interference with balance, speech, respiration or hearing as described in the tables in Chapter 7.

7.1 Hearing loss

Hearing defects are assessed in accordance with the current procedures from Australian Hearing.

Once the binaural percentage loss of hearing has been calculated, it is then converted to a WPI rating.

The calculation for converting the percentage loss of hearing to a WPI rating is:

(Percentage Loss of Hearing)

7.2 Tinnitus

Table 7.2 is used to assess impairment arising as a result of tinnitus in the presence of unilateral or bilateral hearing loss.

Table 7.2: Tinnitus

% WPI	Criteria
0	Continuous tinnitus which has nuisance value but can be forgotten or ignored with background noise or a low level noise generator.
5	Severe continuous tinnitus which causes extreme distress, interferes with concentration and is not assisted by a low level noise generator.

7.3 Olfaction and taste

Only complete loss of olfaction or taste attracts a WPI rating. If the employee is able to detect any odour or taste, even if unable to identify it, the WPI rating is 0.

WPI ratings from this table may not be combined with WPI ratings for the same condition from either Table 12.5.1: Olfactory Nerve (see Chapter 12—The neurological system), or Table 12.5.4: Facial nerve (see Chapter 12—The neurological system).

Table 7.3: Olfaction and taste

% WPI	Criterion
5	Complete loss of olfaction or Complete loss of taste.
10	Complete loss of olfaction and Complete loss of taste.

% WPI

Criterion

Complete loss of olfaction

Complete loss of taste.

Complete loss of olfaction

and

Complete loss of taste.

7.4 Speech

Table 7.4 below is used to assess impairment resulting from interference with speech from local lesions of the organs of speech.

For the purposes of Table 7.4, ‘speech’ means the capacity to produce vocal signals that can be heard, understood, and sustained over a useful period of time.

Table 7.4 must not be used to assess speech impairment resulting from a lesion of the central nervous system. In such cases, assessment should be made under Table 12.3.2: Production of speech and language symbols (see Chapter 12—The neurological system).

WPI ratings from Table 7.4 may not be combined with WPI ratings from Table 12.3.2: Production of speech and language symbols (see Chapter 12—The neurological system).

If there are two separate conditions (one local, and the other a central nervous system condition) interfering with speech production, speech production should be assessed under both Table 7.4 and Table 12.3.2. The greater value is the WPI rating due to speech impairment from all causes.

WPI ratings from within Table 7.4 may not be combined with each other.

If the major problem is one of audibility, intelligibility, or functional efficiency of speech, the criteria appropriate to the area should be used to assess impairment.

If there are problems in more than one area, each area (audibility, intelligibility, and functional efficiency) should be assessed, and the highest value selected as the WPI rating.

Table 7.4: Speech

% WPI	Criteria
% WPI	Audibility	Intelligibility	Functional efficiency
0	Audible in most situations, although may require effort.	Generally intelligible, although some sounds are difficult and some repetition may be needed.	Speech can be sustained except for slowness and some hesitancy.
10	Audible in quiet situations but problems with audibility in noisy environments.	Intelligible although inaccuracies may be frequent and there are obvious difficulties with articulation.	Speech can be sustained but is often discontinuous, interrupted, hesitant and/or slow.
15	Voice tires rapidly, tends to become inaudible after a few seconds. Volume generally low.	Intelligible to family and close friends but strangers find speech generally unintelligible even with repetition.	Difficulty sustaining speech for more than brief periods even when speaking very slowly.
20	Volume very low. Can whisper or produce volume that can be heard only with difficulty by close listener or by telephone.	Mostly unintelligible, except for a few words.	Laboured speech. Rate of sustained speech impractically slow.
30	Inaudible.	Unintelligible.	No sustained speech.

7.5 Air passage defects

Table 7.5 assesses permanent impairment relating to defects of the air passages. Impairments of the lower airways and lung parenchyma, are dealt with in Chapter 2—Respiratory system.

Permanent tracheostomy, or other respiratory stoma, attracts a permanent WPI rating of 25% which may be combined with other values derived from Table 7.5.

An employee is placed in an impairment category based on the criteria in Table 7.5 below.

Table 7.5 applies only to permanent partial obstruction of one or more of the following structures:

oropharnyx
laryngopharynx
larynx
trachea.

Table 7.5 does not apply to nasal obstruction. Nasal obstruction is assessed under Table 7.6: Nasal passage defects (see below).

Prophylactic restriction of activity, such as sporting activity, does not attract the same WPI rating as dyspnoea on participation in the activity.

Table 7.5: Air passage defects

Criteria	% WPI
Criteria	0	10	30	40	50	70	90
Ventilation required	No	No	No	No	No	No	Yes
Dyspnoea at rest	No	No	No	No	Yes	Yes (severe)	Not applicable
Dyspnoea with dressing or grooming	No	No	No	Yes	Yes (severe)	Not applicable	Not applicable
Dyspnoea with walking 200m or climbing eight steps	No	No	Yes	Not applicable	Not applicable	Not applicable	Not applicable
Dyspnoea with hurrying, hill climbing or sporting activity	No	Yes	Not applicable	Not applicable	Not applicable	Not applicable	Not applicable

7.6 Nasal passage defects

Table 7.6 applies only to nasal obstruction.

Table 7.6: Nasal passage defects

% WPI	Criterion
3	Continuous nasal obstruction of sufficient severity to cause mouth breathing at rest.

7.7 Chewing and swallowing

Table 7.7 below is used to assess impairment resulting from facial muscle damage or loss, dental and oral problems, and temporomandibular joint dysfunction.

WPI ratings derived from Table 7.7 may be combined with WPI ratings derived from Table 8.4: Surgically created stomas (see Chapter 8—The digestive system).

For the same condition, WPI ratings derived from Table 7.7 may not be combined with WPI ratings from Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (see Chapter 12—The neurological system).

Table 7.7: Chewing and swallowing

% WPI	Criteria
0	No interference. Food of any desired type may be eaten without difficulty.
2	Very tough or hard food has to be avoided but diet is otherwise as desired.
5	Diet is limited to soft foods.
10	Diet is limited to pureed foods.
20	Diet is limited to liquid foods.
40	No oral ingestion of food or fluid is possible. Food can only be ingested by means of a nasogastric, gastrostomy, oesophagostomy or other tube.

Chapter 8—The Digestive System

8.0 Introduction

Calculation of Body Mass Index (BMI)

8.1 Upper digestive tract—oesophagus, stomach, duodenum, small intestine and pancreas

8.2 Lower gastrointestinal tract—colon and rectum

8.3 Lower gastrointestinal tract—anus

8.4 Surgically created stomas

8.5 Liver—chronic hepatitis and parenchymal liver disease

8.6 Biliary tract

8.7 Hernias of the abdominal wall

8.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

For the purposes of Chapter 8, activities of daily living are those in Figure 8-A (see below).

Figure 8-A: Activities of daily living

Activity	Examples
Self care, personal hygiene	Bathing, grooming, dressing, eating, eliminating.
Communication	Hearing, speaking, reading, writing, using keyboard.
Physical activity	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function	Tactile feeling.
Hand functions	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel	Driving or travelling as a passenger.
Sexual function	Participating in desired sexual activity.
Sleep	Having a restful sleep pattern.
Social and recreational	Participating in individual or group activities, sports activities, hobbies.

Tables 8.1, 8.2 and 8.3 refer to primary and secondary criteria. All criteria from both categories (except where otherwise stipulated) must be met before a WPI rating can be assigned.

Where the condition being assessed interferes with chewing and/or swallowing, assessment is made under whichever of the following tables describes the impairment more specifically:

Table 7.7: Chewing and swallowing (see Chapter 7—Ear, nose and throat disorders)
Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (see Chapter 12—The neurological system).

For the same condition, WPI ratings derived from Table 12.5.6 may not be combined with WPI ratings derived from Table 7.7.

Other complications of bleeding disorders assessed under Table 13.3: Haemorrhagic disorders and platelet disorders (see Chapter 13—The haematopoietic system) may also be assessed under tables in Chapter 8, according to the site of the blood loss. The WPI rating so obtained should be combined with the WPI rating obtained from Table 13.3.

Where applicable, Body Mass Index (BMI) values are used as the objective assessment for weight. See Figure 8-B below for calculation of BMI values.

Calculation of Body Mass Index (BMI)

Body Mass Index (BMI) is calculated as follows:

Weight (kg)

Height2 (m)

The value obtained should be rounded to the nearest whole number.

Figure 8-B: Body Mass Index criteria

BMI	Category	Health risk
<18	Very underweight	Long-term hazard to health.
18-20	Underweight	Low risk to health.
20-25	Acceptable	Least risk for morbidity and minimal mortality.
25-30	Overweight	Low risk to health.
30-40	Morbid obesity	High degree of risk to health.

8.1 Upper digestive tract—oesophagus, stomach, duodenum, small intestine and pancreas

Table 8.1: Upper digestive tract—oesophagus, stomach, duodenum, small intestine and pancreas

See notes to Table 8.1 on the following page.

% WPI	Primary criteria	Secondary criteria
0	Symptoms of upper digestive tract disease with or without anatomical loss or pathological alteration present.	Continuous drug treatment not required to control symptoms.
10	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	One of the following: Continuous drug treatment required to control symptoms, signs or nutritional deficiency Appropriate dietary modifications required to control symptoms or signs.
20	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	Both of the following: Continuous drug treatment required to control symptoms, signs or nutritional deficiency Appropriate dietary modifications required to control symptoms or signs.
30	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	Any one of the following: Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency Appropriate dietary modifications do not completely control symptoms, signs or nutritional deficiency Weight loss with a BMI<20.
40	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	Any two of the following: Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency Appropriate dietary modifications do not completely control symptoms, signs or nutritional deficiency Weight loss with a BMI<20.

Table 8.1 continued on following page.

Table 8.1 (continued)

% WPI	Primary criteria	Secondary criteria
50	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	All of the following: Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency Appropriate dietary modifications do not completely control symptoms, signs or nutritional deficiency Weight loss with a BMI<20.
60	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	All of the following: Continuous drug treatment has little effect on symptoms, signs or nutritional deficiency Appropriate dietary modifications have little effect on symptoms, signs or nutritional deficiency Assistance required with most or all activities of daily living Weight loss with a BMI<20.
70	Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present.	All of the following: Severe impairment of nutritional status uncontrolled by any treatment or dietary modifications Assistance required with all activities of daily living Weight loss with a BMI<20.

Notes to Table 8.1

Continuous drug treatment includes H2 receptor antagonists, proton pump inhibitors, corticosteroids, and pancreatic enzyme supplementation.
Continuous drug treatment does not include antacids, or mixed antacid and alginic acid preparations.
Modified diet does not include the avoidance of a few, or selected, food items. It refers to special diets devised to manage symptoms of the disease and maximise nutrition (for example, lactose-free diet, gluten-free diet).

8.2 Lower gastrointestinal tract—colon and rectum

Table 8.2: Lower gastrointestinal tract—colon and rectum

See notes to Table 8.2 on the following page.

% WPI	Primary criteria	Secondary criteria
0	Signs and/or symptoms of colonic or rectal disease occur infrequently, and/or are of brief duration.	No requirement for any of the following as short term treatment: Limitation of activities of daily living Modified diet Medication. No systemic manifestations. Weight and nutrition can be maintained at desirable levels.
10	Signs and/or symptoms of colonic or rectal disease occur more frequently, and/or are of longer duration.	Generally no requirement for any of the following as long-term treatment to control disease although may be needed short term: Limitation of activities of daily living Modified diet Medication. No systemic manifestations. Weight and nutrition can be maintained at desirable levels.
20	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	Requirement for at least one of the following as long-term treatment to control disease: Limitation of activities of daily living Modified diet Medication. No systemic manifestations. Weight and nutrition can be maintained at desirable levels.

Table 8.2 continued on following page.
Table 8.2 (continued)

% WPI	Primary criteria	Secondary criteria
30	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	Requirement for all of the following as long-term treatment to control disease: Limitation of activities of daily living Modified diet Medication. No systemic manifestations. Weight and nutrition can be maintained at desirable levels.
40	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	Requirement for all of the following as long-term treatment to control disease: Limitation of activities of daily living Modified diet Medication. Presence of one of the following: Systemic manifestations (for example, fever, anaemia) Weight loss with a BMI<20.
50	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	Requirement for all of the following as long-term treatment to control disease: Limitation of activities of daily living Modified diet Medication. Presence of both of the following: Systemic manifestations (for example, fever, anaemia) Weight loss with a BMI<20.

Table 8.2 continued on following page.
Table 8.2 (continued)

% WPI	Primary criteria	Secondary criteria
60	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	None of the following long-term treatments control the disease: Modified diet Medication. Presence of at least one of the following: Limitation of Activities of Daily Living Systemic manifestations (for example, fever, anaemia) Weight loss with a BMI<20.
70	Objective evidence of colonic or rectal disease, with anatomical loss or alteration.	None of the following long-term treatments control the disease: Modified diet Medication. Presence of all of the following: Systemic manifestations (for example, fever, anaemia) Assistance required with activities of daily living Weight loss with a BMI<20.

% WPI

Primary criteria

Secondary criteria

Objective evidence of colonic or rectal disease, with anatomical loss or alteration.

None of the following long-term treatments control the disease:

Modified diet

Medication.

Presence of at least one of the following:

Limitation of Activities of Daily Living

Systemic manifestations (for example, fever, anaemia)
Weight loss with a BMI<20.

Objective evidence of colonic or rectal disease, with anatomical loss or alteration.

None of the following long-term treatments control the disease:

Modified diet

Medication.

Presence of all of the following:

Systemic manifestations (for example, fever, anaemia)
Assistance required with activities of daily living
Weight loss with a BMI<20.

Notes to Table 8.2

Medication does not include fibre supplements, vitamins or other nutritional supplements (unless there is a demonstrated vitamin deficiency), or over the counter preparations.
Modified diet does not include the avoidance of a few, or selected food items. It refers to special diets devised to manage the symptoms of the disease and maximise nutrition (for example, lactose free diet, gluten free diet).

8.3 Lower gastrointestinal tract—anus

Where the anal disorder is part of a colo-rectal disorder (for example, Crohn’s Disease), WPI ratings from Tables 8.2: Lower gastrointestinal tract—colon and rectum (see page 92) and Table 8.3 may be combined using the combined values chart (see Appendix 1).

Table 8.3: Lower gastrointestinal tract—anus

% WPI	Primary criteria	Secondary criteria
0	Signs of organic anal disease are absent or There is no anatomical loss or alteration.	Incontinence of flatus, or other mild or intermittent anal symptoms which can be controlled by treatment.
10	Signs of organic anal disease are present or There is anatomical loss or alteration.	Mild incontinence of flatus and/or Mild incontinence of liquid stool and Mild or intermittent anal symptoms controlled by treatment.
20	Signs of organic anal disease are present or There is anatomical loss or alteration.	Moderate daily faecal incontinence requiring treatment or Continual anal symptoms incompletely controlled by treatment.
30	Signs of organic anal disease are present or There is anatomical loss or alteration.	Moderate daily faecal incontinence requiring treatment and Continual anal symptoms incompletely controlled by treatment.
40	Signs of organic anal disease are present and There is anatomical loss or alteration.	Total faecal incontinence despite treatment or Signs of organic anal disease with severe symptoms unresponsive or not amenable to treatment.

8.4 Surgically created stomas

Using the combined values chart (see Appendix 1), WPI ratings obtained from Table 8.4 may be combined with WPI ratings from other digestive system tables in Chapter 8, and with WPI ratings from Table 7.7: Chewing and swallowing (see page 86, Chapter 7—Ear, nose and throat disorders).

Table 8.4: Surgically created stomas

See note to Table 8.4 immediately following the table.

% WPI	Criteria
10	Colostomy.
15	Ileostomy. Ileal pouch-anal anastomosis.
20	Jejunostomy. Gastrostomy. Oesophagostomy.

Note to Table 8.4

Assessment for surgically created stomas is only allowed when the stoma is permanent and not a defunctioning or temporary stoma.

8.5 Liver—chronic hepatitis and parenchymal liver disease

Table 8.5: Chronic hepatitis and parenchymal liver disease

See notes to Table 8.5 on the following page.

% WPI

Primary criteria

Secondary criteria

Evidence of persistent or intermittent liver disease.

Histological severity—very mild.

Liver function tests may be normal or mildly abnormal.

No history of jaundice, ascites or bleeding oesophageal varices in the last three years.

Adequate nutritional state.

10 - 15

Evidence of persistent liver disease.

Histological severity—mild.

Biochemistry abnormal.

No history of jaundice, ascites, or bleeding oesophageal varices in the last three years.

Adequate nutritional state.

Evidence of chronic liver disease.

Histological severity—moderate.

Biochemistry abnormal.

History of jaundice, ascites or bleeding oesophageal varices in the last 12 months.

Adequate nutritional state

Evidence of progressive, chronic liver disease.

Histological severity—severe.

Biochemistry abnormal.

History of jaundice ascites, or bleeding oesophageal varices in the last 12 months.

Adequate nutritional state.

Easily fatigued.

Evidence of progressive, chronic liver disease.

Histological severity—chronic hepatitis with cirrhosis.

Biochemistry abnormal.

History of jaundice ascites, and/or bleeding oesophageal varices in the last 12 months.

Nutritional state adversely affected.

Fatigue and physical weakness.

Evidence of progressive, chronic liver disease.

Histological severity—chronic hepatitis with cirrhosis.

Persistent signs of hepatic insufficiency.

Biochemistry abnormal.

History of jaundice, ascites and/or bleeding oesophageal varices in the last 12 months.

Nutritional state adversely affected.

Profound fatigue and physical weakness.

Table 8.5 continued on following page.
Table 8.5 (continued)

% WPI

Primary criteria

Secondary criteria

Evidence of advanced, irreparable chronic liver disease.

Histological severity—chronic hepatitis with cirrhosis.

Persistent signs of advanced hepatic insufficiency.

Biochemistry abnormal.

History of jaundice, ascites and/or bleeding oesophageal varices in the last 12 months.

Nutritional state adversely affected.

Profound fatigue and physical weakness.

Assistance required with activities of daily living.

Notes to Table 8.5

Signs of liver disease include: the stigmata of liver disease (spider angiomata, palmar erythema, and gynaecomastia); jaundice; palpably enlarged liver; evidence of abnormal liver size on ultrasound; evidence of intrahepatic lesions on ultrasound or positive antibodies to any of the viruses known to have the potential to cause chronic liver disease.
Jaundice does not include a mild elevation of plasma bilirubin with normal liver enzymes.
Liver function tests include estimates of total bilirubin, albumin, alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), and gamma glutamyl transferase (GGT).
All the criteria, both major and minor, must be present before a particular WPI rating can be allocated. However, liver biopsy is not mandatory and should not be undertaken solely for the purpose of permanent impairment assessment.
Where liver biopsy has not been undertaken the histological criteria may be disregarded.
Assessors should refer to the Principles of Assessment for guidance on awarding an impairment value within a range.

8.6 Biliary tract

Table 8.6: Biliary tract

See note to Table 8.6 immediately following the table.

% WPI	Criteria
0	Cholecystectomy with no biliary tract sequelae.
10	History of biliary type pain without identifiable biliary disease or Documented history of one to three episodes of biliary colic per year with identifiable biliary disease.
20	Documented history of four to six episodes of biliary colic per year with identifiable biliary disease.
30	Documented history of more than six episodes of biliary colic per year with identifiable biliary disease.
40	Permanent irreparable obstruction of the hepatic or common bile duct with recurrent cholangitis or permanent stent.
50	Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice with intermittent hepatic insufficiency.
65	Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice and hepatic insufficiency.
75	Permanent and irreparable common bile duct obstruction with advanced liver disease manifest as persistent jaundice and hepatic insufficiency.

Note to Table 8.6

Biliary tract dysfunction should only be assessed after cholecystectomy or other appropriate biliary tract surgery, except where there are sound medical reasons for not undertaking surgery.

8.7 Hernias of the abdominal wall

Table 8.7: Hernias of the abdominal wall

See note to Table 8.7 immediately following the table.

% WPI	Criteria
5	Abdominal wall defect with slight protrusion of abdominal contents palpable with increased abdominal pressure, readily reducible.
10	Palpable abdominal wall defect with frequent or persistent protrusion of abdominal contents with increased abdominal pressure, manually reducible.
25	Palpable abdominal wall defect with persistent, irreducible or irreparable protrusion of abdominal contents at the site of defect, causing limitation of activities of daily living.

Note to Table 8.7

Hernias should be assessed only after surgical repair, except where there are sound medical reasons for repair not being undertaken.

Chapter 9—The Musculoskeletal System

9.0 Introduction

Part I

The lower extremities—feet and toes, ankles, knees and hips

9.5 Lower extremity amputations

9.6 Spinal nerve root impairments and peripheral nerve injuries affecting

the lower extremities

9.6.1 Spinal nerve root impairment affecting the lower extremity

9.6.2 Peripheral nerve injuries affecting the lower extremities

9.7 Lower extremity function

Part II

The upper extremities—hands and fingers, wrists, elbows and shoulders

Part II—Introduction

9.8 Hands and fingers

9.8.1 Abnormal motion of digits

9.8.2 Sensory losses in the thumb and fingers

9.9 Wrists

9.10 Elbows

9.11 Shoulders

9.12 Upper extremity amputations

9.13 Neurological impairments affecting the upper extremities

9.13.1 Cervical nerve root impairment

9.13.2 Specific nerve lesions affecting the upper extremities

9.13.3 Complex eegional pain syndromes (CRPS)

9.14 Upper extremity function

Part III

The spine

Part III—Introduction

Part III—Definitions of clinical findings for diagnosis-related estimates in

assessing spinal impairment

Part III—Multi-level fractures involving the spinal canal

9.15 Cervical spine—diagnosis-related estimates

9.16 Thoracic spine—diagnosis-related estimates

9.17 Lumbar spine—diagnosis-related estimates

9.18 Fractures of the pelvis

9.0 Introduction

In conducting an assessment, the assessor must have regard to the principles of assessment (see pages 23-26) and the definitions contained in the glossary (see pages 27-28).

Chapter 9 is divided into three parts:

Part I—The lower extremities
Part II—Upper extremities
Part III—The spine.

The range of motion to be measured is the range of active motion. The medical assessor should be satisfied that the claimant is making an appropriate effort to demonstrate the maximal range and that the measurements are consistent (that is, several repetitions). The normal ranges of motion of individual joints in the musculoskeletal system are set out on the next page.

Peripheral vascular disease affecting lower and upper extremities is assessed under Table 1.4 and Table 1.5 (see Chapter 1—The cardiovascular system).

For the purposes of Chapter 9, activities of daily living are those in Figure 9-A (see below).

Figure 9-A: Activities of daily living

Activity	Examples
Self care, personal hygiene	Bathing, grooming, dressing, eating, eliminating.
Communication	Hearing, speaking, reading, writing, using keyboard.
Physical activity	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function	Tactile feeling.
Hand functions	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel	Driving or travelling as a passenger.
Sexual function	Participating in desired sexual activity.
Sleep	Having a restful sleep pattern.
Social and recreational	Participating in individual or group activities, sports activities, hobbies.

Figure 9-B: Tables of normal ranges of motion of joints

Table	Joint	Plane	ROM from	ROM through	ROM to
9.1	Hindfoot/Ankle (subtalar)	Frontal	Eversion 20°	0°	Inversion 30°
9.2	Ankle (talocrural)	Sagittal	Extension 20°	0°	Flexion 40°
9.3	Knee	Sagittal	Extension 0°		Flexion 150°
9.4	Hip	Rotation	External Rotation 50°	0°	Internal Rotation 40°
9.4	Hip	Frontal	Abduction 40°	0°	Adduction 20°
9.4	Hip	Sagittal	Extension 30°	0°	Flexion 100°
9.8.1.a	Thumb—IP joint		Extension 30°	0°	Flexion 80°
9.8.1.a	Thumb—MP joint		Extension 40°	0°	Flexion 60°
9.8.1.b	Thumb—radial abduction/adduction		15° (full radial adduction)		50° (full radial abduction)
9.8.1.b	Thumb adduction		0 cm		8 cm
9.8.1.b	Thumb opposition		0 cm		8 cm
9.8.1.c	Index and middle fingers—DIP joint		Extension 30°	0°	Flexion 70°
9.8.1.c	Index and middle fingers—PIP joint		Extension 30°	0°	Flexion 100°
9.8.1.c	Index and middle fingers—MP joint		Extension 20°	0°	Flexion 90°
9.8.1.d	Ring and little fingers—DIP joint		Extension 30°	0°	Flexion 70°
9.8.1.d	Ring and little fingers—PIP joint		Extension 30°	0°	Flexion 100°
9.8.1.d	Ring and little fingers—MP joint		Extension 20°	0°	Flexion 90°
9.9.1.a	Wrist	Sagittal	Extension 60°	0°	Flexion 60°
9.9.1.b	Wrist	Frontal	Radial Deviation 20°	0°	Ulnar deviation 30°
9.10.1.a	Elbow	Sagittal	Extension 0°	0°	Flexion 140°
9.10.1.b	Elbow (forearm)	Rotation	Supination 80°	0°	Pronation 80°

Figure 9-B continued on following page.
Figure 9-B (continued)

9.11.1.a	Shoulder	Sagittal	Extension 40°	0°	Flexion 180°
9.11.1.b	Shoulder	Rotation	External rotation 90°	0°	Internal Rotation 90°
9.11.1.c	Shoulder	Frontal	Abduction 180°	0°	Adduction 50°

Part I—The lower Extremities—Feet and Toes, Ankles, Knees and Hips

Part I—Introduction

The impairments assessed for each region in the lower extremity are combined to obtain the overall impairment of the lower extremity for the individual extremity, subject to the notes accompanying the applicable tables, or any indication that combination is not permitted.

Where an arthroplasty procedure has been undertaken, refer to the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001. Combine the total WPI rating for abnormal motion with the relevant WPI rating for arthroplasty, obtained from the American Medical Association’s Guide.

A WPI rating for one lower extremity may be combined with a WPI rating for the other lower extremity, except in the case of WPI ratings under Table 9.7: Lower extremity function (see page 122), where the notes accompanying Table 9.7 are followed.

WPI ratings from Table 9.1: Feet and Toes, Table 9.2: Ankles, Table 9.3: Knees or Table 9.4: Hips must not be combined with a WPI rating under Table 9.7 if they assess the same condition in the same lower extremity.

Where a condition cannot be assessed under one of Tables 9.1, 9.2, 9.3 and 9.4, an assessment may be made under the provisions of the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

If the medical assessor considers that the impairment is not adequately assessed using one of Tables 9.1, 9.2, 9.3 and 9.4, and the condition does not cause a reduction in the range of motion of a joint but there is significant interference with gait, the medical assessor should consider the effect of the injury on gait and determine the WPI rating using Table 9.7. Table 9.7 cannot be used if the condition causes a reduction in the range of motion of a joint and an assessment can be made under any one or more of Table 9.1, 9.2, 9.3 or 9.4.

If permanent, conditions such as sesamoiditis, plantar fasciitis, plantar tendonitis, and pes planus, should be assessed under Table 9.7.

All ankylosis assessments from Tables 9.1, 9.2, 9.3 and 9.4 are alternative assessments to those for abnormal motion of the individual joints.

The maximum WPI rating for a single lower extremity in Tables 9.1, 9.2, 9.3 and 9.4 is 40%, including combined WPI ratings.

Complex regional pain syndrome in the lower extremities should be assessed using the same methodology as for the upper extremity substituting lower extremity table where appropriate. The diagnostic requirements of Figure 9-E apply.
Steps in calculating lower extremity impairment

Step 1	Add abnormal motion/ankylosis impairment values within an individual joint.
Step 2	Combine abnormal motion/ankylosis impairment values for different joints in the toes.
Step 3	Add impairment values obtained for each individual toe and combine this value with the impairment values for other joints in the foot to obtain the total abnormal motion/ankylosis impairment assessment for a foot.
Step 4	Combine with abnormal motion/ankylosis impairment assessments for different regions in the lower extremity (that is, knee and hip).
Step 5	Combine with impairment values for peripheral nerve injuries.
Step 6	Combine with impairment values for amputation.

9.1 Feet and toes

Table 9.1 assesses impairments to range of motion of the feet and toes, including ankylosis of one or more joints. The maximum WPI rating under Table 9.1 is 2% for impairment of two or more of the 2nd, 3rd, 4th and 5th toes of one foot.

In the case of toes, the ankylosis referred to in Table 9.1 is that of the metatarso-phalangeal joint.

Ankylosis of the interphalangeal joints of the 2nd, 3rd, 4th or 5th toe attracts a WPI rating of 0. The position of function is the neutral position.

Table 9.1: Feet and toes

% WPI

Criteria (one required—different conditions may be assessed separately)

Ankylosis of any one of the 2nd, 3rd, 4th or 5th toes in position of function.

Interphalangeal flexion of the 1st toe restricted to less than 20.

Metatarso-phalangeal extension of the 1st toe restricted to a range of 15-30.

Metatarso-phalangeal extension of any one of the 2nd, 3rd, 4th and 5th toes restricted to less than 10.

Subtalar inversion restricted to a range of 10-20.

Subtalar eversion restricted to less than 10.

Ankylosis of:

any one of the 2nd, 3rd, 4th or 5th toes in full extension or full flexion
any two of the 2nd, 3rd, 4th or 5th toes in position of function
the 2nd, 3rd and 4th toes in position of function.

Metatarso-phalangeal extension of the 1st toe restricted to less than 15.

Metatarso-phalangeal extension of any two of the 2nd, 3rd, 4th or 5th toes restricted to less than 10

Subtalar inversion restricted to less than 10.

Ankylosis of:

any two of the 2nd, 3rd or 4th toes, plus the 5th toe, in position of function
any two of the 2nd, 3rd, 4th or 5th toes in full extension or full flexion
all four of the 2nd, 3rd, 4th and 5th toes in position of function
the 2nd toe with any two of the 3rd, 4th or 5th toes in full extension
the 3rd, 4th and 5th toes in full extension or full flexion
the 2nd and 3rd toes with either of the 4th or 5th toes in full flexion.

Table 9.1 (continued)

% WPI	Criteria (ONE required – different conditions may be assessed separately)
3	Ankylosis of: all four of the 2nd, 3rd, 4th and 5th toes in full flexion or full extension the 2nd toe with the 4th and 5th toes in full flexion.
4	Ankylosis of: the 1st toe in position of function or full extension the 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in position of function.
5	Ankylosis of: the 1st toe in full flexion the 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in full extension the 1st toe with any two or three of the 2nd, 3rd, 4th or 5th toes in position of function.
6	Ankylosis of: the 1st toe with any two or three of the 2nd, 3rd, 4th or 5th toes in full extension the 1st toe with all four of the 2nd, 3rd, 4th and 5th toes in position of function the 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in full flexion.
7	Ankylosis of: the 1st toe with any two of the 2nd, 3rd, 4th or 5th toes in full flexion the 1st toe with all four of the 2nd, 3rd, 4th and 5th toes in full extension.
8	Ankylosis of the 1st toe with any three or all four of the 2nd, 3rd, 4th and 5th toes in full flexion.
10	Ankylosis of hindfoot with tibia-os calcis angle of 100 to 110.
15	Ankylosis of hindfoot with tibia-os calcis angle of 90 to 95.
20	Ankylosis of hindfoot with tibia-os calcis angle of less than 90.

9.2 Ankles

Table 9.2 assesses impairments to range of motion and deformity of the ankle, as well as ankylosis. Ankle deformity with movement is assessed separately from ankylosis.

Ankylosis in the optimal position is equivalent to a WPI of 4%. The optimal position is the neutral position without flexion, extension, varus or valgus. This is the base level of ankylosis impairment in the ankle.

When ankylosis is not in the optimal position, add the relevant WPI ratings from Table 9.2 for ankylosis in each direction. Then add the base figure of 4% WPI for ankylosis in the optimal position.

The maximum WPI rating for multiple impairments of the ankle and hindfoot is 25% WPI. If the total WPI rating obtained by adding different WPI ratings is higher than 25% WPI, then the final WPI rating for the ankle is 25%.

Table 9.2: Ankles

% WPI	Criteria (one required—different conditions may be assessed separately—but see notes on ankylosis above)
3	Plantar flexion capability restricted to 15-20. Dorsiflexion restricted to less than 10.
4	Ankylosis in optimal position only (see notes).
	Deformity with: varus angulation of 10 valgus angulation of 10-20.
5	Ankylosis not in optimal position: in less than 10 of internal malrotation in 15of external malrotation.
6	Plantar flexion capability restricted to 10 or less. Plantar flexion contracture of 10-15.
7	Ankylosis not in optimal position: in 10 to 15 of dorsiflexion or plantar flexion.
	Deformity with varus angulation of 15-20.
10	Ankylosis not in optimal position: in varus angulation of 5 in valgus angulation of 10 to 15 in 10 to 15 of internal malrotation in 20 to 25 of external malrotation

Table 9.2 continued on following page.
Table 9.2 (continued)

% WPI	Criteria (one required—different conditions may be assessed separately—but see notes on ankylosis above)
12	Plantar flexion contracture of at least 20.
15	Ankylosis not in optimal position: in 20 to 25 of plantar flexion in at least 20 of dorsiflexion in varus angulation of 10 to 15 in valgus angulation of 20 to 25 in 20 to 25 of internal malrotation in 30 to 35 of external malrotation.
17	Ankylosis not in optimal position: in varus angulation of 20 to 25.
20	Deformity with varus angulation of 25 or greater.
21	Ankylosis not in optimal position: in varus angulation of at least 30 in at least 30 of plantar flexion in valgus angulation of at least 30 in at least 30 of internal malrotation in at least 40 of external malrotation.

9.3 Knees

Table 9.3 assesses impairments to range of motion and deformity of the knee, as well as ankylosis. Knee deformity with movement is assessed separately from ankylosis. ‘Deformity’ is measured by the femoral-tibial angle: 3-10 valgus is considered normal.

Ankylosis in the optimal position is equivalent to 27% WPI. The optimal position is 10-15 of flexion with good alignment. This is the base level of ankylosis impairment in the knee. When ankylosis is not in the optimal position, add the relevant WPI ratings from Table 9.3 for ankylosis in each direction. Then add the base figure of 27% WPI for ankylosis in the optimal position.

The maximum WPI rating for multiple impairments of the knee is 40% WPI. If the total WPI rating obtained by adding different WPI ratings is over 40%, then the final WPI rating for the knee is 40%.

Table 9.3: Knees

% WPI

Criteria (one required—

different conditions may be assessed separately)

Flexion of 80-105.

Flexion contracture of 5.

Deformity with:

varus angulation of 2 valgus-0 (neutral)
valgus angulation of 10-12.

Ankylosis not in optimal position:

in 10 to 15 of internal malrotation

in 10 to 15 of external malrotation
in less than 10 of varus

in 10 to 15 of valgus

in 20 to 25 of flexion.

Flexion of 60-75.

Flexion contracture of 10-15.

Deformity with:

varus angulation of 1-7
valgus angulation of 13-15.

Ankylosis not in optimal position:

in 20 to 25 of internal malrotation
in 20 to 25 of external malrotation
in 10 to 15 of varus
in 20 to 25 of valgus
in 30 to 35 of flexion.

Ankylosis not in optimal position:

in at least 30 of internal malrotation
in at least 30 of external malrotation
in at least 20 of varus
in at least 30 of valgus
in at least 40 of flexion.

Table 9.3 continued on following page.
Table 9.3 (continued)

% WPI	Criteria (one required— different conditions may be assessed separately)
14	Flexion of 30-55. Flexion contracture of 20 or greater. Deformity with: varus angulation of more than 12 valgus angulation of more than 20.
20	Flexion of less than 30. Deformity with: varus angulation of more than 12 valgus angulation of more than 20.
27	Ankylosis in optimal position only (see notes above).

9.4 Hips

Table 9.4 assesses impairments of range of motion and deformity of the hip, as well as ankylosis. Hip deformity with movement is assessed separately from ankylosis.

Ankylosis in the optimal position is 20% WPI. The optimal position is 25-40 of flexion with neutral rotation, abduction and adduction. This is the base level of ankylosis impairment in the hip. When ankylosis is not in the optimal position, add the relevant WPI ratings from Table 9.4 for ankylosis in each direction. Then add the base figure of 20% WPI for ankylosis in the optimal position.

The maximum WPI rating for multiple impairments of the hip is 40%. If the total WPI rating obtained by adding different WPI ratings is over 40%, then the final WPI rating for the hip is 40%.

Table 9.4: Hips

% WPI

Criteria (one required—

different conditions may be assessed separately)

Flexion restricted to 80-100.

Flexion contracture of 10-15.

Internal rotation restricted to 10-15.

External rotation restricted to 20-30.

Abduction restricted to 15-25.

Adduction restricted to 15 or less.

Abduction contracture of 5 or less.

Flexion restricted to 50-70.

Flexion contracture of 20-25.

Internal rotation restricted to less than 10.

External rotation restricted to less than 20.

Abduction restricted to 5-10.

Abduction contracture of 6-10.

Ankylosis not in optimal position:

in 20 to 40 of flexion
in at least 5 of internal rotation
in 10-15 of external rotation.

Table 9.4 continued on following page.
Table 9.4 (continued)

% WPI	Criteria (one required— different conditions may be assessed separately)
10	Flexion restricted to less than 50. Flexion contracture of 30 or more. Abduction restricted to less than 5. Abduction contracture of 11-20.
10	Ankylosis not in optimal position: in 10 to 50 of flexion in at least 10 of internal rotation in at least 20 of external rotation in 5-10 of abduction in at least 5 of adduction.
15	Abduction contracture of more than 20.
15	Ankylosis not in optimal position: in 0 to 60 of flexion in at least 20 of internal rotation in at least 30 of external rotation in 15-20 of abduction in at least 10 of adduction.
20	Ankylosis in optimal position (see notes above). Ankylosis not in optimal position: in at least 70 of flexion in at least 30 of internal rotation in at least 40 of external rotation in at least 25 of abduction in at least 15 of adduction.

9.5 Lower extremity amputations

Table 9.5 is the only table used to assess impairment arising from amputations in the lower extremity.

Table 9.7: Lower extremity function must not be used in cases involving amputations.

A WPI rating from Table 9.5 may be combined with other WPI ratings for lower extremity conditions above the amputation site.

Table 9.5: Lower extremity amputations

% WPI	Criteria (one required—different conditions may be assessed separately)
0	Amputation through: interphalangeal joint (distal or proximal) of any one of 2nd, 3rd, 4th or 5th toes any phalanx of any one of the 2nd, 3rd, 4th or 5th toes. Amputation of any portion of soft tissue of any toe.
1	Amputation of any one of the 2nd, 3rd, 4th or 5th toes at the metatarso-phalangeal joint.
2	Amputation of: the first toe at the interphalangeal joint any toe except the first toe through the metatarsal any two of the 2nd, 3rd, 4th or 5th toes at the metatarso-phalangeal joint.
3	Amputation of any three of the 2nd, 3rd, 4th and 5th toes at the metatarso-phalangeal joint.
4	Amputation of all four of the 2nd, 3rd, 4th and 5th toes at the metatarso-phalangeal joint.
5	Amputation of the first toe at the metatarso-phalangeal joint.
8	Amputation of the first metatarsal (first toe).
10	Amputation of all toes of one foot at the metatarso-phalangeal joints.
16	Transmetatarsal amputation.
18	Midfoot amputation.
25	Syme amputation of hindfoot.
28	Amputation of lower leg more than 7.5cm below knee.
32	Amputation of lower leg 7.5cm or less below knee. Knee disarticulation. Amputation above knee distal to midthigh.
36	Amputation above knee through midthigh.
40	Amputation above knee proximal to midthigh. Hip disarticulation.
50	Hemipelvectomy.

9.6 Spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities

Figure 9-C: Grading system

Grading

Sensory deficits or pain

Motor function

Criteria

No sensation

Severe pain that prevents all activity.

No contraction.

No protective sensibility with abnormal sensations

Severe pain that prevents most activity.

A flicker.

Decreased protective sensibility with abnormal sensations

Severe pain that prevents some activity.

Active movement with gravity eliminated.

Diminished light touch and two-point discrimination with some abnormal sensations

Slight pain that interferes with some activity.

Active movement against gravity.

Diminished light touch with or without minimal abnormal sensations

Pain that is forgotten during activity.

Active movement against gravity and resistance.

Normal sensation

No pain.

Normal power.

9.6.1 Spinal nerve root impairment affecting the lower extremity

Table 9.6.1 is to be used where there is involvement of a single spinal nerve. Where there are multiple nerves involved, the respective WPI ratings for each involved nerve should be combined.

Values obtained for pain, discomfort and/or sensory loss should be combined with values obtained for loss of strength, using the combined values chart (see Appendix 1).

Where the same nerve root is assessed, Table 9.6.1 must not be used in conjunction with Table 9.17: Lumbar spine.

Table 9.6.1: Spinal nerve root impairment affecting the lower extremity

Impairment causing pain, discomfort and/or sensory loss

Impairment causing loss of strength

Grading

	5		4	3		2		1		0	5	4	3	2	1		0
Nerve root	% WPI										% WPI							Nerve root
L3	0	1			1		2		3	3	0	2	3	5		7	8	L3
L4	0	1			1		2		3	3	0	3	6	8		12	14	L4
L5	0	1			1		2		3	3	0	3	6	9		13	15	L5
S1	0	1			1		2		3	3	0	2	3	5		7	8	S1

9.6.2 Peripheral nerve injuries affecting the lower extremities

WPI ratings obtained for sensory impairment should be combined with WPI ratings for dysaesthesia, and the total combined with WPI ratings for motor impairment, using the combined values chart (see Appendix 1).

Where the same nerve is assessed, Table 9.6.2a and Table 9.6.2b must not be used in conjunction with Table 9.17: Lumbar spine.

Use the grading system shown in Figure 9-C: Grading system.

Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities

	Sensory grading						Dysaesthesia grading
	Sensory grading						Dysaesthesia grading
	5	4	3	2	1	0	5	4	3	2	1	0
Nerve	% WPI						% WPI						Nerve
Femoral	0	0	0	1	1	1	0	1	1	2	3	3	Femoral
Lateral femoral cutaneous	0	0	0	1	1	1	0	1	1	2	3	3	Lateral femoral cutaneous
Sciatic	0	1	3	5	6	7	0	1	2	4	5	5	Sciatic
Common peroneal	0	0	1	1	2	2	0	0	1	1	2	2	Common peroneal
Tibial	0	1	2	4	4	5	0	1	1	3	3	3	Tibial
Superficial peroneal	0	0	1	1	2	2	0	0	1	1	2	2	Superficial peroneal
Sural	0	0	0	1	1	1	0	0	1	1	2	2	Sural
Medial plantar	0	0	1	1	2	2	0	0	1	1	2	2	Medial plantar
Lateral plantar	0	0	1	1	2	2	0	0	1	1	2	2	Lateral plantar

Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities

	Motor grading
	5	4	3	2	1	0
Nerve	% WPI
Femoral	0	3	6	9	13	15
Obturator	0	1	1	2	3	3
Superior gluteal	0	5	10	15	21	25
Inferior gluteal	0	3	6	9	13	15
Sciatic	0	6	12	18	26	30
Common peroneal	0	3	6	9	13	15
Tibial	0	3	6	9	13	15
Medial plantar	0	0	1	1	2	2
Lateral plantar	0	0	1	1	2	2

9.7 Lower extremity function

Table 9.7 (see following page) should only be used to assess impairment from objectively identified orthopaedic or neurological conditions arising in and affecting the lower extremities. It may not be used to assess impairment from conditions manifesting principally as pain with no clinically demonstrable lower extremity pathology.

A secondary dysfunction consequent to disuse is only assessable under Table 9.7 if this dysfunction is permanent (that is, not likely to improve as a result of surgery, medication or other rehabilitative treatment) and there are objective clinical findings that can be validly assessed using other tables in Chapter 9, Part 1—The lower extremities.

If permanent, conditions such as sesamoiditis, plantar fasciitis, plantar tendonitis, and pes planus, should be assessed under Table 9.7.

Table 9.7 must not be used in cases involving amputations.

A single assessment only may be made under Table 9.7, regardless of whether one or two extremities are affected by the injury. The impairment assessed under Table 9.7 is of overall lower extremity function, rather than that of individual extremities.

Before using Table 9.7 the medical assessor should check the instructions (see Part I—Introduction, page 106) preceding the specific joint impairment tables (Tables 9.1–9.4) and use Table 9.7 strictly in accordance with those instructions. In particular, Table 9.7 cannot be used where the condition causes a reduction in the range of motion of a joint and an assessment can be made under any one or more of Table 9.1, 9.2, 9.3 or 9.4.

Where only one limb is affected, regardless of the number of impairments found in that limb, the limb should be assessed using the relevant tables other than Table 9.7 and all impairments combined using the combined values table (see Appendix 1). The combined impairment rating should then be compared with the rating taken from the relevant row in Table 9.7 and the higher rating obtained from the two methods chosen.

Where both limbs are affected, each limb should be assessed using the relevant tables other than Table 9.7 and all impairments in both limbs combined using the combined values table (see Appendix 1). The combined impairment rating should then be compared with the rating taken from the relevant row in Table 9.7 and the higher rating obtained from the two methods chosen.

Table 9.7 may be used to assess lower extremity impairment arising as a result of spinal cord damage. Observe the special procedure set out in the introduction to Part III of this Chapter. However, Table 9.7 is not to be used to assess lower extremity impairment arising as a result of nerve root compression, or other neurological sequelae of other spinal conditions. These should be assessed under:

Table 9.6.1, Table 9.6.2a or Table 9.6.2b (tables dealing with spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities, see pages 98-100)
Table 9.15: Cervical spine
Table 9.16: Thoracic spine
Table 9.17: Lumbar spine.

To fulfil the requirements of a WPI rating in Table 9.7, there must be one major criterion and at least two minor criteria present (where minor criteria are listed).

‘Manifest difficulty’ is difficulty (such as stumbling, or an altered gait) evident to the medical assessor. The difficulty must be tested clinically: history alone cannot be relied upon in the assessment.

Table 9.7: Lower extremity function

% WPI

Major criteria

(at least one required)

Minor criteria

(at least two required where listed)

Walks at a normal pace in comparison with peers on level ground or uneven ground and can avoid obstacles

Distance walked is not restricted by the condition being assessed (although other factors such as the level of fitness may cause restriction).

Walks at a normal pace in comparison with peers on level ground but has manifest difficulty negotiating uneven ground and avoiding obstacles

Walking is restricted to 1000m or less (may be able to walk further after resting).

Legs give way or lock occasionally without causing falls.

Can negotiate three or more stairs or a ramp (up and down) without the use of a walking aid or hand rails.

Walks at a normal pace in comparison with peers on level ground but is unable to negotiate uneven ground without use of a walking aid or personal assistant

Walking is restricted to 500m or less (may be able to walk further after resting).

Legs give way or lock occasionally without causing falls.

Is unable to negotiate three or more stairs or a ramp (up and down) without the use of a walking aid or hand rails.

Walks at a moderately reduced pace in comparison with peers on level ground

Walking is restricted to 250m or less (may be able to walk further after resting).

Legs give way occasionally, causing falls.

Is unable to negotiate three or more stairs or a ramp (up and down) without use of a walking aid or hand rails.

Is unable to rise from sitting to standing position without use of one hand but can stand without support.

Table 9.7 (continued)

% WPI

Major criteria

(at least one required)

Minor criteria

(at least two required where listed)

Walks at a significantly reduced pace in comparison with peers on level ground

Walking is restricted to 100m or less (may be able to walk further after resting).

Legs give way frequently, causing falls.

Demonstrated medical need for a brace or walking aid (walking stick or crutches) on level ground.

Is unable to negotiate three or more stairs or a ramp (up and down) without assistance from another person.

Is unable to rise from sitting to standing position without use of both hands but can stand without support.

Walks at a greatly reduced pace in comparison with peers on level ground

Walking is restricted to 50m or less (may be able to walk further after resting).

Is restricted to walking around house and yard.

Demonstrated medical need for a walking aid (walking stick or crutches) when walking on level ground.

Is unable to negotiate three or more stairs or a ramp (up and down) under any circumstances.

Is unable to rise from sitting to standing position without personal assistance and is unable to stand without support.

Walks at a very slow pace in comparison with peers on level ground

Walking is restricted to 25m or less (may be able to walk further after resting).

Is restricted to walking around house.

Demonstrated medical need for a quad stick or walking frame as support when standing and walking.

Is unable to negotiate any steps or ramps.

Is unable to rise from sitting to standing position without personal assistance and is unable to stand without support.

Can stand with support of personal assistant but is unable to walk.

Unable to stand or walk.

Part II

The Upper Extremities: Hands and Fingers, Wrists, Elbows and Shoulders

Part II—Introduction

The impairments assessed for each region in each upper extremity are combined (that is, hand, wrist, elbow, shoulder).

The WPI rating for one upper extremity may be combined with a WPI rating for the other upper extremity, except in the case of assessments under Table 9.14, where the notes appearing prior to Table 9.14 are to be followed.

WPI ratings from the following tables must not be combined with a WPI rating under Table 9.14 if they assess the same condition in the same upper extremity:

Tables 9.8.1a, 9.8.1b, 9.8.1c, 9.8.1d (tables dealing with abnormal motion of digits)
Tables 9.8.2a, 9.8.2b, 9.8.2c, 9.8.2d (tables dealing with sensory losses in thumb and fingers)
Tables 9.9.1a, 9.9.1b (tables dealing with wrists)
Tables 9.10.1a, 9.10.1b (tables dealing with elbows)
Tables 9.11.1a, 9.11.1b, 9.11.1c (tables dealing with shoulders).

If the medical assessor considers that the impairment is not adequately assessed using one of Tables 9.9, 9.10, and 9.11, and the condition involves radiographically demonstrated joint instability, radiographically demonstrated arthritis or where the employee has had an arthroplasty, the medical assessor may consider the effect of the injury on upper extremity function instead and determine the WPI rating using Table 9.14. Table 9.14 cannot be used unless the condition involves radiographically demonstrated joint instability or arthritis or the employee has had an arthroplasty.

Where a condition cannot be assessed under a specific table in the upper extremities group, an assessment may be made under the provisions of the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001.

All ankylosis assessments from tables in the upper extremities group are alternative assessments to those for abnormal motion of the individual joints.

The maximum WPI rating for a single upper extremity is 60%, including combined WPI ratings.

Steps in calculating upper extremity impairment

Note that sensory loss in the digit is assessed either as a digit impairment or as a peripheral nerve impairment as appropriate, but not both.

Step 1	Add abnormal motion/ankylosis impairment values within an individual joint.
Step 2	Add abnormal motion/ankylosis impairment values for different joints in the thumb.
Step 3	Combine impairment values for different joints in the other four digits.
Step 4	Combine impairment values for each digit for sensory loss due to digital nerve injury and/or amputation.
Step 5	Add impairment values for each digit to obtain the total hand assessment.
Step 6	Combine with impairment values for different regions in the upper extremity.

9.8 Hands and fingers

Add the WPI ratings for each individual digit to obtain the total WPI rating for the hand.

WPI ratings for abnormal motion or ankylosis of digits are combined with those for sensory losses in the same digits.

9.8.1 Abnormal motion of digits

Table 9.8.1a, Table 9.8.1b, Table 9.8.1c and Table 9.8.1d assess impairments to range of motion of the digits of the hand, including ankylosis of one or more joints.

Impairment values for flexion and extension losses in each individual joint are added to obtain the total WPI rating for loss of range of motion of that joint.

Where there is abnormal motion or ankylosis of more than one joint of the same finger, the WPI ratings for abnormal motion or ankylosis are combined to obtain the WPI rating for that finger.

Where there is abnormal motion or ankylosis of more than one joint of the thumb, the WPI ratings for abnormal motion or ankylosis are added to obtain the WPI rating for the thumb.

Table 9.8.1a: Abnormal motion/ankylosis of the thumb—IP and MP joints

See notes to Table 9.8.1a on page 131.

Direction	IP joint			MP joint			Direction
Extension/ hyperextension	Ankylosis	Loss of extension	Loss of flexion	Ankylosis	Loss of extension	Loss of flexion	Extension/ hyperextension
Extension/ hyperextension	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	Extension/ hyperextension
				2	0	2	40
30	3	0	3	2	0	2	30
20	3	0	3	2	0	2	20
10	2	0	2	2	0	2	10
0	2	0	2	1	0	1	0
10	2	1	1	1	0	1	10
20	2	1	1	1	0	1	20
30	2	1	1	1	1	1	30
40	2	2	1	2	1	1	40
50	2	2	1	2	2	0	50
60	3	2	0	2	2	0	60
70	3	3	0
80	3	3	0
Flexion							Flexion

Table 9.8.1b: Radial abduction/adduction/opposition of the thumb—abnormal motion/ankylosis

See notes to Table 9.8.1b on page 131.

% WPI

Criteria (one required—different conditions may be assessed separately)

Loss of less than 10 of radial adduction.

Loss of less than 35 of radial abduction.

Lack of less than 3cm adduction.

Thumb opposition of more than 6 cm.

Loss of 10-20 of radial adduction.

Loss of 35-40 of radial abduction.

Lack of 3-5 cm adduction.

Thumb opposition of 5 to 6 cm.

Ankylosis in 30 to 35 of radial abduction.

Loss of 25 or more of radial adduction.

Loss of 45 or more of radial abduction.

Lack of 6cm adduction.

Ankylosis in 15-25, or 40-50 of radial abduction.

Ankylosis in 4cm of adduction.

Thumb opposition of 4cm.

Lack of 7cm adduction.

Thumb opposition of 3cm.

Ankylosis in 3cm or 5cm of adduction.

Lack of 8cm adduction.

Ankylosis in 0-2cm or 6-8cm of adduction.

Thumb opposition of 2cm.

Ankylosis in thumb opposition of 5-6cm.

Ankylosis in thumb opposition of 4cm or 7cm.

Thumb opposition of 1cm.

Ankylosis in thumb opposition of 3cm or 8cm.

Ankylosis in thumb opposition of 1 or 2cm.

Thumb opposition of 0cm.

Ankylosis in thumb opposition of 0cm.

Table 9.8.1c: Abnormal motion/ankylosis of the fingers—index and middle fingers

See notes to Table 9.8.1c on page 131.

Direction	Index and middle fingers									Direction
Extension/hyperextension	DIP joint			PIP joint			MP joint			Extension/hyperextension
	Ankylosis	Loss of extension	Loss of flexion	Ankylosis	Loss of extension	Loss of flexion	Ankylosis	Loss of extension	Loss of flexion
	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI
30	5	0	5	8	0	8				30
20	4	0	4	8	0	8	7	0	7	20
10	4	0	4	7	0	7	6	1	6	10
0	4	0	4	7	0	7	6	1	5	0
10	4	0	3	6	1	6	5	1	5	10
20	3	1	3	6	1	5	5	1	4	20
30	4	1	2	6	1	4	5	1	4	30
40	4	2	2	5	2	4	6	3	3	40
50	4	3	1	6	3	3	7	4	2	50
60	4	4	1	7	4	3	8	6	2	60
70	5	5	0	7	5	2	8	8	1	70
80				8	7	1	10	9	1	80
90				8	8	1	11	11	0	90
100				8	8	0				100
Flexion										Flexion

Table 9.8.1d: Abnormal motion/ankylosis of the fingers—ring and little fingers

See notes to Table 9.8.1d on page 131.

Direction	Ring and little fingers									Direction
Extension/hyperextension	DIP joint			PIP joint			MP joint			Extension/hyperextension
	Ankylosis	Loss of extension	Loss of flexion	Ankylosis	Loss of extension	Loss of flexion	Ankylosis	Loss of extension	Loss of flexion
	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI	%WPI
30	3	0	3	4	0	4				30
20	2	0	2	4	0	4	3	0	3	20
10	2	0	2	4	0	4	3	0	3	10
0	2	0	2	3	0	3	3	1	3	0
10	2	0	2	3	0	3	3	1	2	10
20	2	0	2	3	1	3	3	1	2	20
30	2	1	1	3	1	2	3	1	2	30
40	2	1	1	3	1	2	3	2	2	40
50	2	2	1	3	2	2	3	2	1	50
60	2	2	1	3	2	1	4	3	1	60
70	3	3	0	4	3	1	4	4	1	70
80				4	3	1	5	5	1	80
90				4	4	1	5	5	0	90
100				4	4	0				100
Flexion										Flexion

Notes to Tables 9.8.1a, 9.8.1b, 9.8.1c and 9.8.1d

Abbreviations:

IP = interphalangeal.

MP = metacarpo-phalangeal.

CMC = carpometacarpal.

PIP = Proximal interphalangeal.

DIP = Distal interphalangeal.

2. Thumb adduction is the smallest possible distance from the flexor crease of the IP joint of the thumb to the distal palmar crease over the level of the MP joint of the little finger. The normal range of adduction of the thumb is from 8 cm to 0cm.

3. Thumb radial abduction is the largest angle of separation actively formed between the first and second metacarpals in the coronal plane. The normal angle of radial abduction is 50. The smallest angle of thumb radial adduction is 15.

4. Opposition of the thumb is measured as the largest achievable distance between the flexor crease of the IP joint of the thumb to the distal palmar crease directly over the third MP joint. The normal range of opposition of the thumb is from 0 cm to 8 cm. In the case of employees with small hands, compare the loss of opposition with the normal range of opposition in the unaffected hand.

5. Optimal positions of thumb and fingers:

Joint	Optimal position	Joint	Optimal position
Thumb IP	20 of flexion	Finger DIP	20 of flexion
Thumb MP	20 of flexion	Finger PIP	40 of flexion
Thumb CMC	30-35 of radial abduction	Finger MP	30 of flexion

9.8.2 Sensory losses in the thumb and fingers

Table 9.8.2a, Table 9.8.2b, Table 9.8.2c, and Table 9.8.2d (see following page) assess sensory losses in the thumb and fingers due to digital nerve lesions only.

Sensory losses due to peripheral nerve lesions are assessed under Tables 9.13.1, 9.13.2a and 9.13.2b (tables dealing with neurological impairments affecting the upper extremities).

The two-point discrimination test is used to determine sensory loss:

Total sensory loss = two-point discrimination of greater than 15mm
Partial sensory loss = two-point discrimination of 7 to 15mm.

Two-point discrimination of less than 7 mm is not treated as an impairment.

Transverse sensory loss involves both digital nerves (ulnar and radial). Longitudinal sensory loss involves a single digital nerve (ulnar or radial).

Determine the percentage of digit length involved using the method in the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th edition 2001 and consult Table 9.8.2a, Table 9.8.2b, Table 9.8.2c, and Table 9.8.2d, using the corresponding WPI rating for the nerve or nerves involved.

WPI ratings for transverse sensory loss must not be combined with WPI ratings for longitudinal sensory loss in the same digit. The conditions of transverse sensory loss and longitudinal sensory loss in an individual digit are mutually exclusive.

WPI ratings for sensory losses in digits are combined with those for abnormal motion or ankylosis in the same digits.

For the thumb and little finger, losses involving the ulnar digital nerve are rated higher than those of the radial digital nerve. For the other fingers, losses involving the radial digital nerve are rated higher than those of the ulnar digital nerve.

If the little finger has been amputated, the ring finger is assessed as if it were the little finger.

Table 9.8.2a: Sensory losses in the thumb Table 9.8.2b: Sensory losses in the
index and middle fingers

Percentage of digit length	% WPI (thumb)						Percentage of digit length	% WPI (index and middle fingers)
	Transverse loss		Longitudinal loss					Transverse loss		Longitudinal loss
	Both digital nerves		Ulnar digital nerve		Radial digital nerve			Both digital nerves		Ulnar digital nerve		Radial digital nerve
	Total	Partial	Total	Partial	Total	Partial		Total	Partial	Total	Partial	Total	Partial
10	1	1	1	1	1	0	10	1	1	0	0	1	0
20	2	1	1	1	1	1	20	1	1	1	0	1	1
30	3	2	2	1	1	1	30	2	1	1	1	1	1
40	4	2	3	1	2	1	40	2	1	1	1	1	1
50	5	3	3	2	2	1	50	3	2	1	1	2	1
60	7	3	4	2	3	1	60	3	2	1	1	2	1
70	8	4	4	2	3	2	70	4	2	2	1	2	1
80	8	4	5	3	3	2	80	4	2	2	1	3	1
90	10	5	6	3	4	2	90	5	3	2	1	3	2
100	11	5