AMA 6th Edition

SIXTH EDITION
Guides to the Evaluation of

Permanent Impairment
Medical Editor
Robert D. Rondinelli, MD, PhD
Medical Director of Rehabilitation Services
Iowa Health Des Moines
Des Moines, Iowa
Section Editors
Elizabeth Genovese MD, MBA, FACOEM, FAADEP
IMX Medical Management Services
Bala Cynwyd, Pennsylvania
Richard T. Katz, MD
Physical Medicine & Rehabilitation
St. Louis, Missouri
Tom G. Mayer, MD
Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE)
Dallas, Texas
Kathryn L. Mueller, MD, MPH
University of Colorado Health Sciences Center
Denver, Colorado
Mohammed I. Ranavaya, MD, JD, MS, FFOM, FRCPI, CIME
Professor and Chief, Division of Occupational and Disability Medicine
Marshall University, Joan C. Edwards School of Medicine
Huntington, West Virginia
Senior Contributing Editor

Christopher R. Brigham, MD, MMS
Brigham and Associates, Inc.
San Diego, California
Guides_07_FM_i-xxiv.indd i 2/17/09 3:03:52 PM

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© 2008 by the American Medical Association

Sixth Edition-First Printing: November 2007
Second Printing: April 2009
Printed in the United States of America. All rights reserved
Internet address: www.ama-assn.org
Limited portions of the information in this publication may be

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consequences from application of the information in this book.
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Refer to product number OP025407.
ISBN 1-57947-888-9
BQ6509P047:4/09
Library of Congress Cataloging-in-Publication Data

Guides to the evaluation of permanent impairment. — 6th ed. /
medical editor, Robert D. Rondinelli ; section editors,
Elizabeth Genovese ... [et al.] ; senior contributing editor,
Christopher R. Brigham.
p. ; cm.
Includes bibliographical references and index.
Summary: “The emphasis of this edition is on expanding the
spectrum of diagnoses recognized in impairment rating. It is designed
to encourage attention to and documentation of functional consequences
of the impairment as a part of each physician’s detailed history”
—Provided by publisher.
ISBN-13: 978-1-57947-888-9 (alk. paper)
ISBN-10: (invalid) 1-57947-888-9 (alk. paper) 1. Disability
evaluation—Handbooks, manuals, etc. 2. Medical
jurisprudence—Handbooks, manuals, etc. I. Rondinelli,
Robert D. II. Genovese, Elizabeth. III. Brigham,
Christopher R., M.D. IV. American Medical Association.
[DNLM: 1. Disability Evaluation. W 925 G946 2008]
RA1055.5.G85 2008
614’.1—dc22
2007045150
Guides_07_FM_i-xxiv.indd ii 3/6/09 9:39:21 AM

Preface
The American Medical Association’s Guides to the grids arrange diagnoses into five classes of impair-
Evaluation of Permanent Impairment, Sixth Edition ment severity, according to the consensus-based
defines an innovative new international standard for dominant criterion. The functionally based history,
impairment assessment. A consistent, well-designed physical findings, and broadly accepted clinical
methodology was adopted and applied to each test results, where applicable, are then integrated to
chapter to enhance the relevancy of impairment rat- determine severity grade and provide a correspond-
ings, improve internal consistency, promote greater ing impairment value. Ratings are transparent,
precision, and standardize the rating process. The clearly stated, and reproducible. The basic template
goal is to provide an impairment rating guide that is of the diagnosis-based grid is common to each organ
authoritative, fair, and equitable to all parties. The system and chapter; thus, there is greater internal
editorial process used an evidence-based foundation consistency, facilitating the application of this new
when possible and a modified Delphi panel approach method.
to consensus building.
Features of the new edition include the following:
The Guides is a treatise on evaluating impairment. • A standardized approach across organ systems and
Clinical discussions among physician colleagues chapters.
regarding potential severity of an illness or injury • The most contemporary, evidence-based concepts
typically involve four basic points of consideration: and terminology of disablement from the ICF.
(1) what is the problem (diagnosis); (2) what symp- • The latest scientific research and evolving medi-
toms and resulting functional difficulty does the cal opinions provided by nationally and interna-
patient report; (3) what are the physical findings per- tionally recognized experts.
taining to the problem; and (4) what are the results • Unified methodology that helps physicians calcu-
of clinical studies. These same basic considerations late impairment ratings through a grid construct
are used by physicians to evaluate and communi- and promotes consistent scoring of impairment
cate about impairment and, therefore, are used as ratings.
a guiding construct for this edition of the Guides. • A more comprehensive and expanded diagnostic
The emphasis of this edition is on expanding the approach.
spectrum of diagnoses recognized in impairment • Precise documentation of functional outcomes,
rating. It is designed to encourage attention to and physical findings, and clinical test results, as
documentation of functional consequences of the modifiers of impairment severity.
impairment as a part of each physician’s detailed his- • Increased transparency and precision of the
tory, to clarify and delineate key physical findings, impairment ratings.
and to underscore essential clinical test results where • Improved physician interrater reliability.
applicable.
These features provide benefit to all stakeholders
The new methodology applies terminology and
by minimizing conflict and improving decision-
adopts an analytical framework based on the World
making. The process of defining impairment or the
Health Organization’s International Classification
complexities of human function is not perfect;
of Functioning, Disability and Health (ICF); five
however, the Sixth Edition standardizes the rating
impairment classes permit the rating of the patient
process, improves accuracy, and provides a solid
from no impairment to most severe. Diagnosis-based
basis for future editions of the Guides.
grids were developed for each organ system. These
iii
Guides_07_FM_i-xxiv.indd iii 2/17/09 3:03:53 PM

iv Guides to the Evaluation of Permanent Impairment
The AMA implemented a broader process for the • Maintain the current knowledge base and provide
Sixth Edition to ensure collective input, a more historical perspective for the purpose of continuity
comprehensive review before publication, and an for future editions of the Guides.
opportunity for comments from stakeholders on an • Advise on revising, updating, and modifying the
ongoing basis for this and future editions. The pro- Guides.
cess was guided by the Editorial Panel and features
an open, well-defined, and tiered peer review pro- The section editors relied on their experience and
cess. State medical associations and national medi- expertise in impairment rating to collectively define
cal specialty societies were invited to participate the contextual background for the individual chap-
by nominating a disability or impairment physician ters. The Editorial Panel developed five strategies
expert to serve as an Editorial Panel or Advisory to establish the framework and context for the Sixth
Committee member, possible author, content con- Edition:
tributor, and/or reviewer to the new edition. Those 1) Adopt the terminology, definitions, and concep-
nominating members include the: tual framework of disablement of the 2001 ICF in
American Academy of Dermatology place of the current and antiquated terminology of
American Academy of Disability Evaluating the International Classification of Impairments,
Physicians Disabilities and Handicaps (ICIDH);
American Academy of Neurology 2) Become more diagnosis based, with these diagno-
American Academy of Ophthalmology ses being evidence based.
American Academy of Orthopaedic Surgeons 3) Give priority to simplicity and ease of application,
American Academy of Otolaryngology–Head & and following precedent when applicable, with
Neck Surgery the goal of optimizing interrater and intrarater
American Academy of Pain Medicine reliability.
American Academy of Physical Medicine and 4) Stress conceptual and methodological congruity
Rehabilitation within and between organ system ratings.
American Academy of Psychiatry and the Law 5) Provide rating percentages that consider the
American Association for Hand Surgery patient’s clinical and functional history, careful
American Association of Neurological Surgeons physical examination, and thoughtful review and
American College of Chest Physicians synthesis of objective clinical test results.
American College of Occupational and
Environmental Medicine The section editors led a group of specialty-specific,
American Gastroenterological Association expert contributors in developing relevant chapters
American Orthopaedic Foot and Ankle Society within the scope of this established framework.
American Psychiatric Association Specific procedures were developed for addressing
American Society for Surgery of the Hand suggestions for Guides’ revisions and changes on an
American Thoracic Society ongoing basis.
California Medical Association
In addition to the Guides Editorial Panel, an advi-
Congress of Neurological Surgeons
sory committee was assembled and is composed of
International Spinal Intervention Society
numerous representatives from medical specialty
Medical Society of the State of New York
societies that are members of the American Medical
North American Spine Society
Association’s House of Delegates and other experts
Texas Medical Association
from certification organizations, teaching organiza-
Wisconsin Medical Society
tions, and workers’ compensation systems.
Members were chosen based on their contributions to The Guides Advisory Committee is ongoing and
evidence-based medicine research, reputation in their meets annually to discuss items of mutual concern
field, and their expertise in the application of scien- and current issues in impairment and disability. The
tific methods to problems of impairment evaluation. Advisory Committee’s primary objectives are to:
• Serve as a resource to the Guides Editorial Panel
The Guides Editorial Panel was established to
by giving advice on impairment rating as relevant
include a medical editor, five section editors, and
to the member’s specialty.
five core physician experts. The Editorial Panel’s
• Provide documentation to staff and the Editorial
responsibilities were to:
Panel regarding the medical appropriateness of
• Act as an expert resource in spearheading the
changes under consideration for inclusion in the
development process of the Sixth Edition.
Guides.
Guides_07_FM_i-xxiv.indd iv 2/17/09 3:03:54 PM

Preface v
• Assist in the review and further development of

relevant impairment issues and in the preparation
of technical education material and articles per-
taining to the Guides.
• Promote and educate its membership on the use
and benefits of the Guides.
As recommendations are received, they will be

forwarded to members of the Guides Advisory
Committee representing the relevant specialty orga-
nization or organizations. Based on current scientific
and clinical evidence, the Advisory Committee
members will determine the merit of each recom-
mendation. If the Advisory Committee reaches
consensus on accepting a recommendation, it is
forwarded to the Editorial Panel for final decision
and inclusion in the Guides. The goals of the new
approach are to obtain broad input from the stake-
holders and to develop a process for defining impair-
ment that is supportable, high-quality, efficient, and
effective.
Robert D. Rondinelli, MD, PhD
Guides Medical Editor
Guides_07_FM_i-xxiv.indd v 2/17/09 3:03:54 PM

vi Guides to the Evaluation of Permanent Impairment
Editorial Panel August Colenbrander, MD

American Academy of Ophthalmology
Novato, California
Gunnar B. J. Andersson, MD, PhD
Rush University Medical Center Paul L. Enright, MD
Chicago, Illinois American Thoracic Society
Tucson, Arizona
Christopher R. Brigham, MD, MMS Marjorie Eskay-Auerbach, MD, JD
Brigham and Associates, Inc. North American Spine Society
San Diego, California Tucson, Arizona
Linda Cocchiarella, MD, MSc Jonathan S. Garay, DO
Medical Director, Long Island Occupational and Medical Society of the State of New York
Environmental Health Center New York, New York
SUNY-Stony Brook University Martin Grabois, MD
Stony Brook, New York American Academy of Pain Medicine
Houston, Texas
Elizabeth Genovese MD, MBA, FACOEM, FAADEP
Morton L. Kasdan, MD
IMX Medical Management Services
American Society for Surgery of the Hand
Bala Cynwyd, Pennsylvania
Louisville, Kentucky
Richard T. Katz, MD Douglas Martin, MD
Physical Medicine & Rehabilitation American Academy of Disability Evaluating Physicians
St. Louis, Misssouri Sioux City, Iowa
Robert J. Masone, MD
Tom G. Mayer, MD International Spinal Intervention Society
Productive Rehabilitation Institute of Dallas for Lancaster, Ohio
Ergonomics (PRIDE)
Dallas, Texas Steven J. McCabe, MD
American Association for Hand Surgery
Kathryn L. Mueller, MD, MPH Louisville, Kentucky
University of Colorado Health Sciences Center Robert T. Sataloff, MD
Denver, Colorado American Academy of Otolaryngology–Head and Neck
Surgery
Mohammed I. Ranavaya, MD, JD, MS, FFOM, FRCPI, Philadelphia, Pennsylvania
CIME
Charlotte H. Smith, MD
Professor and Chief, Division of Occupational and
Texas Medical Association
Disability Medicine
Austin, Texas
Marshall University, Joan C. Edwards School of Medicine
Huntington, West Virginia Ralph S. Smith, MD
American Academy of Psychiatry and the Law
James P. Rathmell, MD Charleston, West Virginia
MGH Pain Center Lee T. Snook, MD
Massachusetts General Hospital California Medical Association
Harvard Medical School Sacramento, California
Boston, Massachusetts
E. Randolph Soo Hoo, MD
Robert D. Rondinelli, MD, PhD American College of Occupational and Environmental
Medical Director of Rehabilitation Services Medicine
Iowa Health Des Moines Tucson, Arizona
Des Moines, Iowa Akshay Sood, MD
American College of Chest Physicians
Albuquerque, New Mexico
Gregory R. Trost, MD
Advisory Committee American Association of Neurological Surgeons and
Congress of Neurological Surgeons
Gary L. Woods, MD Madison, Wisconsin
Chair, Guides Advisory Committee
Sridhar Vasudevan, MD
Concord, New Hampshire
Wisconsin Medical Society
Stanley J. Bigos, MD Milwaukee, Wisconsin
American Academy of Orthopaedic Surgeons
Silverdale, Washington
Guides_07_FM_i-xxiv.indd vi 3/3/09 4:45:04 PM

Contributors vii
Contributors
Lorne K. Direnfeld, MD, FRCP (C) Tom G. Mayer, MD
Senior Contributing Kahului, Hawaii Productive Rehabilitation Institute of
Editor Dallas for Ergonomics (PRIDE)
Robert A. Dobie, MD Dallas, Texas
Christopher R. Brigham, MD, University of California, Davis
MMS Sacramento, California J. Mark Melhorn, MD, FAADEP
Brigham and Associates, Inc. The Hand Center
San Diego, California Leon Ensalada, MD, MPH Clinical Assistant Professor
John F. Kennedy Special Warfare Section of Orthopaedics
Center and School Department of Surgery
Contributing Editors Fort Bragg, North Carolina University of Kansas School of
Marjorie Eskay-Auerbach, MD, JD Medicine
Tucson, Arizona Marjorie Eskay-Auerbach, MD, JD Wichita, Kansas
Tucson, Arizona
Mark H. Hyman, MD, FACP, Vert Mooney, MD
FAADEP Eugene P. Frenkel, MD San Diego, California
Associate Clinical Professor of University of Texas Southwestern
Medicine, UCLA Medical Center Kathryn L. Mueller, MD, MPH
Los Angeles, California Dallas, Texas University of Colorado Health
Sciences Center
Robert J. Gatchel, PhD, ABPP Denver, Colorado
Chapter Contributors Department of Psychology
College of Science William Nemeth, MD, FAADEP
Gunnar B. J. Andersson, MD, PhD The University of Texas at Arlington Austin, Texas
Rush University Medical Center
Chicago, Illinois Elizabeth Genovese, MD, MBA, Alan K. Novick, MD
FACOEM, FAADEP Hollywood, Florida
Robert J. Barth, PhD IMX Medical Management Services
Parkridge Hospital Plaza Bala Cynwyd, Pennsylvania Karin A. Pacheco, MD, MSPH
Chattanooga, Tennessee National Jewish Medical and
Mark H. Hyman, MD, FACP, Research Center
Christopher R. Brigham, MD, FAADEP Denver, Colorado
MMS Associate Clinical Professor of
Brigham and Associates Medicine, UCLA Brooke S. Parish, MD
Portland, Maine Los Angeles, California University of New Mexico
Albuquerque, New Mexico
Joel V. Brill, MD Harold E. Hoffman, MD, FRCPC,
Predictive Health, LLC FACOEM Inder Perkash, MD, FACS, FRCS
Scottsdale, Arizona Meadowlark Place Professional Palo Alto, California
Centre
Charles N. Brooks, MD, FAADEP Edmonton, Alberta, Canada Glenn Pfeffer, MD
Bellevue, Washington Cedars-Sinai Medical Center
Richard T. Katz, MD Los Angeles, California
Scott Brown, MD Professor of Clinical Neurology
Sinai Hospital of Baltimore- (PM&R) Peter B. Polatin, MD
Sinai Rehabilitation Center Washington University School of Dallas, Texas
Baltimore, Maryland Medicine
St. Louis, Missouri Gregory Powell, MD
Neil A. Busis, MD Associated Orthopedics & Sports
Pittsburgh Neurological Center Randall D. Lea, MD, FAADEP Medicine
Pittsburgh, Pennsylvania Center of Orthopedic Care & Plano, Texas
Evaluation Medicine
August Colenbrander, MD Baton Rouge, Louisiana Mohammed I. Ranavaya, MD, JD
The Smith-Kettlewell Eye Research Marshall University, Joan C. Edwards
Institute and California Pacific Barry S. Levinson, MD School of Medicine
Medical Center University of Texas Southwestern Huntington, West Virginia
San Francisco, California Medical Center
Dallas, Texas James P. Rathmell, MD
Stephen L. Demeter, MD, MPH, MGH Pain Center
FAADEP Leonard N. Matheson, PhD Massachusetts General Hospital
Honolulu Sports Medical Clinic Epic Rehab Harvard Medical School
Honolulu, Hawaii Chesterfield, Missouri Boston, Massachusetts
Guides_07_FM_i-xxiv.indd vii 2/17/09 3:03:55 PM

viii Guides to the Evaluation of Permanent Impairment
James P. Robinson, MD, PhD Naomi N. Shields, MD Paulette S. Wehner, MD

Clinical Associate Professor Wichita, Kansas Professor and Chief, Division of
Department of Rehabiliation Cardiovascular Medicine
Medicine Stacey L. Smith, MD Marshall University, Joan C. Edwards
University of Washington Washington University School of School of Medicine
Seattle, Washington Medicine Huntington, West Virginia
St. Louis, Missouri
Robert D. Rondinelli, MD, PhD Stephen Wetmore, MD, MBA
Medical Director of Rehabilitation Joel S. Steinberg, MD Professor and Chair
Services Willoughby, Ohio Department of Otolaryngology
Iowa Health Des Moines West Virginia University of School of
Des Moines, Iowa Richard Strain, Jr., MD Medicine
Hollywood, Florida Morgantown, West Virginia
Robert T. Sataloff, MD, DMA,
FACS James B. Talmage, MD Richard D. Wetzel, MD
Professor and Chairman Occupational Health Center, LLC St. Louis, Missouri
Department of Otolaryngology Cookeville, Tennessee
Drexel University College of Sean Yutzy, MD
Medicine Russell L. Travis, MD, FAADEP University of New Mexico Health
Philadelphia, Pennsylvania Cardinal Hill Hospital Sciences Center
Lexington, Kentucky Albuquerque, New Mexico
Marcia Scott, MD
Cambridge, Massachusetts Nancy Webb, MD Matthew J. Zirwas, MD
Kelsey-Seybold Clinic Ohio State University School of
William Shaw, MD, FAADEP Houston, Texas Medicine
Denver, Colorado Columbus, Ohio
Guides_07_FM_i-xxiv.indd viii 2/17/09 3:03:55 PM

Reviewers ix
Reviewers
Jean-Jacques Abitbol, MD William Boucher, MD, MPH, Lorne K. Direnfeld, MD, FRCP (C)
San Diego, California FACOEM Kahului, Hawaii
South Portland, Maine
Charles S. Abrams, MD Anthony J. Dorto, DC, MD
Philadelphia, Pennsylvania Søren Brage, MD, PhD Miami, Florida
Oslo, Norway
Victor Adlin, MD Dwight K. Dowda, MB BS, MPH,
Philadelphia, Pennsylvania Glen A. Brasseur, DC, RN FAFOM, FACOEM, FAADEP
Fort Worth, Texas Sydney, NSW, Australia
Alex Ambroz, MD, MPH
Martinsburg, West Virginia Donald P. Brobst, MD Mark A. Doyne, MD, FAAOS,
Birmingham, Alabama FAADEP, FACPE
Paul D. Anderson, MD Dallas, Texas
Castroville, California Charles Brooks, MD
Bellevue, Washington Joseph P. Drozda, Jr., MD
Gerald Aronoff, MD, DABPM St. Louis, Missouri
Charlotte, North Carolina Sherri P. Brown, Esq., BS, JD
Lexington, Kentucky Leon Ensalada, MD, MPH
Leonard B. Alenick, MD Waitsfield, Vermont
Lakewood, Washington Daniel Bruns, PsyD
Greeley, Colorado Paul E. Epstein, MD
Christine Baker, MA Philadelphia, Pennsylvania
Berkeley, California Robert T. Buchanan, MD
Highlands, North Carolina Marjorie Eskay-Auerbach, MD, JD
George W. Balfour Tucson, Arizona
Van Nuys, California Frederick W. Burgess, MD, PhD
Providence, RI Barbara A. Esses, MD
Robert J. Barth, PhD, FNAN Denver, Colorado
Chattanooga, TN John F. Burton, Jr., PhD Economics,
BS, LLB Steven D. Feinberg, MD
Donald R. Barthel, JD Princeton, New Jersey Palo Alto, California
Sacremento, California
Greg B. Cairns, JD William D. Frey, PhD
Janet A. Bertness, JD, ScM. Denver, Colorado Rockville, Maryland
Providence, Rhode Island
Ross W. Cairns Bert S. Furmansky, MD, MPA
Peter V. Bieri, MD Melbourne, Victoria, Australia Denver, Colorado
Lawrence, Kansas
Francis I. Catlin, MD, ScD John J. Gerhardt, MD
Martin Black, MD Houston, Texas Portland, Oregon
Philadelphia, Pennsylvania
James C. Causey, Jr., JD Howard H. Goldman, MD, PhD
William Blair, MD Seattle, Washington Baltimore, Maryland
Woodway, Texas
Jennifer Christian, MD, MPH Martin Grabois, MD
Bernard R. Blais, MD Wayland, Massachussetts Houston, Texas
Clifton Park, New York
Robert A. Cohen, MD, FCCP Bruce A. Guberman, MD
Ronald J. Bloomfield, MD Chicago, Illinois Huntington, West Virginia
Columbus, Ohio
Charles R. Crane, MD Scott Haldeman, DC, MD, PhD,
Zachary Bloomgarden, MD Dallas, Texas FRCP (C)
New York, NY Santa Ana, California
Robert O. Crapo, MD
William C. Boeck, MD Salt Lake City, Utah Luann Haley, JD
Santa Monica, California Tucson, Arizona
Chris Cunneen, MBBS, FRACGP
Richard P. Bonfiglio, MD Medical Advisor, Q-Comp Philip Harber, MD, MPH
Physical Medicine and Rehabilitation Brisbane, Old, Australia Los Angeles, California
Murrysville, Pennsylvania
Paul R. Dionne, JD R. Norman Harden, MD
Robert Bonner, MD, MPH Lewiston, Maine Chicago, Illinois
Hartford, Connecticut
Guides_07_FM_i-xxiv.indd ix 2/17/09 3:03:56 PM

x Guides to the Evaluation of Permanent Impairment
Larry Herron, MD James Luck, Jr, MD David C. Randolph, MD, MPH,

San Luis Obispo, California Los Angeles, California FAADEP
Cincinnati, Ohio
Jay Himmelstein, MD, MPH Patrick R. Luers, MD
Shrewsbury, Massachusetts Sandy, Utah Carrie A. Redlich, MD, MPH
New Haven, Connecticut
Sue Anne Howard, Esq., BA, JD Arthur Lurvey, MD, FACP, FACE
Morgantown, West Virginia Los Angeles, California Michael M. Romash, MD
Chesapeake, Virginia
J. David Hubbard, RN Janis H. Malan, Esq.
Dallas, Texas Hunt Valley, Maryland Charles R. Rondeau, JD, BA
Los Angeles, California
Mark H. Hyman, MD, FACP, Peter J. Mandell, MD
FAADEP Burlingame, California Jacob Rosenweig, MD, PhD
Los Angeles, California Delray Beach, Florida
Douglas W. Martin, MD, FAADEP,
Richard Kahman, MD FACOEM, FAAFP Henry J. Roth, MD
Santa Barbara, California North Sioux City, South Dakota Denver, Colorado
Stanley S. Kaplan DC, DABCO Robert J. Masone, MD, DABPM Debra H. Rowse, MD, MS
Cocoa Beach, Florida Lancaster, Ohio Scottsdale, Arizona
Morton Kasdan, MD Annyce Mayer, MD, MSPH David Schenkar, MD

Louisville, Kentucky Denver, Colorado Hailey, Idaho
Kenneth B. Kauvar, MD Todd McFarren, BA, MA, JD Andrew Sew Hoy, MD

Denver, Colorado Watsonville, California Los Angeles, California
Kenneth Kingdon, JD, LLM Roy T. McKay, PhD Stanley L. Schrier, MD

Rancho Palos Verdes, California Cincinnati, Ohio Stanford, California
David M. Klein, MD Thomas Blair Megowan, BA Raymond J. Schumacher, MD, MPH

Port Charlotte, Florida Los Angeles, California Tucson, Arizona
E. Klimek, MD, FRCPC FAADEP Frank M. Messana, DO, CIME William S. Shaw, MD
St. Catharines, Ontario, Canada Gary, Indiana Denver, Colorado
Randall D. Lea, MD Ali Reza Moattari, MD Lisa M. Shulman, MD

Baton Rouge, Louisiana Newport Coast, California Baltimore, Maryland
Norma J. Leclair, PhD, RN Peter A. Moskovitz, MD Mitchel U. Silverman, MD

Gray, Maine Washington, DC Sherman Oaks, California
Steven W. Leclair, PhD William E. Narrow, MD, MPH Roy L. Silverstein, MD

Gray, Maine Arlington, Virgina Cleveland, Ohio
Philip C. Lening, BA, DC Ellen K. Oakes, OTR Dorsett D. Smith, MD, FACP, FCCP,
Houston, Texas Denver, Colorado FACOEM
Carefree, Arizona
Gideon Letz, MD, MPH Fred H. Olin, MD
Stinson Beach, California San Antonio, Texas Ralph S. Smith, Jr, MD, MBA
Charleston, West Virginia
William Levasseur, JD Steve R. Ommen, MD
Baltimore, Maryland Rochester, Minnesota Lee T. Snook, Jr, MD, DAAPM,
FACP
Philip Levy, MD Richard K. Osenbach, MD Sacramento, California
Phoenix, Arizona Durham, North Carolina
Trevor Soergel, MD
Alan Lipkin, MD Cornelius Passani, MD Indianapolis, Indiana
Denver, Colorado Santa Barbara, California
E. Randolph Soo Hoo, MD, MPH,
Philipp M. Lippe, MD, FACS, Scott J. Primack, MD FACOEM
FACPM Englewood, Colorado Tucson, Arizona
San Jose, California
John D. Pro, MD, CIME
Lee’s Summit, Missouri
Guides_07_FM_i-xxiv.indd x 2/17/09 3:03:56 PM

Reviewers xi
Henry Stockbridge, MD, MPH Russell Travis, MD Paul E Wakim, DO, FAAOOS
Olympia, Washington Lexington, Kentucky Huntington Beach, California
Daniel Y. Sumner, JD Jon B. Tucker, MD Pamela A. Warren, PhD

Tallahassee, Florida Pittsburgh, Pennsylvania Urbana, Illinois
D. Lachlan Taylor, JD Craig Uejo, MD, MPH, CIME Izak F. Wessels, MD, FRCSE,
Oakland, California San Diego, California FRCOphth, FACS
Chattanooga, Tennessee
Marc T. Taylor, MD Schneider Urs, MD, MBA
San Antonio, Texas Zurich, Switzerland Alan G. Zacharia, MD
Daly City, California
Lloyd Toft, MBBS Nancy L. Von Ruden, BS
Brisbane, Australia Owatonna, Minnesota Edward G. Zurad, MD
Tunkhannock, Pennsylvania
David B. Torrey, JD Gordon Waddell, CBE, DSc, MD,
Pittsburgh, Pennsylvania FRCS
Cardiff, United Kingdom
Mary C. Townsend, DrPH
Pittsburgh, Pennsylvania
Guides_07_FM_i-xxiv.indd xi 2/17/09 3:03:56 PM

Guides_07_FM_i-xxiv.indd xii 2/17/09 3:03:56 PM
Table of Contents
P R E FAC E iii CHAPTER 3
Pain-Related Impairment 31
CHAPTER 1
3.1 Definition and Classification of Pain . . . . . . . . 32
Conceptual Foundations and 3.2 Controversies Surrounding Pain-Related
Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Philosophy 1
3.3 The Rating System . . . . . . . . . . . . . . . . . . . . . 37
1.1 History of the Guides . . . . . . . . . . . . . . . . . . . . 1 3.4 Future Directions—Need for Research
1.2 New Directions for the Sixth Edition . . . . . . . . . 2 and Dialogue to Establish the Validity
of Rating Pain-Related Impairment . . . . . . . . . 40
1.3 The International Classification of
Functioning, Disability, and Health (ICF): 3.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
A Contemporary Model of Disablement . . . . . . 3 3.6 Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1.4 Measurement Issues . . . . . . . . . . . . . . . . . . . . . 6 3.7 Appendixes. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
1.5 Balancing Science and Clinical Judgment . . . . . 8
1.6 The Case for Simplification and Ease of
CHAPTER 4
Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7 The Application of Functional Assessment . . . . 9 The Cardiovascular System 47
1.8 The Need for Internal Consistency and
a Uniform Template . . . . . . . . . . . . . . . . . . . . 11 4.1 Principles of Assessment . . . . . . . . . . . . . . . . . 48
1.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.2 Valvular Heart Disease . . . . . . . . . . . . . . . . . . 51
4.3 Coronary Artery Disease . . . . . . . . . . . . . . . . . 54
4.4 Cardiomyopathies . . . . . . . . . . . . . . . . . . . . . . 57
CHAPTER 2
4.5 Pericardial Heart Disease . . . . . . . . . . . . . . . . . 60
Practical Application of the Guides 19 4.6 Dysrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.7 Hypertensive Cardiovascular Disease . . . . . . . . 65
2.1 Use of the Guides in Workers’ Compensation
4.8 Vascular Diseases Affecting the Extremities . . . 68
and Other Disability Systems . . . . . . . . . . . . . . 20
4.9 Diseases of the Pulmonary Artery . . . . . . . . . . 71
2.2 Organ System and Whole Body Approach
to Impairment Ratings . . . . . . . . . . . . . . . . . . 21 4.10 Cardiovascular Impairment Evaluation
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
2.3 Use of the Guides . . . . . . . . . . . . . . . . . . . . . . 23
2.4 Rules of Application for the Guides . . . . . . . . . 24
2.5 Concepts Important to the Independent
Medical Examiner . . . . . . . . . . . . . . . . . . . . . . 25
2.6 Impairment Evaluation and the Law . . . . . . . . 27
2.7 Preparing Reports . . . . . . . . . . . . . . . . . . . . . . 28
xiii
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xiv Guides to the Evaluation of Permanent Impairment
CHAPTER 5 CHAPTER 7
The Pulmonary System 77 The Urinary and Reproductive

Systems 129
5.1 Assessing the Pulmonary System . . . . . . . . . . 78
5.2 Clinical Presentation of Pulmonary Disease . . . 78 7.1 Principles of Assessment . . . . . . . . . . . . . . . . 130
5.3 Environmental Exposures, Lifestyle Choices, 7.2 The Urinary System . . . . . . . . . . . . . . . . . . . . 131
and Pulmonary Disease . . . . . . . . . . . . . . . . . . 80
7.3 Upper Urinary Tract . . . . . . . . . . . . . . . . . . . 132
5.4 Clinical Evaluation, Imaging Studies,
7.4 Urinary Diversion . . . . . . . . . . . . . . . . . . . . . 138
and Other Tests for Evaluating Pulmonary
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 7.5 Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
5.5 Methodology for Determining the Grade 7.6 Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
in an Impairment Class . . . . . . . . . . . . . . . . . . 86 7.7 Male Reproductive Organs . . . . . . . . . . . . . . 143
5.6 Asthma and Other Hyperreactive Airway 7.8 Female Reproductive Organs . . . . . . . . . . . . 149
Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.9 Urinary and Reproductive Systems
5.7 Hypersensitivity Pneumonitis. . . . . . . . . . . . . . 91 Impairment Evaluation Summary. . . . . . . . . . 156
5.8 Pneumoconiosis . . . . . . . . . . . . . . . . . . . . . . . 91
5.9 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 92
CHAPTER 8
5.10 Sleep Disorders and Other Impairments
Related to Pulmonary System . . . . . . . . . . . . . 92 The Skin 159
5.11 Examples of Impairment due to Pulmonary
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 8.1 Principles of Assessment . . . . . . . . . . . . . . . . 160
5.12 Pulmonary Impairment Evaluation 8.2 Disfigurement . . . . . . . . . . . . . . . . . . . . . . . . 162
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
8.3 Scars and Skin Grafts . . . . . . . . . . . . . . . . . . 162
8.4 Contact Dermatitis . . . . . . . . . . . . . . . . . . . . 163
CHAPTER 6 8.5 Natural Rubber Latex Allergy . . . . . . . . . . . . 164
8.6 Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 164
The Digestive System 101 8.7 Criteria for Rating Permanent Impairment
due to Skin Disorders . . . . . . . . . . . . . . . . . . 164
6.1 Principles of Assessment . . . . . . . . . . . . . . . . 102
8.8 Skin Impairment Evaluation Summary . . . . . . 178
6.2 Upper Digestive Tract . . . . . . . . . . . . . . . . . . 106
6.3 Colon, Rectum, and Anus . . . . . . . . . . . . . . . 113
6.4 Enterocutaneous Fistulas. . . . . . . . . . . . . . . . 118 CHAPTER 9
6.5 Liver and Biliary Tract . . . . . . . . . . . . . . . . . . 118
The Hematopoietic System 183
6.6 Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6.7 Digestive System Impairment Evaluation 9.1 Principles of Assessment . . . . . . . . . . . . . . . . 184
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
9.2 Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
9.3 Myeloproliferative Disorders, including
Polycythemia, Myelofibrosis, and
Essential Thrombocytosis . . . . . . . . . . . . . . . 191
9.4 White Blood Cell Diseases or
Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . 193
9.5 Hemorrhagic and Platelet Disorders . . . . . . . 201
9.6 Thrombotic Disorders . . . . . . . . . . . . . . . . . . 206
9.7 Criteria for Rating Permanent Impairment
due to Lymphoma and Metastatic
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
9.8 Hematologic Impairment Evaluation
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
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Table of Contents xv
C H A P T E R 10 C H A P T E R 13
The Endocrine System 213 The Central and Peripheral

Nervous System 321
10.2 Hypothalamic-Pituitary Axis . . . . . . . . . . . . . 218 13.1 Principles of Assessment . . . . . . . . . . . . . . . . 322
10.3 Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 13.2 Method for Rating Impairments due to
10.4 Parathyroids . . . . . . . . . . . . . . . . . . . . . . . . . 223 Nervous System Disorders . . . . . . . . . . . . . . . 326
10.5 Adrenal Cortex . . . . . . . . . . . . . . . . . . . . . . . 226 13.3 Criteria for Rating Cerebral Impairments . . . . 326
10.6 Adrenal Medulla . . . . . . . . . . . . . . . . . . . . . . 230 13.4 Criteria for Rating Impairment due to
10.7 Pancreas (Islets of Langerhans) . . . . . . . . . . . 232 Spinal Cord Dysfunction and Movement
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
10.8 Gonads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
13.5 Criteria for Rating Impairments of the
10.9 Mammary Glands . . . . . . . . . . . . . . . . . . . . . 239 Upper Extremities due to CNS
10.10 Metabolic Bone Disease . . . . . . . . . . . . . . . . 241 Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 335
10.11 Endocrine System Impairment Evaluation 13.6 Criteria for Rating Impairments of Station,
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Gait, and Movement Disorders . . . . . . . . . . . 336
13.7 Criteria for Rating Neurogenic Bowel,
Bladder, and Sexual Dysfunction . . . . . . . . . . 336
C H A P T E R 11
13.8 Criteria for Rating Neurogenic Respiratory
Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . 337
Ear, Nose, Throat, and Related
13.9 Criteria for Rating Peripheral Neuropathies,
Structures 247 Neuromuscular Junction Disorders, and
Myopathies. . . . . . . . . . . . . . . . . . . . . . . . . . 339
13.10 Criteria for Rating Impairments Related to
11.2 Hearing and Tinnitus . . . . . . . . . . . . . . . . . . . 248 Complex Regional Pain Syndrome . . . . . . . . . 341
11.3 The Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 13.11 Criteria for Rating Impairments Related to
11.4 The Nose, Throat, and Related Structures . . . 265 Craniocephalic Pain. . . . . . . . . . . . . . . . . . . . 341
13.12 Criteria for Rating Miscellaneous Peripheral
Nerves of the Head and Trunk . . . . . . . . . . . 343
C H A P T E R 12 13.13 Nervous System Impairment Evaluation
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . .344
The Visual System 281
12.1 Principles of Assessment . . . . . . . . . . . . . . . . 282 C H A P T E R 14

12.2 Impairment of Visual Acuity . . . . . . . . . . . . . 285
12.3 Impairment of the Visual Field. . . . . . . . . . . . 293 Mental and Behavioral Disorders 347
12.4 Impairment of the Visual System . . . . . . . . . . 303
12.5 Visual Acuity Measurement at Near
(Reading Acuity) . . . . . . . . . . . . . . . . . . . . . . 309 14.2 Psychiatric/Psychological Evaluation . . . . . . . 349
12.6 Reporting Aids . . . . . . . . . . . . . . . . . . . . . . . 312 14.3 Special Features of the Mental and
Behavioral Disorders Independent
Medical Examination. . . . . . . . . . . . . . . . . . . 351
14.4 Maximum Medical Improvement. . . . . . . . . . 353
14.5 Concepts for Impairment Ratings . . . . . . . . . 355
14.6 Method of Impairment Rating. . . . . . . . . . . . 356
14.7 Examples of Impairment Ratings due to
Mental and Behavioral Disorders . . . . . . . . . . 360
14.8 Appendix: Brief Psychiatric Rating Scale . . . . 369
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xvi Guides to the Evaluation of Permanent Impairment
C H A P T E R 15 C H A P T E R 17
The Upper Extremities 383 The Spine and Pelvis 557
15.1 Principles of Assessment . . . . . . . . . . . . . . . . 385 17.1 Principles of Assessment . . . . . . . . . . . . . . . . 558

15.2 Diagnosis-Based Impairment . . . . . . . . . . . . . 387 17.2 Diagnosis-Based Impairment . . . . . . . . . . . . . 560
15.3 Adjustment Grid and Grade Modifiers: 17.3 Adjustment Grid and Grade Modifiers:
Non-Key Factors . . . . . . . . . . . . . . . . . . . . . . 405 Non-Key Factors . . . . . . . . . . . . . . . . . . . . . . 566
15.4 Peripheral Nerve Impairment. . . . . . . . . . . . . 419 17.4 Pelvic Impairment . . . . . . . . . . . . . . . . . . . . . 592
15.5 Complex Regional Pain Syndrome 17.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . 450 17.6 Appendix 17-A: Pain Disability
15.6 Amputation Impairment . . . . . . . . . . . . . . . . 454 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . 599
15.7 Range of Motion Impairment . . . . . . . . . . . . 459
15.8 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
APPENDIX 603
15.9 Appendix 15-A: Functional Assessment
Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . 482 Appendix A: Combined Values Chart . . . . . . . . . . . . 604
Appendix 15-B: Electrodiagnostic Evaluation Appendix B: Burden of Treatment Scoring . . . . . . . . 607
of Entrapment Syndromes. . . . . . . . . . . . . . . 487
G L O S S A RY 609
C H A P T E R 16
The Lower Extremities 493 INDEX 617

16.2 Diagnosis-Based Impairment . . . . . . . . . . . . . 497
16.3 Adjustment Grid and Grade Modifiers –
Non-Key Factors . . . . . . . . . . . . . . . . . . . . . . 515
16.4 Peripheral Nerve Impairment. . . . . . . . . . . . . 531
16.5 Complex Regional Pain Syndrome
Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . 538
16.6 Amputation Impairment . . . . . . . . . . . . . . . . 542
16.7 Range of Motion Impairment . . . . . . . . . . . . 543
16.8 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
16.9 Appendix 16-A: Lower Limb Questionnaire . . 555
Guides_07_FM_i-xxiv.indd xvi 3/3/09 4:45:05 PM

Tables
CHAPTER 1 Table 4-3 Energy Expenditure in METs During

Bicycle Ergometry . . . . . . . . . . . . . . . . 49
Conceptual Foundations and Table 4-4 Methodology for Determining the
Philosophy 1 Grade in an Impairment Class . . . . . . . 50
*Table 4-5 Criteria for Rating Permanent
Table 1-1 Self-Care . . . . . . . . . . . . . . . . . . . . . . . 7 Impairment due to Valvular Heart
Table 1-2 Hierarchy of Study Types . . . . . . . . . . . . 8 Disease . . . . . . . . . . . . . . . . . . . . . . . . 53
Table 1-3 ICF Codes and Functional Levels . . . . . 11 *Table 4-6 Criteria for Rating Impairment due to
Coronary Artery Disease . . . . . . . . . . . 55
Table 1-4 Sample Impairment Functional
Classification . . . . . . . . . . . . . . . . . . . 11 *Table 4-7 Criteria for Rating Impairment due to
Cardiomyopathies . . . . . . . . . . . . . . . . 59
*Table 1-5 Generic Template for Impairment
Classification Grids . . . . . . . . . . . . . . . 13 *Table 4-8 Criteria for Rating Impairment due to
Pericardial Heart Disease . . . . . . . . . . . 61
Table 1-6 General Principles and Rules for
Calculating Impairment . . . . . . . . . . . . 14 *Table 4-9 Criteria for Rating Permanent
Impairment due to Dysrhythmias . . . . 64
Table 4-10 Classification of Blood Pressure
CHAPTER 2 for Adults . . . . . . . . . . . . . . . . . . . . . . 66
*Table 4-11 Criteria for Rating Impairment due to
Practical Application of the Guides 19 Hypertensive Cardiovascular
Disease . . . . . . . . . . . . . . . . . . . . . . . . 67
Table 2-1 Fundamental Principles of the *Table 4-12 Criteria for Rating Impairment due to
Guides . . . . . . . . . . . . . . . . . . . . . . . . 20 Peripheral Vascular Disease – Lower
Extremity . . . . . . . . . . . . . . . . . . . . . . 69
CHAPTER 3
Peripheral Vascular Disease – Upper
Extremity . . . . . . . . . . . . . . . . . . . . . . 70
Diseases of the Pulmonary Artery . . . . 72
*Table 3-1 Pain-Related Impairment and Whole
Person Impairment Based on Pain Table 4-15 Cardiac Impairment Evaluation
Disability Questionnaire . . . . . . . . . . . 40 Summary . . . . . . . . . . . . . . . . . . . . . . 74
CHAPTER 4 CHAPTER 5
The Cardiovascular System 47 The Pulmonary System 77
Table 4-1 NYHA Functional Classification of Table 5-1 Impairment Classification of

Cardiac Disease. . . . . . . . . . . . . . . . . . 48 Dyspnea (Adapted) . . . . . . . . . . . . . . . 79
Table 4-2 Relationship of METs and Table 5-2 Impairment Classification for
Functional Class According to Prolonged Physical Work Intensity
5 Treadmill Protocols . . . . . . . . . . . . . . 49 by Oxygen Consumption . . . . . . . . . . 85
xvii
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xviii Guides to the Evaluation of Permanent Impairment
Table 5-3 Methodology for Determining the *Table 7-3 Criteria for Rating Permanent
Grade in an Impairment Class . . . . . . . 86 Impairment due to Urinary
*Table 5-4 Criteria for Rating Permanent Diversion Disorders . . . . . . . . . . . . . . 138
Impairment due to Pulmonary *Table 7-4 Criteria for Rating Permanent
Dysfunctiona . . . . . . . . . . . . . . . . . . . 88 Impairment due to Bladder
*Table 5-5 Criteria for Rating Permanent Disease . . . . . . . . . . . . . . . . . . . . . . . 139
Impairment due to Asthma . . . . . . . . . 90 *Table 7-5 Criteria for Rating Permanent
Table 5-6 Scale for Judging Capabilities of Impairment due to Urethral
Subjects With Cancer . . . . . . . . . . . . . 92 Disease . . . . . . . . . . . . . . . . . . . . . . . 141
Table 5-7 Pulmonary Impairment Evaluation *Table 7-6 Criteria for Rating Permanent
Summary . . . . . . . . . . . . . . . . . . . . . . 96 Impairment due to Penile Disease . . . 144
Impairment due to Scrotal
CHAPTER 6 Disease . . . . . . . . . . . . . . . . . . . . . . . 146
*Table 7-8 Criteria for Rating Impairment due
The Digestive System 101 to Testicular, Epididymal, and
Spermatic Cord Disease . . . . . . . . . . 147
Table 6-1 Desirable Weights for Men by *Table 7-9 Criteria for Rating Impairment due
Height and Body Build . . . . . . . . . . . 104 to Prostate Disease . . . . . . . . . . . . . . 149
Table 6-2 Desirable Weights for Women by *Table 7-10 Criteria for Rating Permanent
Height and Body Build . . . . . . . . . . . 104 Impairment due to Vulval and
Table 6-3 Methodology for Determining the Vaginal Disease . . . . . . . . . . . . . . . . 151
Grade in an Impairment Class . . . . . . 105 *Table 7-11 Criteria for Rating Permanent
*Table 6-4 Criteria for Rating Permanent Impairment due to Cervical and
Impairment due to Upper Digestive Uterine Disease . . . . . . . . . . . . . . . . . 152
Tract (Esophagus, Stomach and *Table 7-12 Criteria for Rating Permanent
Duodenum, Small Intestine, and Impairment due to Fallopian Tube
Pancreas) Disease . . . . . . . . . . . . . . . 107 and Ovarian Disease . . . . . . . . . . . . . 154
*Table 6-5 Criteria for Rating Permanent Table 7-13 Urinary and Reproductive Systems
Impairment due to Colonic and Impairment Evaluation Summary. . . . 156
Rectal Disorders . . . . . . . . . . . . . . . . 114
Impairment due to Anal Disease . . . 116 CHAPTER 8
Table 6-7 Impairments From Surgically
Created Stomas . . . . . . . . . . . . . . . . 118 The Skin 159
Impairment due to Liver Disease . . . . 119 Table 8-1 Structure, Functions, and Disorders
of the Skin . . . . . . . . . . . . . . . . . . . . 160
Impairment due to Biliary Tract *Table 8-2 Criteria for Rating Permanent
Disease . . . . . . . . . . . . . . . . . . . . . . . 120 Impairment due to Skin Disorders . . . 166
*Table 6-10 Criteria for Rating Permanent Table 8-3 Skin Impairment Evaluation
Impairment due to Herniation . . . . . . 122 Summary . . . . . . . . . . . . . . . . . . . . . 178
Table 6-11 Digestive System Impairment
Evaluation Summary . . . . . . . . . . . . . 124
CHAPTER 9
CHAPTER 7
Table 9-1 Karnofsky Performance Status Scale

The Urinary and Reproductive Definitions Rating (%) Criteria . . . . . . 185
Systems 129 Table 9-2 Eastern Cooperative Oncology
Group Performance Status Scale
Table 7-1 Methodology for Determining the (ECOG-PSS) . . . . . . . . . . . . . . . . . . . 185
Grade in an Impairment Class . . . . . . 130
Table 9-3 Burden of Treatment Compliance . . . 186
Table 9-4 Methodology for Determining the
Impairment due to Upper Urinary
Tract Disease. . . . . . . . . . . . . . . . . . . 134
Guides_07_FM_i-xxiv.indd xviii 2/17/09 3:03:59 PM

Tables xix
*Table 9-5 Criteria for Rating Permanent *Table 10-13 Criteria for Rating Impairment due
Impairment due to Anemia . . . . . . . . 189 to Mammary Disorders . . . . . . . . . . . 240
*Table 9-6 Criteria for Rating Permanent *Table 10-14 Criteria for Rating Impairment due
Impairment due to Neutropenia . . . . 194 to Metabolic Bone Disease . . . . . . . . 242
*Table 9-7 Criteria for Rating Permanent Table 10-15 Endocrine System Impairment
Impairment due to the Leukemias . . . 196 Evaluation Summary . . . . . . . . . . . . . 244
Impairment due to HIV Disease . . . . . 199
*Table 9-9 Criteria for Rating Impairment due C H A P T E R 11
to Platelet Disorders . . . . . . . . . . . . . 202
to the Hemophilias . . . . . . . . . . . . . . 204 Structures 247
to Other Bleeding Disorders . . . . . . . 205 Table 11-1 Monaural Hearing Loss and
Impairment . . . . . . . . . . . . . . . . . . . . 250
to Thrombotic Disorders . . . . . . . . . . 208 Table 11-2 Computation of Binaural Hearing
Impairment . . . . . . . . . . . . . . . . . . . . 252
to Lymphoma and Metastatic Table 11-3 Relationship of Binaural Hearing
Disease . . . . . . . . . . . . . . . . . . . . . . . 209 Impairment to Impairment of the
Whole Person . . . . . . . . . . . . . . . . . . 254
Table 9-14 Hematologic Impairment Evaluation
Summary . . . . . . . . . . . . . . . . . . . . . 210 *Table 11-4 Criteria for Rating Impairments due
to Vestibular Disorders . . . . . . . . . . . 258
C H A P T E R 10 to Facial Disorders and/or
Disfigurement . . . . . . . . . . . . . . . . . . 262
The Endocrine System 213 *Table 11-6 Criteria for Rating Impairment due
to Air Passage Deficits . . . . . . . . . . . 267
Table 10-1 Methodology for Determining the *Table 11-7 Impairments of Mastication and
Grade in an Impairment Class . . . . . . 215 Deglutition: Relationship of
Table 10-2a Enteral, Intranasal, and Topical Dietary Restrictions to Permanent
Medications . . . . . . . . . . . . . . . . . . . 217 Impairment . . . . . . . . . . . . . . . . . . . . 269
Table 10-2b Parenteral Medications . . . . . . . . . . . 217 *Table 11-8 Criteria for Rating Voice and
Table 10-3 Points Assigned for Dietary Speech Impairment . . . . . . . . . . . . . . 274
Modification . . . . . . . . . . . . . . . . . . . 217
Table 10-4 Procedure-Based Points . . . . . . . . . . 218
C H A P T E R 12
to Disorders of the Hypothalamic- The Visual System 281
Pituitary Axis. . . . . . . . . . . . . . . . . . . 220
*Table 10-6 Criteria for Rating Impairment due Table 12-1 Calculation Steps for the Visual
to Thyroid Abnormalities. . . . . . . . . . 223 System . . . . . . . . . . . . . . . . . . . . . . . 283
*Table 10-7 Criteria for Rating Impairment due *Table 12-2 Impairment of Visual Acuity . . . . . . . 288
to Disorders of the Parathyroids . . . . 224 Table 12-3 Calculation of the Acuity-Related
*Table 10-8 Criteria for Rating Impairment due Impairment Rating . . . . . . . . . . . . . . 289
to Disorders of the Adrenal *Table 12-4 Classification of Impairment of
Cortex . . . . . . . . . . . . . . . . . . . . . . . 227 Visual Acuity . . . . . . . . . . . . . . . . . . . 290
*Table 10-9 Criteria for Rating Impairment due Table 12-5 Impairment of the Visual Field . . . . . 296
to Disorders of the Adrenal
Medulla . . . . . . . . . . . . . . . . . . . . . . 231 Table 12-6 Conversion of Field Radius to
Field Score . . . . . . . . . . . . . . . . . . . . 296
to Diabetes Mellitus . . . . . . . . . . . . . 234 Table 12-7 Calculation of the Visual Field–
Related Impairment Rating . . . . . . . . 297
to Hypoglycemia . . . . . . . . . . . . . . . . 237 *Table 12-8 Classification of Impairment of
Visual Field . . . . . . . . . . . . . . . . . . . . 298
to Gonadal Disorders . . . . . . . . . . . . 239 Table 12-9 Correction for Central Scotomata . . . 304
Guides_07_FM_i-xxiv.indd xix 2/17/09 3:03:59 PM

xx Guides to the Evaluation of Permanent Impairment
*Table 12-10 Classification of Impairment of Table 13-18 Grading System for Rating
the Visual System and of the Impairment due to Migraine
Whole Person . . . . . . . . . . . . . . . . . . 307 Headache . . . . . . . . . . . . . . . . . . . . . 342
Table 12-11 Determination of Reading Acuity and *Table 13-19 Criteria for Rating Trigeminal or
Impairment Rating Using Letter Glossopharyngeal Neuralgia . . . . . . . 343
Size and Viewing Distance . . . . . . . . 310 *Table 13-20 Criteria for Rating Miscellaeous
Peripheral Nerves . . . . . . . . . . . . . . .344
C H A P T E R 13
C H A P T E R 14
The Central and Peripheral
Nervous System 321 Mental and Behavioral Disorders 347
Table 13-1 Summary of Chapters Used to Rate Table 14-1 Multiaxial System of the
Various Neurologic Disorders . . . . . . 323 DSM-IV-TR . . . . . . . . . . . . . . . . . . . . 348
Table 13-2 Activities of Daily Living . . . . . . . . . . 323 Table 14-2 Mental Status Examination . . . . . . . . 349
Table 13-3 Neurologic Impairments That are Table 14-3 Selected Psychological Assessment
Combined With the Most Severe Tools in Adults . . . . . . . . . . . . . . . . . 350
Cerebral Impairment . . . . . . . . . . . . . 326 Table 14-4 Suggestions for the M&BD IME. . . . . 352
*Table 13-4 Criteria for Rating Impairment of Table 14-5 Functional Impairment Scales for
Consciousness and Awareness . . . . . 327 Patients With M&BD . . . . . . . . . . . . . 352
*Table 13-5 Criteria for Rating Impairment due Table 14-6 Factors That May Affect
to Episodic Loss of Consciousness Motivation . . . . . . . . . . . . . . . . . . . . 353
or Awareness . . . . . . . . . . . . . . . . . . 328 Table 14-7 Characteristics Suggestive of
*Table 13-6 Criteria for Rating Impairment due Malingering . . . . . . . . . . . . . . . . . . . 354
to Sleep and Arousal Disorders . . . . . 329 Table 14-8 BPRS Form . . . . . . . . . . . . . . . . . . . . 357
Table 13-7 Mental Status Exam for the *Table 14-9 Impairment Score of Brief
Neurologically Impaired Patient . . . . . 330 Psychiatric Rating Scale (BPRS) . . . . . 357
*Table 13-8 Criteria for Rating Neurologic *Table 14-10 Impairment Score of Global
Impairment due to Alteration in Assessment of Functioning
Mental Status, Cognition, and Scale (GAF) . . . . . . . . . . . . . . . . . . . . 358
Highest Integrative Function
(MSCHIF) . . . . . . . . . . . . . . . . . . . . . 331 Table 14-11 Self-Care, Personal Hygiene, and
Activities of Daily Living . . . . . . . . . . 358
to Aphasia or Dysphasia . . . . . . . . . . 332 Table 14-12 Role Functioning, Social and
Recreational Activities . . . . . . . . . . . . 359
Table 13-10 Global Assessment of Functioning
(GAF) Impairment Score . . . . . . . . . . 334 Table 14-13 Travel . . . . . . . . . . . . . . . . . . . . . . . . 359
*Table 13-11 Criteria for Rating Impairments of Table 14-14 Interpersonal Relationships . . . . . . . . 359
the Upper Extremities due to CNS Table 14-15 Concentration, Persistence, and
Dysfunction . . . . . . . . . . . . . . . . . . . 335 Pace . . . . . . . . . . . . . . . . . . . . . . . . . 359
*Table 13-12 Criteria for Rating Impairments due Table 14-16 Resilience and Employability . . . . . . . 360
to Station and Gait Disorders . . . . . . 336 *Table 14-17 Impairment Score of Psychiatric
*Table 13-13 Criteria for Rating the Neurogenic Impairment Rating Scale (PIRS) . . . . . 360
Bowel . . . . . . . . . . . . . . . . . . . . . . . . 337
*Table 13-14 Criteria for Rating the Neurogenic
Bladder . . . . . . . . . . . . . . . . . . . . . . . 337 C H A P T E R 15
*Table 13-15 Criteria for Rating Neurogenic
Sexual Dysfunction . . . . . . . . . . . . . . 338
The Upper Extremities 383
*Table 13-16 Criteria for Rating Neurogenic Table 15-1 Definition of Impairment Classes. . . . 385
Respiratory Dysfunction . . . . . . . . . . 338
*Table 15-2 Digit Regional Grid: Digit
Table 13-17 Dysesthetic Pain Secondary to Impairments . . . . . . . . . . . . . . . . . . . 391
Peripheral Neuropathy or Spinal
Cord Injury . . . . . . . . . . . . . . . . . . . . 339 *Table 15-3 Wrist Regional Grid: Upper
Extremity Impairments . . . . . . . . . . . 395
*Table 15-4 Elbow Regional Grid: Upper
Extremity Impairments . . . . . . . . . . . 398
Guides_07_FM_i-xxiv.indd xx 2/17/09 3:04:00 PM

Tables xxi
*Table 15-5 Shoulder Regional Grid: Upper *Table 15-33 Elbow/Forearm Range of Motion . . . 474
Extremity Impairments . . . . . . . . . . . 401 *Table 15-34 Shoulder Range of Motion . . . . . . . . 475
Table 15-6 Adjustment Grid: Summary. . . . . . . . 406 *Table 15-35 Range of Motion Grade Modifiers . . 477
Table 15-7 Functional History Adjustment: *Table 15-36 Functional History Grade
Upper Extremities . . . . . . . . . . . . . . . 406 Adjustment: Range of Motion. . . . . . 477
Table 15-8 Physical Examination Adjustment: Table 15-37 Activities of Daily Living
Upper Extremities . . . . . . . . . . . . . . . 408 Questionnaire . . . . . . . . . . . . . . . . . . 483
Table 15-9 Clinical Studies Adjustment: Table 15-38 ADLs Questionnaire Evaluation . . . . .484
Upper Extremities . . . . . . . . . . . . . . . 410
Table 15-39 Comparison Between QuickDASH
*Table 15-10 Methodology for Determining the and ADL Questionnaires . . . . . . . . . . 485
Table 15-40 Self-Report Functional Assessment
Table 15-11 Impairment Values Calculated From Measures . . . . . . . . . . . . . . . . . . . . . 486
Upper Extremity Impairment . . . . . . . 420
Table 15-12 Impairment Values Calculated
From Digit Impairment . . . . . . . . . . . 421 C H A P T E R 16
Table 15-13 Monofilament Test Criteria . . . . . . . . 424
Table 15-14 Sensory and Motor Severity . . . . . . . 425 The Lower Extremities 493
Table 15-15 Sensory Quality Impairment
Table 16-1 Definition of Impairment Classes. . . . 495
Classification . . . . . . . . . . . . . . . . . . 426
*Table 16-2 Foot and Ankle Regional Grid –
Table 15-16 Digit Impairment for Transverse and
Lower Extremity Impairments . . . . . . 501
Longitudinal Sensory Losses in Thumb
and Little Finger Based on Percent of *Table 16-3 Knee Regional Grid – Lower
Digital Length Involved . . . . . . . . . . . 427 Extremity Impairments . . . . . . . . . . . 509
Table 15-17 Digit Impairment for Transverse and *Table 16-4 Hip Regional Grid – Lower
Longitudinal Sensory Losses in Index, Extremity Impairments . . . . . . . . . . . 512
Middle, and Ring Fingers . . . . . . . . . 427 Table 16-5 Adjustment Grid: Summary. . . . . . . . 515
Table 15-18 Impairment for Sensory Only Table 16-6 Functional History Adjustment –
Peripheral Nerve Injury . . . . . . . . . . . 429 Lower Extremities . . . . . . . . . . . . . . . 516
Table 15-19 Origins and Functions of Peripheral Table 16-7 Physical Examination Adjustment –
Nerves of Upper Extremity Emanating Lower Extremities . . . . . . . . . . . . . . . 517
From Brachial Plexus . . . . . . . . . . . . . 431 Table 16-8 Clinical Studies Adjustment – Lower
*Table 15-20 Brachial Plexus Impairment: Upper Extremities . . . . . . . . . . . . . . . . . . . . 519
Extremity Impairments . . . . . . . . . . . 434 *Table 16-9 Methodology for Determining the
*Table 15-21 Peripheral Nerve Impairment: Grade in an Impairment Class . . . . . . 520
Upper Extremity Impairments . . . . . . 436 *Table 16-10 Impairment Values Calculated From
Table 15-22 Activities of Daily Living . . . . . . . . . . 445 Lower Extremity Impairment . . . . . . . 530
*Table 15-23 Entrapment/Compression Table 16-11 Sensory and Motor Severity . . . . . . . 533
Neuropathy Impairment . . . . . . . . . . 449 *Table 16-12 Peripheral Nerve Impairment –
*Table 15-24 Diagnostic Criteria for Complex Lower Extremity Impairments . . . . . . 534
Regional Pain Syndrome . . . . . . . . . . 453 *Table 16-13 Diagnostic Criteria for Complex
*Table 15-25 Objective Diagnostic Criteria Points Regional Pain Syndrome . . . . . . . . . . 539
for Complex Regional Pain *Table 16-14 Objective Diagnostic Criteria
Syndrome . . . . . . . . . . . . . . . . . . . . . 453 Points for Complex Regional
*Table 15-26 Complex Regional Pain Syndrome Pain Syndrome . . . . . . . . . . . . . . . . . 540
(Type I): Upper Extremity *Table 16-15 Complex Regional Pain Syndrome
Impairments . . . . . . . . . . . . . . . . . . . 454 (Type 1) – Lower Extremity
Table 15-27 Level of Amputation . . . . . . . . . . . . . 456 Impairments . . . . . . . . . . . . . . . . . . . 541
*Table 15-28 Impairment for Upper Limb *Table 16-16 Amputation Impairment . . . . . . . . . . 542
Amputation at Various Levels . . . . . . 457 Table 16-17 Functional History Net Modifier . . . . 545
*Table 15-29 Amputation Impairment . . . . . . . . . . 460 *Table 16-18 Lesser Toe Impairments. . . . . . . . . . . 549
*Table 15-30 Thumb Range of Motion. . . . . . . . . . 468 *Table 16-19 Greater Toe Impairments . . . . . . . . . 549
*Table 15-31 Finger Range of Motion . . . . . . . . . . 470 *Table 16-20 Hindfoot Motion Impairments. . . . . . 549
*Table 15-32 Wrist Range of Motion . . . . . . . . . . . 473
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xxii Guides to the Evaluation of Permanent Impairment
*Table 16-21 Ankle or Hindfoot Deformity *Table 17-4 Lumbar Spine Regional Grid:
Impairments . . . . . . . . . . . . . . . . . . . 549 Spine Impairments . . . . . . . . . . . . . . 570
*Table 16-22 Ankle Motion Impairments . . . . . . . . 549 Table 17-5 Adjustment Grid: Summary. . . . . . . . 575
*Table 16-23 Knee Motion Impairments . . . . . . . . 549 Table 17-6 Functional History Adjustment:
*Table 16-24 Hip Motion Impairments – Lower Spine . . . . . . . . . . . . . . . . . . . . . . . . 575
Extremity Impairment . . . . . . . . . . . . 549 Table 17-7 Physical Examination Adjustment:
*Table 16-25 Range of Motion ICF Spine . . . . . . . . . . . . . . . . . . . . . . . . 576
Classification . . . . . . . . . . . . . . . . . . 550 Table 17-8 Common Radicular Syndromes . . . . . 578
Table 17-9 Clinical Studies Adjustment: Spine . . 581
*Table 17-10 Methodology for Determining the
C H A P T E R 17 Grade in an Impairment Class . . . . . . 582
The Spine and Pelvis 557 *Table 17-11 Diagnosis-Based Impairment
Grid: Pelvis . . . . . . . . . . . . . . . . . . . . 593
Table 17-1 Definition of Impairment Classes *Table 17-12 Functional History Adjustment:
and Impairment Ranges . . . . . . . . . . 559 Pelvis . . . . . . . . . . . . . . . . . . . . . . . . 594
*Table 17-2 Cervical Spine Regional Grid: *Table 17-13 Physical Examination Adjustment:
Spine Impairments . . . . . . . . . . . . . . 564 Pelvis . . . . . . . . . . . . . . . . . . . . . . . . 595
*Table 17-3 Thoracic Spine Regional Grid: *Table 17-14 Clinical Studies Adjustment: Pelvis. . . 595
Spine Impairments . . . . . . . . . . . . . . 567 *Table 17-A PDQ Scoring . . . . . . . . . . . . . . . . . . . 599
* Indicates Impairment Rating Table
Guides_07_FM_i-xxiv.indd xxii 2/17/09 3:04:01 PM

Illustrations
CHAPTER 1 Figure 12-6 Effect of Nasal Field Loss on the

Binocular Field . . . . . . . . . . . . . . . . . 302
Conceptual Foundations and Figure 12-7 Effect of Temporal Field Loss on
Philosophy 1 the Binocular Field . . . . . . . . . . . . . . 303
Figure 12-8 Conversion From VSI to WPI . . . . . . . 307
Figure 1-1 ICF Model of Disablement. . . . . . . . . . . 3 Figure 12-9 Evaluation of Permanent Visual
Figure 1-2 World Health Organization’s Impairment . . . . . . . . . . . . . . . . . . . . 313
International Classification of Illness . . . 4 Figure 12-10 Overlay Grid for Goldmann Fields . . . 315
Figure 12-11 Overlay Grids for Humphrey Field
Plots . . . . . . . . . . . . . . . . . . . . . . . . . 317
CHAPTER 2
Practical Application of the Guides 19

C H A P T E R 15
Figure 2-1 Hierarchy in Whole Person Concept
for Upper and Lower Extremities. . . . . 22
Figure 2-2 Hierarchy in Whole Person Concept Figure 15-1 Upper Extremity Regions . . . . . . . . . 384
for Upper Extremity and Hand . . . . . . 22
Figure 15-2 Upper Extremity Impairment
Figure 2-3 Sample Report for Permanent Evaluation . . . . . . . . . . . . . . . . . . . . . 388
Medical Impairment . . . . . . . . . . . . . . 30
Figure 15-3 Techniques for Measuring the
Scaphoid, Lunate Axis, and
Long Axis of the Radius and
CHAPTER 3
Corresponding Angles . . . . . . . . . . . 409
Pain-Related Impairment 31 Figure 15-4 Digit Impairment due to Thumb
Amputation at Various Lengths or
Total Transverse Sensory Loss . . . . . . 426
Figure 3-1 Nociception . . . . . . . . . . . . . . . . . . . . 33
Figure 15-5 Digit Impairment due to Finger
Amputation at Various Lengths or
C H A P T E R 12 Total Transverse Sensory Loss . . . . . . 426
Figure 15-6 Hand Impairment Values for Total
The Visual System 281 Transverse Sensory Loss and Total
Longitudinal Sensory Loss on
Figure 12-1 Distribution of the Grid Points Radial and Ulnar Sides Involving
for Visual Field Evaluation . . . . . . . . . 295 100 % of the Digit Length. . . . . . . . 428
Figure 12-2 Normal Visual Field . . . . . . . . . . . . . . 299 Figure 15-7 Motor Innervation of the Upper
Extremity . . . . . . . . . . . . . . . . . . . . . 432
Figure 12-3 Midperipheral Scotoma . . . . . . . . . . . 300
Figure 15-8 Cutaneous Innervation of the
Figure 12-4 Juxtafoveal Scotoma . . . . . . . . . . . . . 300
Upper Extremity and Related
Figure 12-5 Tunnel Vision: Automated Peripheral Nerves and Roots . . . . . . . 432
Perimetry Plot . . . . . . . . . . . . . . . . . . 301
xxiii
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xxiv Guides to the Evaluation of Permanent Impairment
Figure 15-9 Impairment Estimates for Upper C H A P T E R 16

Extremity Amputation at Various
Levels . . . . . . . . . . . . . . . . . . . . . . . . 456 The Lower Extremities 493
Figure 15-10 Impairments of the Digits and the
Hand for Amputation at Various Figure 16-1 Lower Extremity Regions. . . . . . . . . . 494
Levels . . . . . . . . . . . . . . . . . . . . . . . . 456 Figure 16-2 Lower Extremity Impairment
Figure 15-11 Digit Impairment Percent for Thumb Evaluation Record . . . . . . . . . . . . . . . 498
Amputation at Various Levels . . . . . . 458 Figure 16-3 Sensory Nerves of the Lower
Figure 15-12 Digit Impairment Percent for Finger Extremity . . . . . . . . . . . . . . . . . . . . . 537
Amputation at Various Levels . . . . . . 458 Figure 16-4 Motor Nerves of the Lower
Figure 15-13 Upper Extremity Range of Motion Extremity . . . . . . . . . . . . . . . . . . . . . 537
Record . . . . . . . . . . . . . . . . . . . . . . . 462 Figure 16-5 Evaluating the Range of Motion
Figure 15-14 Measurement of MCP Joint Position of a Toe: The Metatarsophalangeal
in Flexion, Extension Lag, Full (MTP) Joint of the Great Toe . . . . . . . 545
Extension, and Hyperextension . . . . . 466 Figure 16-6 Measuring Inversion and Eversion . . . 546
Figure 15-15 Neutral Position and Flexion of Figure 16-7 Measuring Ankle Dorsiflexion
Thumb IP Joint . . . . . . . . . . . . . . . . . 467 (Extension) and Plantar Flexion . . . . . 546
Figure 15-16 Flexion of Thumb MCP Joint . . . . . . . 467 Figure 16-8 Measuring Knee Flexion . . . . . . . . . . 546
Figure 15-17 Neutral Position of Thumb MCP Figure 16-9 Using a Goniometer to Measure
Joint . . . . . . . . . . . . . . . . . . . . . . . . . 467 Flexion of the Right Hip . . . . . . . . . . 547
Figure 15-18 Thumb Radial Abduction, Figure 16-10 Neutral Position, Abduction, and
Measuring the Angle of Separation Adduction of Right Hip . . . . . . . . . . . 547
Formed Between First and Second Figure 16-11 Measuring Internal and External
Metacarpals in Coronal Plane . . . . . . 467 Hip Rotation . . . . . . . . . . . . . . . . . . .548
Figure 15-19 Adduction of Thumb . . . . . . . . . . . . 467 Figure 16-12 Lower Extremity Range of Motion
Figure 15-20 Linear Measurements of Thumb Record . . . . . . . . . . . . . . . . . . . . . . . 551
Opposition (cm) at Various Figure 16-13 Lower Extremity Impairment
Positions . . . . . . . . . . . . . . . . . . . . . . 467 Evaluation Record Example . . . . . . . . 554
Figure 15-21 Neutral Position and Flexion of
Finger DIP Joint . . . . . . . . . . . . . . . . . 470
Figure 15-22 Neutral Position and Flexion of C H A P T E R 17
Finger PIP Joint . . . . . . . . . . . . . . . . . 470
Figure 15-23 Neutral Position and Flexion of The Spine and Pelvis 557
Finger MCP Joint. . . . . . . . . . . . . . . . 471
Figure 17-1 Spine and Pelvis Regions . . . . . . . . . . 558
Figure 15-24 Wrist Flexion and Extension . . . . . . . 472
Figure 17-2 Spine and Pelvis Impairment
Figure 15-25 Radial Deviation and Ulnar
Evaluation Record . . . . . . . . . . . . . . . 561
Deviation of the Right Wrist . . . . . . . 473
Figure 17-3 Skin Areas Innervated by Cervical
Figure 15-26 Flexion and Extension of Elbow. . . . . 474
and Thoracic Nerve Roots Showing
Figure 15-27 Pronation and Supination of Autonomous Zones . . . . . . . . . . . . . 577
Forearm . . . . . . . . . . . . . . . . . . . . . . 475
Figure 17-4 Skin Areas Innervated by Thoracic
Figure 15-28 Shoulder Flexion and Extension. . . . . 475 and Lumbosacral Nerve Roots and
Figure 15-29 Shoulder Abduction and Showing Autonomous Zones . . . . . . 578
Adduction . . . . . . . . . . . . . . . . . . . . 476 Figure 17-5 Loss of Motion Segment Integrity,
Figure 15-30 Shoulder External Rotation and Translation . . . . . . . . . . . . . . . . . . . . 579
Internal Rotation . . . . . . . . . . . . . . . . 476 Figure 17-6 Loss of Motion Segment Integrity,
Figure 15-31 Upper Extremity Impairment Angular Motion (Sagittal Rotation),
Evaluation Example . . . . . . . . . . . . . .480 Lumbar Spine . . . . . . . . . . . . . . . . . . 580
Figure 17-7 Spine and Pelvis Evaluation Record
Example . . . . . . . . . . . . . . . . . . . . . . 598
Figure 17-A Pain Disability Questionnaire . . . . . . . 600
Guides_07_FM_i-xxiv.indd xxiv 2/17/09 3:04:01 PM

Chapter 1
CHAPTER 1
Conceptual Foundations
and Philosophy
1.1 History of the Guides
1.2 New Directions for the Sixth Edition
1.3 The International Classification of

Functioning, Disability, and Health (ICF):
A Contemporary Model of Disablement
1.4 Measurement Issues
1.5 Balancing Science and Clinical Judgment
1.6 The Case for Simplification and Ease of

1.1 History of the Guides
Application
Tolerance of and care for the sick and the disabled
may be elemental components of our social fabric
1.7 The Application of Functional Assessment
rooted in the very origins of human society.
Anthropological evidence supports the notion that
1.8 The Need for Internal Consistency and a
our earliest ancestors were afforded communal
Uniform Template
benefits in terms of improved odds of survival of
hereditary and physical impairments that might
1.9 Summary
otherwise prove fatal to the individual.1 The concept
of compensation for personal injuries and resulting
disabilities is hardly a contemporary one; historical
evidence documents that social justice and compen-
sation systems for injured parties have been around
since recorded history.1,2
Since antiquity, from ancient Babylonian societies
4000 years ago to the Roman Empire many centuries
later, lawgivers attempted to legislate justice in
moral, social and economic spheres, which inter alia
provided for pecuniary compensation.3 These various
attempts to legislate monetary compensation for
personal injuries were aimed at ridding the society of
the blood feud and replacing it with a more civilized
and enlightened system involving the exchange of
monetary value for losses resulting from personal
injuries. For example, the Lombard laws 2 millennia
Guides6e_01_001-018.indd 1 2/17/09 2:22:32 PM

2 Guides to the Evaluation of Permanent Impairment
Chapter 1
ago set forth monetary compensation values for all • Numerical ratings were more the representation of
sorts of injuries, from minor loss such as teeth to the “legal fiction than medical reality.”17
loss of eye and limbs. These systems even accounted
Recommended changes included:
for cosmetic loss, doubling the value of a lost tooth
if it showed on smile.4 Such monetary compensation • Standardized assessment of Activities of Daily
schemes, in terms of their whole person values, Living (ADL) limitations associated with physical
are strikingly similar to some of our contemporary impairments.
systems of compensation for disablement.
• Application of functional assessment tools to
The Guides reflects experience with impairment validate impairment rating scales.
ratings over the centuries1,2 and started in 1958 with
• Include measures of functional loss in the
publication by the American Medical Association
impairment rating.
(AMA) of the article, A Guide to the Evaluation
of Permanent Impairment of the Extremities and • Overall improvements in intrarater and interrater
Back.5 Over the next 12 years, 12 additional guides reliability and internal consistency.14
appeared in JAMA, and in 1971 a compendium
Although attempts were made to correct these
of these 13 guides became the First Edition of the
deficiencies in the Fifth Edition, problems persisted.
Guides.6
These were attributable, in part, to adherence to
The Guides is revised periodically to incorporate antiquated and confusing terminology, limited
current scientific clinical knowledge and judgment. validity and reliability of the ratings, lack of
For example, the Third Edition, published in 1988, meaningful and consistent application of functional
introduced pie charts for range of motion (ROM) assessment tools, and lack of internal consistency.14
impairment evaluation of the upper extremities.7 In A high error rate among all ratings has been
1993 the Fourth Edition introduced the Diagnosis- reported.18 In this edition there is a paradigm shift,
Related Estimates (DRE) or “injury” model to the which adopts a contemporary model of disablement;
evaluation of spinal injuries.8 A pain chapter was it is simplified, functionally based, and internally
introduced in the Fourth Edition and refined in the consistent to the fullest extent possible.
Fifth Edition in 2000.9 The Fifth Edition modified
the DRE method and expanded the ROM method 1.2b Five New Axioms of the
for spinal impairment evaluations. The Sixth Edition Sixth Edition
represents this continued evolution and introduces a The vision embodied by this paradigm shift is
“paradigm shift” to the assessment of impairment. articulated in terms of 5 specific new axioms. These
axioms provide direction and define priorities:
1. The Guides adopts the terminology and
conceptual framework of disablement as put
1.2 New Directions for the forward by the International Classification of
Sixth Edition Functioning, Disability, and Health (ICF).19
2. The Guides becomes more diagnosis based with
1.2a Previous Criticisms of the Guides these diagnoses being evidence-based when
The Guides is revised to reflect the latest scientific possible.
research and evolving medical evidence. Earlier
3. Simplicity, ease-of-application, and following
versions of the Guides were subject to criticisms,10–17
precedent, where applicable, are given high
which included the following:
priority, with the goal of optimizing interrater
• There was a failure to provide a comprehensive, and intrarater reliability.
valid, reliable, unbiased, and evidence-based
4. Rating percentages derived according to the
rating system.
Guides are functionally based, to the fullest
• Impairment ratings did not adequately or practical extent possible.
accurately reflect loss of function.
5. The Guides stresses conceptual and methodological
congruity within and between organ system ratings.
Guides6e_01_001-018.indd 2 2/17/09 2:22:34 PM

Conceptual Foundations and Philosophy 3
Chapter 1
1.3 The International 3. Participation: involvement in life situations and
Classification of Functioning, participation restrictions are barriers to experi-
encing such involvement.
Disability, and Health (ICF):
These components comprise functioning and dis-
A Contemporary Model of ability in the model. In turn, they are related interac-
Disablement tively to an individual with a given health condition,
disorder, or disease, and to environmental factors
and personal factors of each specific case.19
1.3a ICF Model
The World Health Organization (WHO) devel-
1.3b Applications of ICF Model
oped a comprehensive model of disablement,
to the Guides
the International Classification of Functioning,
Disability, and Health (ICF)19; this classification Advantages of ICF Model
is depicted in Figure 1-1. The ICF framework is The ICF model appears to be the best model for the
intended for describing and measuring health and Guides. It acknowledges the complex and dynamic
disability at the individual and population levels. interactions between an individual with a given
It consists of 3 key components: health condition, the environment, and personal fac-
tors. The relationships between impairment, activity
1. Body functions and body structures: physi-
limitations, and participation are not assumed to be
ological functions and body parts, respectively;
linear or unidirectional. An individual may experi-
these can vary from the normal state, in terms
ence measurable impairment without significant
of loss or deviations, which are referred to as
activity limitations that do not produce restrictions
impairments.
to major life activities such as work or recreation. On
2. Activity: task execution by the individual and the other hand, one can experience significant activ-
activity limitations are difficulties the individual ity limitations and/or participation restrictions in the
may experience carrying out such activities. absence of demonstrable impairment.
F I G U R E 1 -1
ICF Model of Disablement
Health Condition,
Disorder or Disease
Body Functions and

Activity Participation
Structures
No Participation
Normal Variation No Activity Limitation Restriction
Complete Impairment Complete Activity Complete Participation

Limitation Restriction
Environmental Personal
Guides6e_01_001-018.indd 3 2/17/09 2:22:35 PM

Chapter 1
History of Models of Disablement

The traditional model of disablement was based on the International Classification of Impairments,
Disabilities, and Handicaps (ICIDH) that the WHO presented more than a quarter century ago.20 This model,
depicted in Figure 1-2, focuses on the individual and extends across 4 levels of disablement in linear fashion.
The first level, pathology (a disease or trauma at the tissue level), is viewed as giving rise to impairment (an
abnormality in anatomic or physiological structure or function at the organ system level). This, in turn, gives
rise to disability (the functional consequences to the individual in terms of abilities lost) within one’s personal
sphere (ie, mobility; Activities of Daily Living, or ADLs); and eventually to handicap (a disadvantage to a
given individual in terms of role fulfillment) in their societal sphere (may include barriers or impediments to
functioning in a major life activity, such as work).14
The ICIDH model is overly simplistic and unidirectional. This unidirectional depiction of the relationships
among impairments, disabilities, and handicaps implies causation and irreversibility; disabilities and handi-
caps can also give rise to impairments. The ICIDH model also lacks sufficient complexity to fully account
for important environmental modifiers of a biological, psychological, and social nature.15 For example, the
societal consequences of impairment may be substantially mitigated by environmental accommodations
such as those mandated by the Americans with Disabilities Act,21 and by greater acceptance and enabling
expectations.
Interim Developments of the WHO and Institute of Medicine
Saad Nagi22 developed a conceptual model of disablement in the 1960s that was similar to the WHO model.
It recognized that the correlations among impairments, functional limitations, and associated disabilities were
poor. He suggested that environmental factors were important modifiers of this relationship, albeit in a unidi-
rectional sense.
In 1991 the Institute of Medicine (IOM) defined disability as “a function of the interaction of the person with
the environment” and produced an interactive model of the “enabling-disabling process,” which identified
3 independent modifiers, including biology (ie, heredity), environment (ie, physical, social, psychological),
and lifestyle and behavior.23
In 1997, a second International Classification of Impairments, Disabilities, and Handicaps (ICIDH-2)
was presented by the WHO.24 This model changed terminology of disablement (referencing impairments,
disability, and handicap) to that of enablement (referencing impairments, activities, and participations). It
provided unified and standard language to characterize the functional consequences of a variety of health
conditions.24
FIGURE 1-2
World Health Organization’s International Classification of Illness
Pathology Impairment Disability Handicap
The underlying The immediate The functional The social and

disease or diagnosis physiological consequences, societal
consequences, abilities lost consequences,
symptoms, and signs freedoms lost
Rondinelli RD, Duncan PW. The concepts of impairment and disability. In Rondinelli RD, Katz RT, eds. Impairment
Rating and Disability Evaluation. Philadelphia, Pa: WB Saunders Co; 2000:19. Used with permission.
Guides6e_01_001-018.indd 4 2/17/09 2:22:35 PM

Chapter 1
The ICF recognizes that limitations to participation 1.3d Operational Definitions: Impairment,
may secondarily produce activity restrictions Disability, Handicap
or impairments. It also recognizes the impact For purposes of the Guides, the following operational
of environmental and personal factors to the definitions and disclaimer apply:
consequences of disease. Activity limitations and
Impairment: a significant deviation, loss, or loss of
participation restrictions are not static. They may
use of any body structure or body function in an indi-
vary over time and be influenced by numerous
vidual with a health condition, disorder, or disease.
physical and psychological factors that may also vary
over time. Disability: activity limitations and/or participation
restrictions in an individual with a health condition,
The ICF model is designed to be enabling in its
disorder, or disease.
approach and etiologically neutral in addressing
human functioning as well as disability. It is Impairment rating enables the physician to render a
inclusive in dealing with personal and environmental quantitative estimate of losses to the individual as a
determinants of health and disablement, and is result of their health condition, disorder, or disease.
causally interactive as opposed to linearly predictive Impairment ratings are defined by anatomic, struc-
of its constructs and associations. tural, functional, and diagnostic criteria; physicians
are generally familiar with these criteria, based on
International Appeal and Applications their broader training and clinical experience. These
The ICF was developed out of a worldwide ratings are determined by following accepted diag-
consensus process, which embodies broad cultural nostic processes and procedures. Most physicians are
values and perspectives. The ICF model (unlike not trained in assessing the full array of human func-
its predecessor, the ICIDH) was endorsed by the tional activities and participations that are required
World Health Assembly in May 200125 and is now for comprehensive disability determinations.
a member of the WHO Family of International Impairment rating is a physician-driven first approx-
Classifications. This acceptance reflects the imation of a process that attempts to link impairment
increasing worldwide importance placed on with a quantitative estimate of functional losses in
recognition and reduction of burden of care one’s personal sphere of activity. As a result, the fol-
associated with health conditions. lowing operational definition will continue to apply:
Impairment rating: consensus-derived percentage
1.3c ICF Terminology and Definitions
estimate of loss of activity reflecting severity for a
According to the ICF, the following terms and
given health condition, and the degree of associated
definitions apply:
limitations in terms of ADLs.
• Body functions: physiological functions of body
There are important remaining differences between
systems (including psychological functions).
the ICF and Guides terminology. The ICF model
• Body structures: anatomic parts of the body such depicts only an association between body function/
as organs, limbs, and their components. structure, activity, participation, and a given health
condition. Typically, in assessing impairment, the
• Activity: execution of a task or action by an
physician must determine if the health condition is
individual.
causally related to an event or exposure.
• Participation: involvement in a life situation.
The relationship between impairment and disability
• Impairments: problems in body function or remains both complex and difficult, if not impossible,
structure such as a significant deviation or loss. to predict. In some conditions there is a strong
association between level of injury and the degree of
• Activity limitations: difficulties an individual
functional loss expected in one’s personal sphere of
may have in executing activities.
activity (mobility and ADLs). The same level of injury
• Participation restrictions: problems an is in no way predictive of an affected individual’s
individual may experience in involvement in ability to participate in major life functions (including
life situations. work) when appropriate motivation, technology, and
Guides6e_01_001-018.indd 5 2/17/09 2:22:36 PM

Chapter 1
sufficient accommodations are available. Disability Examples of Impairment and Disability

may be influenced by physical, psychological, and
Christopher Reeve was a well known celebrity
psychosocial factors that can change over time.
who suffered a traumatic spinal cord injury
The Guides is not intended to be used for direct esti- resulting in a high-level cervical tetraplegia, a
mates of work participation restrictions. Impairment condition that would have an unusually high
percentages derived according to the Guides’ criteria expected impairment rating due to the near-
do not directly measure work participation restric- complete activity limitations that typically
tions. The intent of the Guides is to develop stan- accompany it. In his particular case, he required
dardized impairment ratings to be used as follows: elaborate mobility and ventilatory assistive equip-
ment and the 24-hour availability of a personal
1. Fix the diagnosis and associated percentage
care attendant to assist with virtually all self-
of physical and functional loss at “Maximum
care activities. However, Mr. Reeve was highly
Medical Improvement” (MMI) (see Chapter 2).
exceptional in terms of his public persona and
2. Enable a patient with an impairment rating to renown, and his access to significant personal
exit from a system of temporary disablement financial assets and other resources. He was able
(eg, temporary total or partial disablement under to martial these constructively to create an educa-
workers’ compensation before MMI). tion and research foundation for which he was the
principal spokesperson, and to become globally
3. Provide diagnosis and taxonomic classification of
recognized as a prime advocate for the spinal
impairment as a segue into other systems of long-
cord injured and disabled. His vocational success
term disablement.
would be judged exceptional even for any able-
In disability evaluation, the impairment rating bodied individual, and underscores the fact that
is one of several determinants of disablement. participation restrictions do not correlate with
Impairment rating is the determinant most amenable activity limitations in many instances.
to physician assessment; it must be further integrated
Similarly, a given physical impairment can be
with contextual information typically provided
highly disabling in one vocational context and
by nonphysician sources regarding psychological,
virtually non-disabling in another. For example,
social, vocational, and avocational issues.
amputation of one’s great toe might preclude
the vocation of a ballerina who must dance “on
1.3e Domains of Personal Function
point,” whereas the same amputation might be
There are 2 domains of human personal function
of no functional consequence to a construction
that are most often affected by impairments and for
worker equipped with an appropriately fitted
which well-accepted measurement tools exist, and
work boot.
hence they are of particular interest to the impair-
ment rater. These are mobility and “self-care,” which
can be further defined and categorized as follows.26
These mobility and self-care activities may be per-
Mobility formed independently (without the use of a helper
Transfer: movement of one’s body position while or adaptive aids) or modified independently (require
remaining at the same point in space (eg, supine to the use of adaptive aids but no helper), or they may
side lying, supine to sit, sit to stand). require helper assistance with or without adaptive
aids. The highest level of independence with which
Ambulation: movement of one’s body from one
the given activity is consistently and safely carried
point in space to another (eg, walking, stair climbing,
out at the individual’s baseline is considered the
wheelchair locomotion).
functional level for that individual.27
Self-Care
Activities of Daily Living (ADLs): basic self-care
activities performed in one’s personal sphere (eg,
feeding, bathing, hygiene, dressing; see Table 1-1).
1.4 Measurement Issues
Instrumental Activities of Daily Living (IADLs): Measurement issues are important determinants in
complex self-care activities (eg, financial manage- defining impairment. The process of impairment
ment, medications, meal preparation), which may be rating relies on criteria that may be discrete (ie,
delegated to others (see Table 1-1). amputation of a limb) or continuous (ie, loss of range
Guides6e_01_001-018.indd 6 2/17/09 2:22:37 PM

Chapter 1
TA B L E 1 -1
Self-Care Measurement Scales
Activities of Daily Living (ADLs) Nominal scales categorize items into different,
Bathing, showering internally equivalent groups based on a single
Bowel and bladder management criterion. They may be dichotomous (ie, 1 of 2
Dressing possible groups such as male vs female) or non-
Eating
dichotomous (ie, the colors of the spectrum).
Ordinal scales categorize items hierarchically,
Feeding
based on order of magnitude, where intervals
Functional mobility between groups are not assumed to be equal
Personal device care and the order of magnitude may differ for each
Personal hygiene and grooming group. Ordinal scales are most commonly used in
Sexual activity clinical practice and are typical of the self-report
Sleep/rest
functional outcome scales being adopted here.
Interval scales, by contrast, are continuous scales,
Toilet hygiene
which are rank ordered according to uniform and
Instrumental Activities of Daily Living (IADLs) sequential units of increment (ie, temperature
Care of others (including selecting and supervising scale). Ratio scales are interval scales whose
caregivers) zero point reflects absence of the quantity being
Care of pets measured.12
Child rearing
Analysis of nominal and ordinal data requires
Communication device use special considerations to avoid mistaken infer-
Community mobility ence of the results.29,30 Controversy surrounds
Financial management summation and averaging of subtest scores to
Health management and maintenance produce an overall result for comparative pur-
poses. As such, continuous-scale measures lend
Home establishment and maintenance
themselves more readily to rigorous statistical
Meal preparation and cleanup
analysis than is possible for discrete counter-
Safety procedures and emergency responses parts.12 Since the comparative data being drawn
Shopping upon for some organ systems of the Guides
Source: Youngstrom. 26 remain largely discrete, by nature, and have not
been subjected to appropriate Rasch analysis or
other manipulations, the use of normative statis-
tics (eg, means, standard deviations) for compara-
of motion). Severity of an impairment also can vary tive purposes in such cases remains problematic
according to discrete (ie, level of amputation) or con- and will be avoided.
tinuous (ie, degrees of motion lost) criteria. There are
4 levels of measurement whereby test results can be
analyzed and interpreted, including nominal, ordinal,
Validity is the extent to which an instrument mea-
interval, and ratio.28 Nominal and ordinal scales are
sures that which it is intended to measure.
used to classify discrete measures because the scores
they produce occupy mutually exclusive categories. Previous work examining the validity of musculo-
Interval and ratio scales apply to continuous mea- skeletal impairments derived according to the Guides
sures because the scores produced occupy points on a has yielded equivocal results.15,32,33 One study33 exam-
continuum within an available range of scores.12 ined the validity of hand impairments due to loss of
ROM or to amputation, and in terms of correlations
Precision, accuracy, reliability, and validity are criti-
of impairment ratings and objective measures of hand
cal issues in defining impairment. Precision refers
function. Approximately two thirds of the correlations
to the smallest unit of change that a measurement
were significant; hence, these results were touted as
instrument can distinguish. Sensitivity to change is
a validation of impairment ratings. However, the R2
critical to the measurement of the clinical effects
coefficients derived from these correlations (amount
of treatment, and the sensitivity of a measurement
of variance actually “explained” in terms of these
scale should be appropriate to the level of precision
correlations and regressions) were quite low (exceeded
required in a given case. Reliability is the extent to
.5 in only 8% of correlations.) Another similar
which a measurement provides consistent information.
Guides6e_01_001-018.indd 7 3/3/09 4:47:30 PM

Chapter 1
Precision and Accuracy measurement of functional losses in terms of ADLs,

in the derivation of these ratings.
Consideration must be given to feasibility and
practicality of achieving a given level of preci-
sion, including cost and availability of equipment,
and time required and ease of application in the
field. For example, a Thomas test can rapidly
1.5 Balancing Science and
reveal presence of a hip flexion contracture to an Clinical Judgment
examiner but is less precise than standard gonio-
metric assessment of ROM for impairment rating
1.5a The Relative Merits of Study Designs
purposes. The term accuracy defines the ability
The relative merits of research study designs have
of a measurement to correctly (and precisely)
been examined, and hierarchies of evidence have
assess the condition or process being measured.
been proposed.34–36 The Agency for Health Care
The ability to do so depends on minimizing
Policy and Research has adopted a hierarchy of study
sources of error, which in human performance
types,37 based on ability of study design to minimize
measurement include examiner training and
the possibility of bias and confounding influence,
skills required to use, the interface between sub-
as listed in Table 1-2.35 Strength of evidence is based
ject and measurement device, and the instrument
largely on reliability estimates of study design.35
itself. Generally speaking, examiner training is
Steps for determining levels of evidence and grades
usually the most variable.31
of recommendations for evidence-based clinical
guidelines are as follows:
• Levels of evidence are defined and ranked hierar-
study32 showed significant correlations between lower chically based on study design (see Table 1-2) and
extremity impairments associated with fractures methodological quality of individual studies.
and measures of functional performance as well as
• Questions to be addressed are carefully defined.
limitations measured on the Sickness Impact Profile
(SIP). Again, these results were used to tout validity. • Eligible evidence is defined, as are inclusion and
However, the associated R2 coefficients were again exclusion criteria.
quite small (R2 ⫽ .32 and .30, respectively).
• All studies meeting the aforementioned criteria
A more recent study15 estimated upper extremity relating to a specific question are obtained using
impairments due to a simulated “fusion” at the meta- clearly defined search strategies.
carpophalangeal joint of the dominant extremity in
• Eligible studies are summarized in an evidence
otherwise healthy adult subjects, using individually
table.
fabricated hand splints. They examined randomized,
real-time performance on standardized measures of • The strength of evidence to support a given
hand function with and without the splints, to obtain intervention or hypothesis is stated.
correlations and regressions of impairment ratings
• Judgments regarding the consistency, generaliz-
and functional performance. Although simulated
ability, applicability, and overall clinical impact
impairments in that study led to slowing of perfor-
are considered in linking evidence to clinical
mance on all functional measures, the correlations
recommendations.
of degree of slowing and magnitude of impairment
were not significant. The methodological limitations
and small number of these studies preclude defini-
tive conclusions concerning validity of impairment TA B L E 1-2
ratings at this time. Hierarchy of Study Types
Collectively, these studies do suggest that the cri- Systematic reviews and meta-analyses of randomized
controlled trials
terion validity of musculoskeletal impairment rat-
ings, as traditionally determined, remains limited. Randomized controlled trials
What this means is that functional losses (in terms Nonrandomized intervention studies
of ADLs) associated with impairment are not being Observational studies
captured by (and reflected in) the impairment ratings Nonexperimental studies
themselves. Likewise, such validity as is possible
Expert opinion
to achieve in impairment ratings can be expected
to improve if greater attention is paid to direct
Guides6e_01_001-018.indd 8 2/17/09 2:22:38 PM

Chapter 1
• Grades of recommendations are based on Validity
strength of supporting evidence as modulated by
Using the target analogy, if a gun (instrument) is
the judgment of guideline developers, especially
aimed at the target, validity is the ability to hit the
in the absence of evidence.
target at the point being aimed at. For purposes of
Historically, the numerical ratings applied for organ discussion here, impairment ratings can be con-
system impairment and whole person impairment sidered in terms of their content validity, construct
throughout the Guides are based largely on consen- validity, and criterion validity. Content validity
sus and expert opinion. Research has focused on of a particular test refers to its ability to cover
reliability and reproducibility of ratings17 and func- a representative sample of a particular domain
tional validity of ratings.15,32,33 The evidence basis for being measured. For example, “hand impairment”
impairment percentages assignable to ICF functional is determined by examining digital amputation
levels must await further empirical testing;19 infra- level, joint ROM, sensory loss, and/or other ana-
structure exists to develop such studies based on the tomic and functional aspects of the hand. Such
ICF model, core sets, and ADL assessments.38,39 validity is generally asserted by expert opinion
(Delphi panel). Construct validity refers to the
Impairment and disability are complex concepts that
extent to which the test measures some theoretical
are not yet amenable to evidence-based definition.
construct such as functioning (eg, ADLs), pain,
Diagnoses should be evidence-based, however, the
or suffering. Criterion validity refers to whether
impact of injury or illness is dependent on factors
or not the test measure in question correlates well
beyond physical and psychological aspects, includ-
(is predictive) with some independent criterion
ing psychosocial, behavioral and contextual issues.
or “gold standard.” For example, a contrast veno-
Therefore, it is more challenging to obtain data
gram is a highly accurate test for detecting deep
needed to define an evidence-based approach to
venous thrombosis (DVT). A venous Doppler is a
impairment assessment.
less invasive and less costly alternative, which has
Given the dearth of higher-level, evidence-based crite- shown high criterion validity to a venogram and,
ria on which to base impairment ratings, the following hence, is typically used instead to make the diag-
approach was followed for this edition of the Guides: nosis of DVT in the clinical setting.12
1. Current literature was consulted to ensure
evidence-based approach for diagnoses used to
determine consensus based impairment ratings.
consensus based and will remain so until future
2. Where ratings must be consensus based, due to
validation studies can be carried out.
absence or lack of valid objective data, explana-
tion of the specific basis on which the ratings are
derived is provided. Normative judgments that
are not data driven will follow precedent in many
cases and must await future validation studies
1.6 The Case for Simplification
before significant change is adopted. and Ease of Application
3. Attempts have been made to normalize impair-
The consensus of the Guides’ editors is that sim-
ment ratings across organ systems to improve
plification and brevity, in conjunction with greater
internal consistency. Decisions, in such cases, are
clarity, are needed. When evidence-based criteria are
lacking, priorities for simplification apply.
Reliability
A simple conceptualization of reliability is to
consider a gun as a measurement instrument, and 1.7The Application of
the shots fired at a target as the measurements Functional Assessment
themselves. If the shots cluster tightly, the gun is
shooting with high reliability, regardless of where
the cluster appears on the target. If the shots fail 1.7a Earlier Approaches That
to cluster, the reliability is low.12 Reliability can Have Worked Well
vary significantly between instruments for a given Criticism of previous editions of the Guides includes
rater, and between raters for a given instrument.40 lack of validity due, in part, to inadequate attention
to functional assessment.13,15,17 Historically, attention
Guides6e_01_001-018.indd 9 2/17/09 2:22:38 PM

Chapter 1
to functional (as opposed to anatomic) loss in Functional assessment can be approached from a
impairment rating determinations has varied by global and/or organ-specific level. Several global
organ system and the availability of functional data. functional assessment scales have been developed
In the cardiovascular system, for example, anatomic with multiple applications (eg, Short-Form 36).44
loss refers to damage to an organ or body system No brief and simple-to-use scale appears available
(eg, left ventricular hypertrophy), whereas functional that can serve for multiorgan system functional
loss includes loss such as decreased ejection fraction assessment purposes. In several specific organ
of the heart. The New York Heart Association41 systems, general functional outcome scales that
also provides a well-accepted 4-class, functionally are well accepted exist to determine functional
based scheme (NYHA classes I-IV) according loss in relation to symptom severity. For example,
to symptoms with activity and overall functional the NYHA’s Classification of Cardiac Disease41
ability in terms of ADLs. There is good evidence- and the American Thoracic Society’s Impairment
based research linking the NYHA functional class Classification of Dyspnea 45 have well-documented
to clinical status (activity tolerance) and metabolic grading schemes for symptom severity which have
equivalents (METs) achievable on treadmill testing.42 been validated against objective measures of meta-
Similarly, in the respiratory system, a functionally bolic energy expenditure and pulmonary function
based classification of dyspnea in relation to ADLs43 testing, respectively.
has been applied, and impairment ratings have
For the musculoskeletal organ system, no such
been developed based on results of pulmonary
well-accepted, cross-validated outcome scales exist.
function testing as well as exercise test results.
However, there are a number of organ-specific,
The ADL-based functional assessment needs to be
self-reporting functional assessment tools. These
incorporated into the neurologic, musculoskeletal,
tools were typically developed to assess postsurgical
and other organ systems of the Guides.
outcomes. Application of such normalized data to a
skewed population of patients undergoing impair-
1.7b Self-Report Assessment Tools and
ment ratings is potentially misleading. These tools
the Need for Empirical Validation Through
can generate consistent and standardized self-report
In-Office Applications
data for this subgroup, which can have descriptive
Functional assessment should be one aspect of impair-
and analytical applications toward impairment rat-
ment rating, but not the only aspect. Diagnosis, history,
ing. The resulting scores can be rank ordered into
and physical examination; appropriate confirma-
“no deficit; mild; moderate; severe; and extreme”
tory tests; and functional outcome scores must all be
deficit categories to help quantify an individual’s
incorporated.
perceived pain, suffering, and functional result.
The rating physician using the Guides should weigh Such self-report tests can be easily and consistently
all available information, emphasizing the impor- administered in the physician’s office and quickly
tance of some and deemphasizing other information, scored by the examiner. As results are wholly based
so long as it is consistent and concordant with the on self-report, intentional manipulation of impair-
pathology at issue. Patients may underreport or over- ment rating is possible. Therefore, when these test
report their symptom complex, and any resulting results tend to place an individual in an impairment
clinical outcome tool based on self-report may be grade that is higher or lower than that suggested
scored inappropriately low or high. Examiners must by other parameters, the evaluator must assess the
exercise their ability to observe the patient perform validity and consistency of conventional information
certain functional tasks to help determine if self- before assigning a rating.
report is accurate.
With appropriate scaling, functional scores may also
be helpful in developing an impairment percentage
1.7c Choice of Functional adjustment that is organ-specific and functionally
Assessment Tools based. What this means is that the tool was origi-
This edition differentiates between the relative con- nally designed to give the examiner the ability to
tributions of history of clinical presentation, physical assess a postsurgical patient’s individual test score
findings, objective test results, and associated func- (standardized) in relation to the normative data of the
tional losses to the impairment rating. Functional population for which it was derived (ie, “Mrs. Smith
assessment is discussed more explicitly in most scored at the 55th percentile; based on the popula-
chapters of this edition and is integrated with clinical tion mean of 50% she is slightly better than average
presentation, physical findings, and objective testing. in functional outcome.”) The results of such tools,
Guides6e_01_001-018.indd 10 2/17/09 2:22:39 PM

Chapter 1
if reliable, may be used to adjust the impairment TA B L E 1-3
percentage to reflect different functional outcomes. ICF Codes and Functional Levels
Introducing functional assessment is done conserva- 5-Scale Taxonomy
tively, in order that the impact on impairment ratings
ICF Code
can be studied subsequently and its significance can
be better understood. xxx.0 NO problem (none, absent, negligible …)
xxx.1 MILD problem (slight, low …)
The following self-reported orthopedic functional
xxx.2 MODERATE problem (medium, fair …)
assessment tools are used:
xxx.3 SEVERE problem (high, extreme …)
• Spine: Pain Disability Questionnaire (PDQ).46 xxx.4 COMPLETE problem (total …)
• Upper extremity: Shorter version of the
Disabilities of the Arm, Shoulder, and Hand
(DASH) Questionnaire—the QuickDASH.47
• Lower extremity: Lower Limb Outcomes
The 5 classes of functional impairment are scored 0
Questionnaire.48
to 4 and range from level 0 (no functional problem)
The rationale for the selection of these tools is to level 4 (complete problem with total functional
explained in the musculoskeletal chapters (Chapters 15 loss). Although percentages of loss may eventually
to 17). Physicians should include functional assessment be assigned to each functional class, this must await
as part of their regular impairment rating examination. formal validation studies specific to each diagnosis
The resulting data should help provide impetus for of interest.
development of evidence-based functional outcome
The basic structure of the ICF parallels other
assessment tools that are more ideally suited for
mutually exclusive ordinal categories of functional
impairment ratings.
assessment. For example, in the pulmonary
literature a 5-class dyspnea index49 was proposed
to differentiate patients according to symptoms
1.8The Need for Internal with level of exertion and degree of functional
Consistency and a Uniform dependence (Table 1-4). Similar functionally based
descriptive differentiators exist or could easily be
Template developed for a variety of conditions (eg, angina
for coronary heart disease; joint pain and stiffness
for rheumatoid arthritis) other than dyspnea (see
1.8a ICF Scale of Capacity and
for example, the Karnofsky Scale for cancer
Performance Qualifiers (Levels 0–4)
patients).50
A challenge with the Sixth Edition was to develop
a generic template for impairment grids that would
yield maximal internal consistency of impairment
ratings across organ systems. Previously, there was
considerable variation in the number of impairment TA B L E 1- 4
classes. The spectrum included some organ systems Sample Impairment Functional Classification
having no impairment percentage (eg, psychiatric Functional Impairment Class
disorders), 2 classes (eg, thyroid disorders),
Functional Class Impairment
3 classes (eg, bladder disorders; penile and cervical
disorders), 4 classes (eg, heart disorders, respira- 0 No symptoms with strenuous
activity (independent)
tory disorders), 5 classes (eg, peripheral vascular
1 Symptoms with strenuous activity;
disorders, dermatologic disorders), and 6 classes no symptoms with normal activity
(eg, visual acuity disorders). There was also a wider (independent)
range and variation in impairment percentages 2 Symptoms with normal activity
within organ systems. (independent)
The ICF has created a functionally based taxonomy 3 Symptoms with minimal activity
(partially dependent)
that links specific conditions to an ordinal level of
clinical severity based on (as yet unverified) percent- 4 Symptoms at rest (totally
dependent)
ages of functions lost, as presented in Table 1-3.19
Guides6e_01_001-018.indd 11 2/17/09 2:22:40 PM

Chapter 1
1.8b Basic Components of the Template the day of the examination. However, for certain
Each grid has a structure that includes the following organs such as the cardiac, pulmonary, and renal
components: systems, well-validated organ-specific functional
test measures exist that correlate well with levels
• Impairment class: 5 classes whenever possible;
of impairment. For these systems it appears more
classes 0 to 4 have been chosen to be consistent
appropriate to choose Objective Test Results as
with ICF taxonomy.
the key factor of the impairment rating. Although
• Impairment percentage: range within each uncommon, Physical Findings, or alternative
respective impairment class. factors, may, on occasion, be the main factors in
determining impairment. The decision regarding
• Impairment criterion 1: History of Clinical
which key factor is the primary determinant
Presentation—historical data to support the
of impairment will be clearly stated for each
diagnosis-based or regional nature of the
organ system impairment grid selected, and the
impairment class.
examiner must proceed accordingly.
• Impairment criterion 2: Physical Findings—
2. Each impairment class will have a corresponding
examination findings for each impairment class.
range of available impairment ratings, respec-
• Impairment criterion 3: Clinical Studies or tively. For example, class 2 for disease process
Objective Test Results—specified where appli- “X” may correspond to a rating that ranges from
cable for each impairment class. 15% to 27% of whole person impairment. When
possible, the range within each class is divided
• Impairment criterion 4: Functional History or
into 5 impairment grades (A to E), respectively.
Assessment—evidence of symptomatic dysfunc-
The amount will differ between organ systems
tion and functional loss due to impairment.
and disease processes and will be clearly delin-
The grids are not so rigid to distort the inherent chal- eated for each impairment grid. The first grade
lenges to impairment rating for any particular organ is the lowest impairment rating that could be
system. Different organ systems may, of necessity, assigned for that impairment class; the last grade
format the 4 impairment criteria in slightly differ- is the highest. Interim choices will be equidis-
ing ways. For example, for some disease processes, tant whenever possible from the bottom and top
physical examination or objective test results are not of the range of grades in each class. Going back
material factors in driving the impairment rating. to our example, if the examiner determines that
One or both may then be omitted; if an additional the key factor places a patient into class 2, the
factor is deemed relevant to determining impairment choices for the impairment rating will be 15%,
(ie, Burden of Treatment Compliance, or BOTC, 18%, 21%, 24%, or 27%, for grades A through E,
see Appendix B), it may be added to the grid as an respectively.
alternative.
3. With use of the key factor (History of Clinical
Presentation in our example), and if the
1.8c Generic Template for Uniformity and
patient is in class 2, the patient will generally
Ease of Application
receive a rating (grade “C” for 21%) that is
The following generic template illustrates the format
midway between the top and bottom of the
being encouraged throughout the Guides and is
available range. After the key factor has led to a
presented in Table 1-5.
preliminary impairment rating, it will be adjusted
The process of assigning impairment according to based on the results from rating the other
the template is as follows: impairment criteria (non-key factors).
1. The examiner will note which impairment 4. The next step requires the examiner to adjust for
criterion is held to be the “key factor” used to factors other than that considered “key.” Non-key
determine the appropriate impairment class factors may include results of Functional History,
for the condition(s) being rated at Maximum Physical Examination, and Clinical Studies. If
Medical Improvement (MMI). For most organ the examiner determines that the other factors
systems or disease processes (eg, neurologic affecting the rating are in the same class (class
and musculoskeletal organ systems) this will 2 in this example) that had been used for the key
be the History of Clinical Presentation, since it factor rating, the final rating will generally stay
captures considerable information regarding an in the middle of that class (21% in our example).
individual’s prior clinical course that is relevant On the other hand, if the remaining adjustment
to the rating but which may not be apparent on factors are higher or lower than that used for the
Guides6e_01_001-018.indd 12 2/17/09 2:22:40 PM

Chapter 1
TA B L E 1- 5 Generic Template for Impairment Classification Grids
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT
RATING (%) 0 Minimal % Moderate % Severe % Very Severe %
SEVERITY GRADE
(%) (ABCDE) (ABCDE) (ABCDE) (ABCDE)
HISTORY No current Symptoms Constant mild Constant moder- Constant severe

OF CLINICAL symptoms controlled with symptoms ate symptoms symptoms
PRESENTATIONa continuous despite continu- despite continu- despite continu-
and/or
treatment ous treatment ous treatment ous treatment
intermittent
or or or or
symptoms that
do not require intermittent, intermittent, intermittent, intermittent
treatment mild symptoms moderate symp- severe symptoms extreme symp-
despite continu- toms despite despite continu- toms despite
ous treatment continuous ous treatment continuous
treatment treatment
PHYSICAL No current signs Physical find- Constant mild Constant mod- Constant severe
EXAMINATION of disease ings not present physical findings erate physical physical findings
OR PHYSICAL with continuous despite continu- findings despite despite continu-
FINDINGSb treatment ous treatment continuous ous treatment
treatment
or or or
or
intermittent, intermittent intermittent
mild physical moderate intermittent extreme findings
findings findings severe findings
CLINICAL Testing currently Consistently nor- Persistent mild Persistent moder- Persistent severe,
STUDIES OR normal mal with continu- abnormalities ate abnormalities abnormalities
OBJECTIVE TEST ous treatment despite continu- despite continu- despite continu-
RESULTS c ous treatment ous treatment ous treatment
or
or or or
intermittent mild
abnormalities intermittent intermit- intermit-
moderate tent severe tent extreme
abnormalities abnormalities abnormalities
a, b
Descriptors will be disease-specific; mild, moderate, severe, and extreme need to be defined.
c
Descriptors will be disease-specific and based on the number of abnormalities found.
The following is used as a grade modifier in the musculoskeletal chapters:
FUNCTIONAL Asymptomatic Pain/symptoms Pain/symptoms Pain/symptoms Pain/symptoms

HISTORYd with strenuous/ with normal with less than at rest; Unable to
vigorous activity; activity; Able to normal activ- perform self-care
Able to perform perform self-care ity (minimal); activities
self-care activities activities with Requires assis-
independently modification but tance to perform
unassisted self-care activities
d
Based on self-report or scores from the PDQ, QuickDASH, Lower Limb Outcomes Questionnaire, or other self-report tool.
The following will be added in selected chapters when compliance with treatment minimizes objective evidence of organ
dysfunction but results in a significant compromise in ADLs:
BURDEN OF None Will be based on factors such as number and route of medications taken or the
TREATMENT need to regularly undergo diagnostic tests or invasive procedures if not already
COMPLIANCEe considered in the preliminary rating
e
Based on information in Appendix B; depending on the score, the examiner can opt to add 1 to 3 percentage points.
Guides6e_01_001-018.indd 13 2/17/09 2:22:41 PM

Chapter 1
key factor rating, the resulting impairment grade relevant chapters and differ among organ systems
will be modified, assuming the adjustment factor and diseases.
was reliable and not used to define the impair-
9. With the addition of the information from the
ment. In our example, if Physical Findings and
BOTC and the functional history, there is no
Objective Test Results (both non-key factors)
longer any justification for adding any additional
each place a patient into class 3, the final rating
impairment to the final rating to reflect the
will be class 2, (grade E) 27%. If the Physical
impact of medication or treatment side effects, or
Findings correspond to class 3 and the Objective
pain.
Test Results to class 1, the final rating will be
class 2, (grade C) 21%.
1.8d General Principles and Rules for
5. If adjustment of the impairment rating oth- Calculating Impairment
erwise moves the rating to a higher or lower Most impairments are based on the Diagnosis-based
impairment class, the examiner should stop at Impairments (DBI) where Impairment Class is
the highest or lowest grade in the impairment determined by the diagnosis and/or other specific
class initially determined by the key factor. For criteria; this is then adjusted by “non-key” fac-
example, if the Functional History and Physical tors (grade modifiers) that may include Functional
Examination both were rated as consistent History/Assessment, Physical Examination/Findings,
with class 4, whereas the key factor (History and Clinical Studies/Objective Test Results. The
of Clinical Presentation) somehow placed the principles and rules for calculating impairment are
patient in class 2, this would preclude going any shown in Table 1-6.
higher than 27% (grade E), although the exam-
iner might want to be certain that the non-key
factors were, indeed, correct.
6. Use of the middle impairment grade in a given
class as the default value under this new system
would ordinarily leave one with no way to move
a rating in the middle of class 4 (or the highest
TA B L E 1- 6
class in a given impairment table) to an even
higher grade. In these situations, ratings for General Principles and Rules for Calculating
Impairment
non-key factors may be used to move the rating
to a higher grade in class 4 if the information 1. Use “History of Clinical Presentation,” “Physical
Findings,” or “Objective Test Results” as the key
regarding the other factors denotes extreme factor (depending on body part or disease process)
pathology. When relevant, instructions regarding to assign subject to an impairment class in row 3, as
how to make this determination will be provided well as a grade (A–E) for that impairment class as the
in each table. initial whole person impairment rating. If the severity
grade is ambiguous, default to the median grade
7. Some chapters will include an assessment of the (grade C). The key factor always determines the class
within which the final impairment will fall.
Functional History that will be used as one of the
non-key factors to adjust the final impairment 2. Assign classes based on the other (non-key)
impairment criteria from the remaining 2 rows.
rating within a class by using a self-report tool
such as the PDQ, QuickDASH, Lower Limb 3. Increase the initial rating (when another non-key class
assignment is higher) or decrease (when the non-key
Outcomes Questionnaire, or alternative. The class is lower) by 1 or more grades (depending on how
examining physician is to score the self-report great the difference is between the factor rating for
tool and to assess results for consistency and each successive row, compared to the initial key factor
class or grade). Assign the impairment percentage.
credibility before adjusting the impairment rating
This is the preliminary impairment rating for the
higher or lower than the default value. The rating organ system.
physician must provide rationale for deciding that 4. In rare situations one will also calculate the Burden
functional test results are clinically consistent of Treatment Compliance (see chapter specific tables
and credible. or the Appendix) and modify the grade further
based on the result (or even use it as the basis for the
8. Some chapters will include an assessment of impairment class assignment) when no other factors
the BOTC in the impairment rating. These may are easily quantified.
shift the impairment grade in a class higher than 5. Combine the ratings from different organ systems to
it would otherwise be. Details are listed in the come up with a final impairment rating.
Guides6e_01_001-018.indd 14 2/17/09 2:22:42 PM

Chapter 1
1.8e History of Clinical Presentation condition. As tests are the most objective source of
History of Clinical Presentation (row 3 of Table 1-5) data available, the results that would lead to a patient
includes pertinent history and case summary data at being placed in one class, as opposed to another,
MMI that identify an anatomic region or diagnosis must be described as specifically as possible in
being considered, confirm history of illness or the chapter and in the grid itself. Each chapter will
injury, and support the selection of the particular delineate the key factor of the impairment class
disease-specific impairment grid. Historical within a given grid. Tests that identify organ-specific
indicators of severity and chronicity of the condition functional deficits that are not necessarily associated
are included. Symptom listings for each condition with impairment in ADLs, or are predominantly
should be as specific as possible. In general, obtained to develop treatment protocols or assess
individuals with no symptoms or anticipated future prognosis, should be listed in this section, as well
symptoms (although they may have had symptoms as dynamic tests that describe organ function. For
in the past) will be in class 0; those with minimal example, for cardiac disease, an ECG is a relatively
or intermittent moderate symptoms, in class 1; and static test, whereas an ejection fraction could be
those with constant symptoms that persist despite used for the functional assessment. Likewise, for
treatment, in class 4. The middle classes are reserved renal disease the serum creatinine would be the
for those patients whose symptoms fall in between objective test, whereas the creatinine clearance
these in severity. is more indicative of organ function. Typically, a
combination of the key factor and non-key factors
To place individuals into a specific category, the
will be used to determine a place within a class and
evaluator must determine:
grade, and the key factor may vary within chapters
• Whether symptoms are consistent with the or between chapters. Although the default rating for
condition for which the rating is being performed. each class is, by definition, the median grade, the
If not, their impact, if any, will be captured by examiner can adjust this if a suitable rationale is
the functional assessment tool, where relevant. provided.
• Whether symptoms are intermittent, continuous,
1.8h Functional Assessment
or both.
Functional Assessment or History, considers the
• The severity of these symptoms (based on organ functional impact of the condition, disorder, or dis-
system-specific characterizations). ease. Grade assignment for functional symptoms is
based on subjective reports that are attributable to
1.8f Physical Findings the impairment. These reports may include a self-
Physical Examination, or Findings (row 4) identify report tool that is administered, scored, and assessed
pertinent findings on physical examination that for consistency with the clinical presentation, and
corroborate or refute the diagnosis itself, or that for credibility. Functional History Grade Modifier
serve as indicative measures of severity of the should be applied only to the single, highest
particular condition. These should also be as diagnosis-based Impairment. Specific jurisdic-
disease-specific as possible. As was the case for tions may modify this process such that Functional
History of Clinical Presentation, class 0 will be for History Adjustment is considered for each
those patients who may have had findings in the past Diagnosis-based Impairment or not considered at all
but are now healthy (with no expectation that they as a Grade Modifier.
will have recurrent findings), while class 4 is for
those patients with severe continuous findings that 1.8i Determining the Burden of
persist despite treatment (ie, are not controlled by Treatment Compliance
treatment) or with extreme intermittent findings. Complying with the treatment and testing necessary
to maintain oneself in a state that is relatively free
1.8g Objective Test Results of symptoms or signs leads to better systemic func-
Objective Test Results or Clinical Studies (row tion. However, complying with a complicated treat-
5) identify objective tests—for example, X rays, ment regimen does have an impact on ADLs. One
computed tomography (CT), magnetic imaging chapter (endocrine, Chapter 10) uses the BOTC as a
(MRI), laboratory tests, electrocardiography (ECG), key factor to determine impairment class; elsewhere,
electromyography (EMG), and ultrasonography— BOTC may serve as one of the non-key factors to
with specific findings that confirm or validate the help determine the impairment grade in an impair-
diagnosis and/or indicate severity of the particular ment class. The BOTC refers to the impairment
Guides6e_01_001-018.indd 15 2/17/09 2:22:43 PM

Chapter 1
that results from adhering to a complex regimen of References

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Guides6e_01_001-018.indd 18 2/17/09 2:22:44 PM

CHAPTER 2
Practical Application
Chapter 2
of the Guides
2.1 Use of the Guides in Workers’ Compensation

and Other Disability Systems
2.2 Organ System and Whole Body Approach to

Impairment Ratings
2.3 Use of the Guides
2.4 Rules of Application for the Guides
2.5 Concepts Important to the Independent

Medical Examiner
Introduction
2.6 Impairment Evaluation and the Law
This chapter outlines the key concepts, principles,
and rationale underlying the application of the AMA
2.7 Preparing Reports
Guides to impairment rating for all human organ
systems.
The Guides is written by medical doctors for medi-
cal doctors and others permitted to do impairment
evaluations. It is a tool to translate human pathol-
ogy resulting from a trauma or disease process into
a percentage of the whole person. This is achieved
using criteria that are consistent with the pathology.
Thus, to insure reliable impairment estimates, the
assessing doctor must possess the requisite medical
knowledge, skills, and abilities.
Whole person impairment is the result of an impair-
ment evaluation. The whole person impairment is
a percentage based on a consensus of opinion from
multidisciplinary medical specialties and cumula-
tive experience. The whole person impairment rating
ranges from normal (0%) to totally dependent on
others for care (90⫹%) to approaching death (100%).
Although doctors wrote the Guides, this book is not
likely to be used in the practice of therapeutic medi-
cine. The primary purpose of the Guides is to rate
19
Guides6e_02_019-030.indd 19 2/17/09 2:23:09 PM

impairment to assist adjudicators and others in 2.1Use of the Guides in Workers’

determining the financial compensation to be Compensation and Other
awarded to individuals who, as a result of injury or
illness, have suffered measurable physical and/or Disability Systems
psychological loss. The Guides is a reference for
doctors for impairment assessment and is a first step
Chapter 2
2.1a Workers’ Compensation

toward disability assessment. This book has applica-
There is increased use of the Guides to translate
tion to other stakeholders in the adjudicative process
objective clinical findings into a percentage of the
of personal injury claims such as claims profession-
whole person. Typically this number is used to mea-
als, attorneys, and fact finders.
sure the residual deficit, a loss—a number that is
From its inception, the goal of the Guides has been then converted to a monetary award to the injured
to provide a standardized, objective approach to party.1 The scheme is most commonly used in vari-
evaluating medical impairment. Physicians must use ous workers’ compensation systems in the United
their clinical knowledge, skills, and abilities to arrive States and abroad.
at a specific diagnosis; define the pathology; and rate
In the United States, 44 states, 2 commonwealths,
impairments based on the Guides’ criteria. The Sixth
and federal employee compensation systems (in
Edition integrates scientific and medical advance-
about 90⫹% of US jurisdictions) either mandate or
ment using a more valid and reproducible framework
recommend using the Guides to measure impairment
that combines the consequences of anatomic deficit
in workers’ compensation claims. Even in the hand-
with the functional deficit.
ful of states that have not yet adopted the Guides
The key principles of the Guides are summarized in to evaluate impairment in workers’ compensation
Table 2-1. cases, the Guides is often used to assess damages
in personal injury claims under federal statutes and
state common law.
TA B L E 2 -1
Fundamental Principles of the Guides
1. Concepts and philosophy in this chapter are the fundamental principles of the Guides.
2. No impairment may exceed 100% whole person impairment. No impairment arising from a member or organ of the
body may exceed the amputation value of that member.
3. All regional impairments in the same organ or body system shall be combined as prescribed by the rule, at the same
level first and further combined with the other regional impairments at the whole person level.
4. Impairments must be rated in accordance with the chapter relevant to the organ or system where the injury primarily
arose or where the greatest dysfunction consistent with objectively documented pathology remains.
5. Only permanent impairment may be rated according to the Guides, and only after Maximum Medical Improvement
(MMI) status is certified.
6. Impairment evaluation requires medical knowledge. Physicians duly recognized by an appropriate jurisdiction should
perform such assessments within their applicable scope of practice and field of expertise.
7. A valid impairment evaluation report based on the Guides must contain the 3-step approach described in Section 2.7.
8. The evaluating physician must use knowledge, skill, and ability generally accepted by the medical scientific commu-
nity when evaluating an individual, to arrive at the correct impairment rating according to the Guides.
9. The Guides is based on objective criteria. The physician must use all clinical knowledge, skill, and abilities in determining
whether the measurements, test results, or written historical information are consistent and concordant with the
pathology being evaluated. If such findings, or an impairment estimate based on these findings, conflict with established
medical principles, they cannot be used to justify an impairment rating.
10. Range of motion and strength measurement techniques should be assessed carefully in the presence of apparent
self-inhibition secondary to pain or fear.
11. The Guides does not permit the rating of future impairment.
12. If the Guides provides more than one method to rate a particular impairment or condition, the method producing the
higher rating must be used.
13. Subjective complaints that are not clinically verifiable are generally not ratable under the Guides.
14. Round all fractional impairment ratings, whether intermediate or final, to the nearest whole number, unless
otherwise specified.
Guides6e_02_019-030.indd 20 2/17/09 2:23:10 PM

2.1b Federal Systems Ontario, Canada, for the adjudication of personal

Federal systems that use the Guides include the injury claims arising from motor vehicle accidents.
Federal Employees Compensation Act (FECA) and In the United States, although not officially man-
the Longshore and Harbor Workers’ Compensation dated, the Guides is often used to quantify the extent
Act. Federal workers’ compensation laws cover all of injuries resulting from an automobile casualty or
federal employees (including postal workers) and personal injury. Insurers may use an impairment rat-
Chapter 2
citizens of Washington, DC. ing as one of the factors in determining the reserve
or settlement value of a claim. Attorneys may use
Under FECA,2 employees are entitled to neces-
this to quantify the impact of an injury. With no-
sary medical care, wage-loss compensation when
fault insurance, some states restrict access to the
the injury disables them from working, and other
court system to cases reaching a specifically defined
benefits, including scheduled awards. Benefits are
permanent impairment according to each state’s
available under this act to federal employees, Peace
own impairment guidelines threshold. For example,
Corps members, and AmeriCorps VISTA volunteers.
in the province of Ontario, a fixed injury may be
According to the FECA Compensation Schedule,
documented by the presence of physical impairment
benefit is given for permanent impairment to spe-
according to the AMA Guides at a certain threshold.
cific body parts, including extremities, hearing,
vision, and loss of specific organs. Awards are based
on a formula of 66 2/3% of monthly earnings multi-
plied by a specified number of weeks’ compensation
for a specific body part; for the upper extremity this
2.2 Organ System and Whole
includes arm, hand, and individual digits. For a more Body Approach to Impairment
comprehensive review than is possible here of how Ratings
these systems work, readers are referred to texts
available or reviewed elsewhere.3
2.2a Regional vs Whole Person
2.1c International Use of the Guides Impairments
The past 2 decades have also seen the increased use The Guides’ impairment ratings reflect the sever-
of the Guides in jurisdictions outside the United ity of the organ or body system impairment and the
States. For example, several Canadian provinces resulting functional limitations of the whole person.
use the Guides to adjudicate workers’ compensation Impairments must be rated using the chapter most
claims; the province of Ontario uses it to adjudicate relevant to the organ or system where the injury
motor vehicle accident personal injury claims. In primarily arose or where the greatest dysfunction
the mid-1990s, Ontario denied patients involved in consistent with the objectively documented pathol-
motor vehicle accidents access to common-law court ogy remains. Most organ or body system chapters
unless the case involved catastrophic impairment. in the Guides provide impairment ratings based on
Catastrophic impairment was statutorily defined as whole person impairment. Some chapters, such as
at least 55% whole person impairment according to Chapters 15 to 17 (musculoskeletal) and Chapter 11
the Guides. (hearing loss), provide regional impairment ratings
(eg, percent impairment of upper or lower extrem-
This statutorily mandated use of the Guides to adju-
ity) according to separate schedules. These regional
dicate personal injury claims outside the workers’
ratings may be convertible to whole person impair-
compensation arena spread across the globe. New
ment ratings unless jurisdictional contraindications
Zealand has used the Guides for the past decade
exist or otherwise specifically requested by the
to adjudicate all personal injury claims. Likewise,
referring source. For example, some jurisdictions
almost all jurisdictions in Australia currently use the
(eg, Missouri and Hawaii) have separate schedules
Guides to adjudicate workers’ compensation claims
for monetary compensation based on regional vs
pursuant to various statutory schemes. Nearly half
whole person impairment.
the jurisdictions in Australia have also adopted vari-
ous motor vehicle acts requiring that compensatory
2.2b Hierarchy in Whole Person Concept
awards be based on the Guides.
In some musculoskeletal regions, a hierarchy of vari-
ous values, from distal to proximal, is used to reflect
2.1d Automobile and Personal
the relative importance of certain parts in each
Injury Claims
region. For example, the different fingers are given
Use of the Guides is mandated by law in sev-
varying weights when rating hand impairments, and
eral jurisdictions in Australia, New Zealand, and
hand impairments carry greater weight than other
Guides6e_02_019-030.indd 21 2/17/09 2:23:11 PM

F I G U R E 2 -1
Hierarchy in Whole Person Concept for Upper and Lower Extremities
Upper Extremity 100%

Chapter 2
Whole Person 40% 50% 60% 100%
Lower Extremity 100%
parts of the arm when upper extremity impairments 2.2c The Combined Values Chart
are rated. This hierarchy represents the unique and Various organ system impairments in the same
relative importance of each part to the entire region’s individual can be accounted for with 1 numerical
overall functioning. No impairment may exceed value by using the Combined Values Chart (in the
100% of the whole person, nor can any impairment Appendix), which enables the physician to account
arising from a member or organ of the body exceed for the effects of multiple impairments with a sum-
the amputation value of that member. The various mary value. The method of combining impairments
hierarchal relationships of the musculoskeletal sys- is based on the idea that a second or a succeeding
tem are exemplified in Figures 2-1 and 2-2. impairment should apply not to the whole but only to
FIGURE 2-2
Hierarchy in Whole Person Concept for Upper Extremity and Hand
Thumb x .4
Index x .2
Hand
Middle
conv x .9
x .1
Ring
Little
Upper x .6
Extremity
Whole
Person
Guides6e_02_019-030.indd 22 2/17/09 2:23:12 PM

the part that remains after the first and other impair- permanent impairment by analogy is permissible
ments have been applied. Multiple impairments are only if the Guides provides no other method for rat-
combined using a mathematical formula, listed in ing objectively identifiable impairment.
the Combined Values Chart.
2.3a Who Performs Impairment Ratings?
According to this method, multiple impairments are
Impairment evaluation requires medical knowledge;
Chapter 2
successively combined by first combining the larg-
therefore, mostly doctors who are qualified in
est number with the next largest remaining number,
allopathic or osteopathic medicine or chiropractic
and then further combining it with the next largest
medicine use the Guides to evaluate permanent
remaining number, and then further repeating the
impairment. For the purpose of determining impair-
process until all given impairment numbers are
ment, the appropriate health regulatory agency in a
combined. The resulting final impairment value is
given jurisdiction is the best-suited authority to deter-
always equal to or less than the collective sum of all
mine the definition of doctor in regard to who uses the
the impairment values taken individually.
Guides to rate impairment in that jurisdiction.
2.2d Combining Impairments in It must be emphasized, however, that even though
and Between Organ Systems the Guides is mainly written by medical doctors for
To determine whole person impairment where multi- medical doctors and others permitted to do impair-
ple organ systems are involved, the physician should ment evaluations, nonphysician evaluators may ana-
begin with an estimate of the individual’s most sig- lyze an impairment evaluation to determine if it was
nificant (primary) impairment and evaluate other performed in accordance with the Guides.
impairments in relation to it. It may be necessary for
The accurate use of the Guides requires a fundamental
the physician to refer to the criteria and estimates in
understanding of anatomy, physiology, pathology, and
several chapters if the impairing condition involves
other appropriate clinical sciences along with a good
several organ systems. Related but separate condi-
understanding of the issues related to impairment and
tions are rated separately and impairment ratings are
disability assessment. Additionally, the knowledge of
combined unless criteria for the second impairment
key concepts and philosophy underlying the Guides, as
are included in the primary impairment.
outlined in Chapter 1 and here, along with the thorough
The examining physician should avoid duplication understanding of the appropriate chapters of the Guides
and/or inflation of the rating by careful consideration are essential for a credible impairment rating.
of the underlying pathophysiology in relation to the
primary organ system. Nonspecific dysfunction or 2.3b Examiner’s Roles and
dysfunction due to the need to adhere to a complex Responsibilities
treatment regimen will be captured by the rating The physician’s role in performing an impairment
for “Burden of Treatment Compliance” (BOTC; see evaluation is to provide an independent, unbiased
Section 1.8i in Chapter 1 and Appendix B). assessment of the individual’s medical condition,
including its effect on function, and of limitations
to the performance of Activities of Daily Living,
or ADLs (as listed in Table 1-1). Although treating
2.3 Use of the Guides physicians may perform impairment ratings on their
patients, it is recognized that these are not indepen-
As referenced in Chapter 1, the Guides provides con- dent and therefore may be subject to greater scrutiny.
cepts, definitions, and rules to evaluate patients with Performing an impairment evaluation requires con-
injuries or illnesses and to translate this evaluation siderable medical expertise and judgment.
into an impairment number to assist legal and other
Thorough, complete and accurate reporting by
systems to calculate compensation.
the rating physician affords the best opportunity
The Guides is of value only if the medical diagnosis to communicate details of the impairment and its
is correct; an incorrect diagnosis leads to an incor- impact, if any, on the patient, in a forum acceptable
rect impairment rating. The most important element to other medical professionals and interested parties,
of the Guides remains the physician’s accurate diag- such as claims professionals, attorneys, and adjudica-
nosis. The increasing complexity of the Guides does tors. Reporting should follow the format and guide-
not replace the synthesis of clinical judgment with lines set forth by the Guides; this will help ensure
medical knowledge. In fact, the converse is true. The that information provided is consistent, reliable, and
increasing complexity of the Guides and its impair- sufficient to enable a fair and competent determina-
ment ratings requires an accurate diagnosis. Rating tion of benefits to which the patient may be entitled.
Guides6e_02_019-030.indd 23 2/17/09 2:23:12 PM

As an impairment evaluator, the physician must treatment due to declining treatment or treatment
understand the regulations pertaining to medical noncompliance. Additionally, the physician should
practice and evaluations. It is also the physician’s estimate the impairment rating that would be likely if
responsibility to provide the necessary medical the patient had cooperated with the treatment recom-
assessment to the party requesting the evaluation, mendations (if the estimated rating is different from
with the patient’s consent, unless otherwise pro- the one determined at the time of the examination).
Chapter 2
scribed by law. The physician needs to ensure that

the patient understands that the evaluations’ purpose
is for medical assessment, not medical treatment.
The performance of an impairment evaluation does 2.4 Rules of Application
not establish a physician-patient relationship. for the Guides
In some cases, the referring source may ask the
physician rater to assess the medical impairment’s
2.4a Confidentiality
impact on the affected individual’s ability to work.
Before performing an impairment evaluation, the phy-
This is beyond the scope of the Guides; however,
sician should obtain the individual’s consent to share
with acquisition of additional knowledge and skills,
the medical information with the party requesting the
physicians may be able to provide a reasonable opin-
evaluation, unless otherwise prescribed by law.
ion in that regard. This would require, at minimum,
the understanding of the essential functions and vari-
2.4b Consistency
ous tasks of the specific occupation, as well as how
The Guides is based on objective criteria. Subjective
the patient’s medical condition interacts with the
complaints (eg, fatigue, difficulty in concentrating,
occupational demands. In many cases, the physician
sleep difficulties, and weakness), when not accom-
may need to obtain additional consultant expertise
panied by demonstrable clinical signs or other inde-
and input; this guidance will better define job-
pendent, measurable abnormalities, are generally not
related functional abilities and limitations, as well as
given separate impairment ratings. Pain complaints
vocational demands pursuant to such determinations.
are evaluated as explained in Chapter 3.
2.3c When Are Impairment Ratings The physician must use all clinical knowledge, skill,
Performed? and abilities in determining whether the measure-
Only permanent impairment may be rated according ments or test results are consistent and concordant
to the Guides, and only after the status of “Maximum with the pathology being evaluated.
Medical Improvement” (MMI) is determined, as
The examiner must base impairment rating on objective
explained in Section 2.5e. Impairment should not be
factors to the fullest extent possible. Patient subjectivity
considered permanent until a reasonable time has
during the examination process itself may potentially
passed for the healing or recovery to occur. This will
contribute to inconsistency of examination findings and
depend on the nature of underlying pathology, as the
test results; for example, a patient may self-limit during
optimal duration for recovery may vary considerably
the assessment of active range of motion or exert sub-
from days to months. The clinical findings must indi-
maximal effort on manual strength testing by reason
cate that the medical condition is static and well stabi-
of pain and/or apprehension. Physical findings in such
lized for the person to have reached MMI.
cases are often inconsistent and disproportionate. Such
There may be circumstances in which a patient either “symptom magnification” (the display of exaggerated
declines or fails to comply with surgical, pharmaco- pain behavior and self-inhibition of effort out of propor-
logic, or therapeutic treatment of impairment. In such tion to observable pathology), when detected, should
cases, an MMI determination may still be required be appropriately discounted by the examiner without
even when logistical barriers or compliance issues impuning the patient for being unmotivated or malin-
preclude optimal disease control and organ function- gering (see Chapter 14). When such findings clearly
ing. If the patient declines therapy for a permanent appear to conflict with what is expected according to
impairment, that decision does not decrease or established medical principles, they must not be used to
increase the estimated percentage of the individual’s justify an impairment rating.
impairment, nor does it preclude an impairment
evaluation per se. However, the physician should 2.4c Interpolating and Rounding Off
make a written comment in his or her report address- Round all fractional impairment ratings, whether
ing the suitability of the therapeutic approach and the intermediate or final, to the nearest whole number.
basis of the individual’s refusal. The physician should Numbers ending in 0.5 must be rounded up in favor
also indicate that the individual is at MMI without of the patient.
Guides6e_02_019-030.indd 24 2/17/09 2:23:13 PM

2.4d Pain and Suffering Legal probability, then, simply means that some-
The impairment ratings in the body organ system thing is more likely to occur than not (probability
chapters make allowance for most of the functional exceeds 50%). On the other hand, the probability of
losses accompanying pain. It should be recognized an event’s occurrence equal to or less than 50% is
that a zero percent impairment rating in Chapters merely a possibility.
4-17 is a numerical impairment rating. The broader
Chapter 2
impairment rating issues associated with pain are 2.5b Causality, Exacerbation, and
discussed in further detail in Chapter 3. Aggravation
Causality is an association between a given cause (an
2.4e Using Assistive Devices event capable of producing an effect) and an effect (a
in Evaluations condition that can result from a specific cause) with
If an individual must regularly use a prosthesis, a reasonable degree of medical probability. Causality
orthosis, or other assistive device, the physician requires determination that each of the following has
should test and evaluate the organ system with the occurred to a reasonable degree of medical certainty:
device. However, if the assistive device is easily
• A causal event took place.
removable, the examiner may choose also to test
without the assistive device in place and then report • The patient experiencing the event has the condi-
both sets of results. For example, ask the patient to tion (eg, impairment).
remove a hearing aid before testing auditory acuity.
• The event could cause the condition.
The physician may also choose to report alterations
in the individual’s organ function with and without • The event caused or materially contributed to the
use of the device, as well as challenges, if any, that condition within medical probability.
are posed by using the device. It should be noted
Although there are circumstances in which an event
that because of an underlying notion of compensa-
was the sole or primary cause of a given effect, in
tion for anatomic loss, many jurisdictions provide for
many instances patients have preexisting pathology
scheduled impairment ratings for extremity losses
that may have contributed to their current clinical
regardless of the functional restoration due to assis-
condition. Aggravation is a circumstance or event
tive devices.
that permanently worsens a preexisting or underly-
If the assistive device is not easily removable, as with ing condition. The terms exacerbation, recurrence,
an implanted lens, evaluate the organ system’s func- or flare-up generally imply worsening of a condition
tioning with the device in place. Test the visual system temporarily, which subsequently returns to baseline.
with and without the patient’s glasses or contact lenses Exacerbation does not equal aggravation.
in place, if they are used, and report both findings.
2.5c Apportionment
Apportionment is an allocation of causation among
multiple factors that caused or significantly contrib-
2.5 Concepts Important to the uted to the injury or disease and resulting impairment.
Independent Medical Examiner Apportionment requires a determination of percent-
age of impairment directly attributable to preexisting
as compared with resulting conditions and directly
2.5a Legal vs Medical Possibility contributing to the total impairment rating derived.
and Probability In such cases the rating physician may estimate these
Legal terminology defines the association between contributions by first developing the following contin-
an event and an outcome as “probable” if it is more gent ratings as based on earlier work:4
likely than not—if the probability of a cause and
1. A “total” impairment rating (A) (an all-inclusive
effect relationship is greater than 50%. There is a
current rating) is derived irrespective of preexist-
“possible” causal relationship between a putative
ing and resulting conditions.
cause and an event when the likelihood of a causal
relationship is equal to or less than 50%. 2. A second “baseline” rating (B) is derived that
accounts solely for preexisting conditions without
This is in contrast to standards in the scientific and
associated or aggravating reinjury.
medical literature, which require the likelihood that
an association between a potential cause and an effect 3. The final rating (C) is derived in which preexist-
to be greater than 95% for the relationship to be con- ing conditions are discounted by subtracting the
sidered “probable.” Everything else is only possible. second from the first rating (A – B).
Guides6e_02_019-030.indd 25 2/17/09 2:23:13 PM

If apportionment is needed, the analysis must consider does not permit the rating of future impairment. There
the nature of the impairment and its relationship to can be some scenarios with individuals now at MMI
each alleged causative factor, along with an explanation but with potential for future progression of their dis-
of the medical basis for all conclusions and opinions. ease. For example, an individual exposed to asbestos
Using this approach to apportionment requires accu- who is currently stable with perhaps some current
rate information and data to determine all impairment objective findings that are unlikely to change in the
Chapter 2
ratings both before and after the most recent injury. next 12 months but with a potential for malignancy in
If different editions of the Guides have been used, the distant future. Nevertheless, these individuals can
the physician must assess their similarity. If the basis be rated based on the current findings with the nota-
of the ratings is similar, a subtraction is appropriate. tion of a potential for progression in the distant future.
If the bases of the ratings differ markedly, the physi-
Thus, MMI represents a point in time in the recovery
cian should evaluate the circumstances and determine
process after an injury when further formal medi-
whether conversion to the earlier or latest edition of the
cal or surgical intervention cannot be expected to
Guides for both ratings is possible. The determination
improve the underlying impairment. Therefore, MMI
should follow the local jurisdiction’s guidelines and
is not predicated on the elimination of symptoms
consider whichever edition best describes the individ-
and/or subjective complaints. Also, MMI can be
ual’s impairment. If no rating was previously assigned,
determined if recovery has reached the stage where
the examiner must use available information to esti-
symptoms can be expected to remain stable with the
mate what the rating was before the new injury, and
passage of time, or can be managed with palliative
subtract this from the “new” rating as noted earlier.
measures that do not alter the underlying impairment
substantially, within medical probability.
2.5d Changes in Impairment
From Prior Ratings Maximum Medical Improvement does not preclude
Although a previous evaluator may have considered a the deterioration of a condition that is expected to
medical impairment to be permanent, unanticipated occur with the passage of time or as a result of the
changes may occur. The condition may have become normal aging process; nor does it preclude allowance
worse as a result of aggravation or clinical progres- for ongoing follow-up for optimal maintenance of
sion, or it may have improved. The physician should the medical condition in question.
assess the current state of the impairment according
In certain instances, the treatment of an illness may
to the criteria in the Guides. If an individual received
result in apparent total remission of the person’s
an impairment rating from an earlier edition and
signs and symptoms. However, if the examiner con-
needs to be reevaluated because of a change in
cludes that with such permanent treatment based
the medical condition, the individual is evaluated
on objective findings, the patient has actually not
according to the latest information pertaining to the
regained his or her previous function, and if the
condition in the current edition of the Guides.
Guides has not provided specific criteria to rate such
Valid assessment of a change in the impairment impairment, the physician may choose to increase
estimate depends on the reliability of the previous the impairment estimate by a small percentage
estimate and the evidence on which it was based. If a (eg, 1% to 3%). Such a discretionary impairment is
prior impairment evaluation was not performed, but provided only once and is not to be duplicative of
sufficiently well documented information is avail- impairment provided for BOTC.
able to currently estimate the prior impairment, the
In some instances, as with organ transplant recipi-
assessment would be performed based on the most
ents who are treated with immunosuppressant phar-
recent Guides’ criteria. However, if the information
maceuticals or persons treated with anticoagulants,
is insufficient to accurately document the change, the
the pharmaceuticals themselves cause impairments.
physician must explain the basis of a prior determi-
In such instances, if the impairment is permanent,
nation and should not estimate the change.
the physician should use the applicable parts of
the Guides to evaluate actual impairment related
2.5e Maximum Medical Improvement
to pharmaceutical effects and combine it with the
Maximum Medical Improvement refers to a status
primary organ system impairment, by means of the
where patients are as good as they are going to be
Combined Values Chart (Appendix).
from the medical and surgical treatment available to
them. It can also be conceptualized as a date from
2.5f Permanency
which further recovery or deterioration is not antici-
Permanency is the condition whereby impairment
pated, although over time (beyond 12 months) there
becomes static or well stabilized with or without
may be some expected change. The Guides, however,
Guides6e_02_019-030.indd 26 3/3/09 4:48:07 PM

medical treatment and is not likely to remit in the

future despite medical treatment, within medical Cultural Differences Examples
probability. This term is usually synonymous with
The examiner must be cognizant of the differ-
MMI, usually occurring when all reasonable medi-
ence in the patient’s fundamental cultural values
cal treatment expected to improve the condition has
and the traditional Western medical view. The
been offered or provided.
Chapter 2
following are examples of essential differences in
Impairment ratings are to be performed when an philosophy toward disease and injury. American
individual is at a state of permanency. However, Native Indians may believe illness is a price
many systemic or organ-based conditions are to be paid for past or future personal deeds.
dynamic rather than static in nature and are, to some Individuals from hierarchal cultures, such as
extent, never at permanency. In such cases, one can traditional Asian and Hispanic cultures, are less
usually anticipate future functional decline based on likely to disagree with a physician out of respect
the natural history of the disease process, which is for the physician’s education and experience.
generally well established in the literature. This may lead a patient to be reluctant to answer
open ended questions or to try and guess the
2.5g Cultural Differences answer desired by the physician when answering
Cultural differences between the examiner and the such questions. They are also likely to view the
patient can greatly increase the risk of the examiner physician as an authoritative figure and as such
misinterpreting the patient’s responses.5 For example, be reluctant to participate in physician-patient
Waddell’s signs are not valid in non-Anglo cultures, decision making, since the physician is expected
as their reliability has been tested only among to know the correct treatment. Both cultures are
English and North American patients. Effective also likely to seek care outside of the western
medical communication requires an understanding medicine. Asians expect to experience some dis-
of and respect for the patient’s cultural background, tance between the provider and themselves and
religious beliefs, and ability to assimilate medical may be uncomfortable with social physical con-
information. Examiners are expected to use quali- tact. Hispanics, however, generally prefer a social
fied interpreters—not family members or untrained situation and are more comfortable if the encoun-
office staff—for impairment rating examinations. ter includes some conversation about family and
some physical contact such as a hand shake. In
Sensitivity and awareness are the keys for examin-
cultures where physical ability is considered an
ers. The examiner should ensure the involvement of
essential element of masculinity, males may suf-
a qualified interpreter for the impairment examina-
fer extreme psychological distress over a physical
tion. In most systems the insurers are required to
impairment that decreases their earning capacity
pay for the interpreter, but frequently the examiner
and lowers their internal sense of masculinity5.
must request the interpreter. When the examiner has
Naturally, no generalization represents a culture
established a level of comfort with the patient, ques-
accurately and all patients must be treated as
tions about what the patient believes caused the con-
individuals.
dition and who has advised and/or treated them can
be very revealing and lead to an accurate impairment
rating. When patients from a different culture have
an unexpected response to treatment of their condi- the doctor’s assertions, and doctors are increasingly
tion, consider cultural differences. faced with the challenge of litigants demanding
multiple opinions.
In the legal context, an impairment evaluation is
a form of expert testimony. The use of the Guides
2.6 Impairment Evaluation requires the physician to use the same skills, knowl-
and the Law edge, and ability as in the therapeutic practice of
medicine in the collection of data and making of an
Physicians have traditionally been regarded as an accurate diagnosis. The Guides then is used to chan-
authority in their craft and are accustomed to getting nel that information and translate it into an impair-
their opinions accepted as the final truth.6 However, ment number.
in a legal proceeding, the physician’s opinion when
Judicial decisions state that arbitrary and dogmatic
unsupported by established science can lead to chal-
opinions, even from well-qualified experts, are not
lenges and cause needless frustration and anxiety for
held credible. Therefore, doctors providing inde-
the physician and others. Contemporary adjudication
pendent medical examinations and expert testimony
process increasingly questions the science behind
Guides6e_02_019-030.indd 27 2/17/09 2:23:14 PM

must be aware that their opinions must be supported valid. Review of all available diagnostic studies and
by scientific evidence or they risk losing credibility. laboratory data is critical in this step.
The physician users of the Guides must use objective
criteria and all available clinical knowledge, skill, 2.7b Analysis of the Findings
and abilities in deciding whether the measurements Discuss how specific findings relate to the conclusion
and/or test results are consistent and concordant with of diagnoses and MMI status. Refer to the current abili-
Chapter 2
the pathology being evaluated. If such findings, or ties of ADLs and any validated deficiencies. Explain
the impairment estimates based on these findings, the absence of any pertinent data and how the physician
conflict with established medical principles, they determined the impairment rating with limited data.
must not be used to justify an impairment rating.
2.7c Discussion of How the Impairment
Rating Was Calculated
Discussion of how the Guides’ criteria were applied
2.7 Preparing Reports to medical information that generated the specific
rating is required for an impairment evaluation to be
A clear, accurate, and complete report must be pro- consistent with the Guides. Compare the appropri-
vided to support a rating of permanent impairment. ate information obtained on history and objective
The following 3-step process is required by the exam- findings with the criteria described in the applicable
iner to estimate impairment according to the Guides: chapter of the Guides. Include an explanation of each
clinical evaluation, analysis of the findings, and dis- impairment value with reference, including pages
cussion of how the impairment rating was calculated. and table number, to the applicable criteria of the
Guides. Combine multiple impairments for a final
2.7a Clinical Evaluation composite whole person impairment number, unless
The relevant history is obtained by a review of medi- otherwise directed by jurisdictional application.
cal records reflecting past medical history and the Discuss how individual ratings were combined or
patient’s presentation of the current history. It is added to create a final number; explain why certain
important to review medical records before perform- ratings were disregarded in the final analysis due to
ing an impairment rating, as this will enable the invalid measurements and test results; and perform
examiner, among other things, to: apportionment, where applicable. Include a summary
list of impairments and impairment ratings by per-
• Clarify or at least document inconsistencies, if any,
centage, including calculation of the whole person
between the history provided by the patient and
impairment, as appropriate.
the history contained in the medical records.
A standard report format Figure 2-3, that the evalu-
• Reconcile inconsistencies, if any, between the
ator may use is provided in this chapter; the purpose
patient’s history during the examination and other
of this form is to ensure that all essential elements
previous medical records. It is necessary to clarify
are included in the impairment evaluation report.
historical inconsistencies because several issues,
This form may be reproduced without permission
including causation, are primarily determined by
from the American Medical Association.
the history.
When relevant chapters include a data collection form
• Focus on the portions of the history pertinent to
or summary form that identifies the specific features
the impairment rating.
to consider for each category of organ system impair-
The physical examination should be performed in ment, it must be used to document the data and be
a manner and setting that facilitates the effective attached with the final report. This will ensure that
communication between the patient and the exam- the process of impairment evaluation according to the
iner, thereby decreasing anxiety and increasing Guides is transparent and is subject to understanding
concentration and effort. If the examiner believes by all parties interested in the outcome.
the patient may be giving an inconsistent effort dur-
The 3-step process described in this section applies
ing the physical examination, the patient should
to rating all organ systems. Although the underly-
be encouraged to give a full effort. For extremity
ing impairment evaluation criteria may differ, the
impairment evaluations, findings should be docu-
process is essentially the same for rating all organ
mented bilaterally; if the contralateral extremity is
systems. The first 2 steps must be performed by a
uninjured, this may serve as the baseline for defining
licensed physician, and if the clinical findings are
“normal” for the impaired extremity. The results of
fully described, any knowledgeable observer may
specific measurements must be reproducible to be
check the findings against the Guides’ criteria.
Guides6e_02_019-030.indd 28 2/17/09 2:23:14 PM

Standards of Legal Admissibility

The standards for the admissibility of the expert testimony to provide medical and scientific evidence have
been around in American Jurisprudence since the Frye case in 1923, which established the “general accept-
ability by the scientific community” standard for admissibility of an expert witnesses scientific opinion.
Chapter 2
In 1975, the U.S. Congress codified the rules for expert witness testimony in Rule 702 of Federal Rules of
Evidence, which essentially means that if scientific, technical or other specialized knowledge will assist
the judge or jury to understand the evidence or to determine a fact in issue, a witness qualified as an expert
by knowledge, skill, experience, training or education, may testify about these issues in the form of expert
opinion testimony.
Rule 702 was recently modified in December, 2002 by Congress incorporating the various U.S. Supreme
Courts decision over the past decade in this area of the law beginning with Daubert vs Merrell Dow
Pharmaceuticalsa, and its progeny (General Electric vs Joinerb, and Kuhmo Tire Company vs Carmichaelc).
This body of U.S. Supreme Court case law is now codified by a modified Rule 702, which sets forth the
appropriate review standards for the federal courts with regard to the admissibility of scientific and expert
opinion. These legal standards make the judge responsible for ensuring that scientific evidence proffered in
the form of expert testimony is reliable and reproducible. Everything from Guides and standards of impair-
ment and disability to causality opinions in various tort claims are challengable under these standards. One
should remember, though, that these federal rules of evidence do not generally apply in state and other court
systems; non-federal jurisdictions in some instances have their own rules of evidence.
With regard to the admissibility of expert opinion and scientific evidence, few cases have been as widely
feared by expert witnesses and misunderstood as Daubert. This was the U.S. Supreme Court’s attempt to pro-
vide a broad, discretionary gate keeping power to federal trial court judges. This power is to be exercised via a
nonexclusive list of tests used to determine whether the scientific theory of methodology underlying the opin-
ion of an expert witness before them is reliable. Daubert tests include peer review of the method, testability
and falsifiability (known error rate) of the scientific theory. Additionally, the judge may still consider “general
acceptance” by the scientific community, the old Frye test.
Although Daubert broadened the scope of federal judge authority by adding several other tests, it must be
recognized that the tests for admissibility of expert opinion or scientific testimony described in Daubert are
not an all exclusive checklist, but rather a general guideline. Subsequent U.S. Supreme Court decisions, such
as Kuhmo Tire Company vs Carmichael, have further clarified this authority and have extended Daubert’s
approach to other kinds of expert testimony, including medical testimony.
What does this all mean to the independent medical examiners offering medical expert testimony in legal
proceedings? The U.S. Supreme Court said it best in General Electric vs Joiner: “The court need not accept
testimony of an expert which is connected to existing data only by the Ipse Dixit of the expert”.
a
Daubert v. Merrell Dow Pharmaceuticals, 509 U.S. 579, 113 SCt. 2786, 125 L.Ed.2d 469 (1993).
b
General Electric Co. v Joiner, 522, US 136, 139, 118 SCt 512 (1997).
c
Kuhmo Tire v Carmichael, 526 US 137, 119 SCt 1167, 1174 (1999).
4. McBride ED. Disability Evaluation and Principles

References of Treatment of Compensible Injuries. 6th ed.
Philadelphia, JB Lippincott Co, 1963.
1. Ranavaya MI, Andersson GB. The impairment and 5. Spector R. Cultural Diversity in Health and Illness. 6th
disability evaluations In: Mayer TG, Gatchel RJ, Polatin ed. Upper Saddle River, NJ: Pearson Education Inc; 2004.
PB, eds. Occupational Musculoskeletal Disorders:
Function, Outcomes & Evidence. Philadelphia, Pa: 6. Guidotti TL, Rose SG. Science on the witness stand:
Lippincott, Williams & Wilkins; 2001. evaluating scientific evidence. In: Guidotti TL, Rose
SG, eds: Law, Adjudication, and Policy. Beverly Farms,
2. Federal Employees’ Compensation Act. Available at Mass: OEM Health Information; 2001.
http://www.dol.gov/esa/regs/compliance/owcp/fecafact.
htm. Accessed June, 2007.
3. Katz RT, Rondinelli RD. Major U.S. disability and
compensation systems graphically compared. Phys Med
Rehabil Clin N Am. 12: 499–501, 2001.
Guides6e_02_019-030.indd 29 2/17/09 2:23:15 PM

FIGURE 2-3
Sample Report for Permanent Medical Impairment
Patient Name: Birthdate: Sex: M F

Address: Phone:
Chapter 2
ID Number: Exam Date: Injury Date:

Diagnosis:
Introduction: Purpose (impairment or IME evaluation, personal injury, workers compensation) and proce-
dures (who performed the exam, patient consent, location of examination)
History of Clinical Presentation:
Functional History:
Physical Examination or Physical Findings:
Clinical Studies or Objective Test Results:
Burden of Treatment Compliance: (when applicable)
Impairment Rating and Rationale: Organ System and Whole Person Impairment (WPI)
Body Part or System Chapter Number, Key Factor Grade Modifiers for: Final Class and Whole Person
Page Number, and Class Functional History, Physical Grade Used in Impairment (%)
Table Number Exam, Clinical Studies & Rating
BOTC (if applicable)
1.
2.
3.
Calculated Total Whole Person Impairment: %
Discussion of Rationale of Impairment and any Possible Inconsistencies in the Examination:
Recommendation: (Further diagnostic or therapeutic follow-up care)
Work Ability, Work Restrictions: (if requested, review abilities and limitations in reference to essential
job activities)
Examining Physician: Printed Name: Signature:
Date: Examination Location:
Guides6e_02_019-030.indd 30 2/17/09 2:23:16 PM

CHAPTER 3
Pain-Related Impairment
Chapter 3
3.1 Definition and Classification of Pain
3.2 Controversies Surrounding Pain-Related

Impairment
3.3 The Rating System
3.4 Future Directions—Need for Research

and Dialogue to Establish the Validity of
Rating Pain-Related Impairment
3.5 Conclusion
3.6 Examples
Introduction
The assessment of impairment associated with
3.7 Appendixes
chronic pain creates vexing problems for any impair-
ment rating system. Experts have disagreed about the
usefulness and questioned the validity of the rating
systems for pain-related impairment (PRI) described
in previous editions of the Guides, and these dif-
ficulties have continued throughout the development
of the current chapter.
Several factors contribute to the controversies that
have surrounded PRI:
• There are fundamental conceptual problems when
pain is construed as a cause of impairment, pri-
marily because there is no objective way to quan-
tify pain or its variable effects on the individual.
• Empirical data are sparse about the role of pain
in impairment. As a result, both proponents and
opponents of PRI must rely on rhetoric rather than
scientific data when they support their positions.
• Whereas much of the AMA Guides’ system reflects
consensus among experts in various areas of medi-
cine, consensus about the appropriate role of PRI
31
Guides6e_03_031-046.indd 31 2/17/09 2:24:04 PM

has been lacking. At one extreme, some experts in currently viewed as the most heuristic perspective
pain medicine have argued that PRI should be given to the understanding, assessment, and treatment of
a prominent role in the Guides, and that the PRI chronic pain disorders, and has replaced the outdated
rating system should permit high percentages of biomedical reductionist perspective.3–7 This biopsy-
whole person impairment (WPI) to be awarded for chosocial approach views chronic pain as a complex
chronic pain. In contrast, others have argued that and dynamic interaction among biological, psycho-
PRI should be dispensed with altogether. logical, and social factors that perpetuates, and may
even worsen, the clinical presentation. Each person
• The arguments for and against the inclusion of PRI
will experience a chronic pain condition uniquely,
in the Guides have not been articulated in pub-
thus accounting for the great individual differences in
lished articles and thus have not been subjected to
how pain is expressed. The complexity of a chronic
the public scrutiny that would be expected for such
pain disorder is especially evident when it persists
an important topic. A consequence is that the pres-
over time, as a range of psychosocial and economic
ent authors have had to rely primarily on informal
factors can interact with pathophysiology to modu-
Chapter 3
data sources as we discuss the arguments for and

late a patient’s report of discomfort and disability
against PRI.
associated with chronic pain. Moreover, even as
healing occurs, all patients experience some degree
of physical deconditioning associated with stiffness
and muscle atrophy in the injured area. Risk factors
3.1 Definition and Classification for profound deconditioning with the injured area
of Pain becoming a “weak link” include extended periods of
inactivity, inhibition of function due to pain, and fear
avoidance. In striking contrast, the traditional and
3.1a Definition of Pain
outdated biomedical approach assumes that all pain
The International Association Study of Pain defines
symptoms have specific physical causes, and attempts
pain as “an unpleasant sensory and emotional expe-
to eradicate the cause directly by identifying and
rience associated with actual or potential tissue dam-
rectifying the presumed pathophysiology. However,
age or described in terms of such damage.”1 Pain is
chronic pain can rarely be understood by the linear,
a prominent symptom in many acute injuries and
nociceptive mechanism. As will be discussed later in
illnesses, and often subsides as the medical condi-
this chapter, there is often an absence of a document-
tion resolves. Since such acute pain is usually short
able relationship between pain and pathophysiology.
lived, it is not a problem that is considered in an
impairment rating system. However, chronic pain is With the above biopsychosocial perspective in mind,
a problem that potentially could be the cause for an CPS can be described as pain that continues beyond
impairment rating. The definition of chronic pain is the normal healing time for the patient’s diagnosis and
imprecise but, in a general way, it refers to pain that includes significant psychosocial dysfunction. It should
persists over time. For the purposes of the Guides, be noted that this definition does not include any
chronic pain is defined as pain that persists beyond specific time frame to use in making the diagnosis of
the expected healing time of the medical disorder CPS. This omission is intentional and reflects clinical
thought to have initiated the pain. For many sections reality, in that some conditions would be expected to
in the Guides, chronic pain will be pain that per- resolve in several days and others in several months or
sists beyond 3 months, as most common conditions even years. The diagnosis of CPS should then be tem-
affecting the musculoskeletal and other organ sys- porally connected to the point at which a given con-
tems will substantially heal in this time frame. The dition or conditions were expected to have resolved,
nervous system is a notable exception. Although any rather than to any arbitrary time period for an injury or
time point is arbitrary, 3 months should encompass event. Regardless of when it occurs, CPS is a condition
the expected healing time in most situations where that ultimately adversely affects the patient’s well-
there is tissue injury but will allow for situations in being, level of function, and quality of life. The major
which there is no expected healing time.2 characteristics associated with CPS include the follow-
ing, with 3 or more required for a diagnosis:
3.1b Chronic Pain Syndrome
• Use of prescription drugs beyond the recom-
In both the Fourth and Fifth Editions of the Guides,
mended duration and/or abuse of or dependence on
a definition of chronic pain syndrome (CPS) was
prescription drugs or other substances.
included that captured the major biopsychosocial
characteristics of chronic pain. Indeed, the biopsy- • Excessive dependence on health care providers,
chosocial approach to chronic pain and disability is spouse, or family.
Guides6e_03_031-046.indd 32 2/17/09 2:24:06 PM

• Secondary physical deconditioning due to disuse rates in pain-specific neurons that are connected
and/or fear-avoidance of physical activity due to pain. to the spinal cord. The next step in nociception—
transmission of pain signals—occurs through the
• Withdrawal from social milieu, including work,
conduction of nerve impulses along the peripheral
recreation, or other social contacts.
nerves to the dorsal horn of the spinal cord, where
• Failure to restore pre-injury function after a peri- the impulses activate second-order neurons that, in
od of disability, such that the physical capacity is turn, relay the pain signals through the thalamus to
insufficient to pursue work, family, or recreational the cerebral cortex where pain perception occurs.
needs. Modulation of the incoming pain signal can occur
at many points along the nociceptive pathway, and
• Development of psychosocial sequelae after the
many of the pain treatments available today influ-
initial incident, including anxiety, fear-avoidance,
ence the perception of pain by influencing the degree
depression, or nonorganic illness behaviors.
of modulation of the incoming pain signals. Thus,
nociceptive pain refers to pain that arises through
Chapter 3
3.1c Nociceptive Pain
the normal activation of pain pathways (ie, the noci-
Nociception refers to the normal series of physio-
ceptive system). Nociceptive pain serves as an essen-
logic events that links tissue injury to the perception
tial protective mechanism. It alerts the individual
of pain (Fig 3-1).8 The process begins with trans-
to the presence of potentially damaging stimuli and
duction of a stimulus at the site of injury; chemi-
warns that person to protect the affected area until
cal, mechanical, and thermal stimuli all can elicit
tissue healing ensues. Once the inciting stimulus is
responses in specific subsets of neurons that carry
removed and tissue healing has ensued, nociceptive
pain stimuli. These stimuli result in increased firing
pain typically resolves.
F I G U R E 3 -1
Nociception
Sequence of normal physiologic events leading to pain perception begins with transduction of a potentially tissue- damaging
noxious stimulus (chemical, thermal, or mechanical) into nerve impulses. Transmission of nerve impulses occurs along the
peripheral nerve toward the dorsal horn of the spinal cord, where signals are relayed via second-order neurons to the cere-
bral cortex, where they result in pain perception. The magnitude of the incoming pain stimuli undergoes modulation by
descending inhibitory traffic; this modulation is the mechanism underlying the analgesia produced by both endogenous and
exogenous opioid analgesics.
PERCEPTION
Cortex
MODULATION
Thalamocortical
projections Thalamus
TRANSMISSION
TRANSDUCTION
Spinothalamic
tract Primary
Afferent
Nociceptor Noxious
Stimulus
Adapted from Katz N, Ferrante FM. Nociception. In: Ferrante FM, VadeBoncouer TR (editors). Postoperative Pain
Management. New York, NY: Churchill Livingstone, 1993.
Guides6e_03_031-046.indd 33 3/3/09 4:48:51 PM

3.1d Neuropathic Pain • Paresthesias/dysesthesias—abnormal pain dis-

Traditionally, neuropathic pain has been defined as tant from the site of actual tissue injury that may
pain caused by abnormal function of the nervous be spontaneous or evoked (eg, the radiating pain
system due to injury or disease. A key feature of associated with lumbar nerve root compression).
neuropathic pain is that, although an affected indi-
• Hyperalgesia—an exaggerated painful response
vidual perceives pain as emanating from some bodily
to a normally noxious stimulus (eg, light pinprick
structure (eg, the distal lower extremity in sciatica, the
leads to extreme and prolonged pain).
radial aspect of the hand in carpal tunnel syndrome),
the pathophysiologic basis for the pain is an abnor- • Allodynia—a painful response to a normally
mality in the functioning of the nervous system, rather nonnoxious stimulus (eg, light touch causes pain).
than an abnormality in the “end-organ” where the
Pain specialists and neurobiologists are divided on
pain is perceived. Thus, the simple relation between
the question of whether pain secondary to nervous
end-organ damage and pain perception found in noci-
system sensitization, such as that believed to occur
ceptive pain is absent in neuropathic pain.
Chapter 3
in patients with fibromyalgia, should be construed

Neurobiologic research during the past 20 years has as a form of neuropathic pain.12 For purposes of
conclusively demonstrated that injury and accom- rating PRI, however, pain associated with nervous
panying nociception can induce functional changes system sensitization is similar to neuropathic pain
in the nervous system that lead to something akin to in that an individual’s perceptions of pain are dis-
neuropathic pain. Activation of peripheral nocicep- sociated from end-organ injury or dysfunction. If
tive nerve fibers almost immediately modifies the anything, pain associated with nervous system sen-
nerve’s response to further stimuli. Nociceptive stim- sitization is even more elusive than traditional neu-
ulation results in the release of neurotransmitters and ropathic pain. The reason for this is that, although
peptides that increase the excitability or “sensitize” the link between end-organ dysfunction and pain
sensory neurons.9 This peripheral sensitization is is severed in neuropathic pain, there is typically
associated with an increased sensitivity to mechani- objectively measurable damage to the nervous sys-
cal and thermal stimuli, and results in reports of pain tem. In contrast, individuals suffering from pain
to normally nonpainful stimuli (allodynia) and an associated with nervous system sensitization fre-
increase in the magnitude of pain caused by noxious quently do not have objective evidence of damage
stimuli (hyperalgesia). Increased input from periph- or dysfunction, either in the end-organ where the
eral nociceptive neurons, in turn, leads to alterations pain is perceived or in the nervous system.
in the spinal cord dorsal horn, both disinhibition
and increased responsiveness of central neurons.10 3.1e Persistent Pain as a Disease Entity
This central sensitization can lead to a number of Persistent pain is a major health problem, with
symptoms and signs, including spontaneous pain, between 18% and 50% of the population report-
spreading pain, and hypersensitivity to touch and ing continuous pain for at least 3 of the last 6
extremes of temperature. Indeed, such increased months.13–15 Chronic pain has been linked with
responsiveness to stimuli has been demonstrated in significant disability.16 Although pain has been
patients with chronic pain following whiplash injury traditionally regarded as a symptom that serves as
and in those with fibromyalgia.11 The processes of a warning signal of an underlying disease process,
peripheral and central sensitization are a normal there is accumulating evidence that persistent pain
consequence of tissue injury, and they offer signifi- should be considered a disease entity in its own
cant protection to the organism; after tissue injury, right.2 Indeed, permanent changes in the respon-
sensitization serves as a reminder that the region is siveness of both the peripheral and central nervous
injured and should be closely guarded until the tissue systems can persist even after all tissue healing
has healed. However, the same neuronal mechanisms has ensued; thus, persistent pain can become a
can lead to persistent pain even after all evidence of self-perpetuating condition. The individual is
the initial inciting disease or injury have resolved. often left with ongoing pain without identifiable
This persistent sensitization can subserve pain per- signs of the original inciting disease process that
ceptions that share key features with neuropathic initiated the pain. This results in a multitude of
pain as defined above, including: consequences that can lead to significant impair-
ment for the individual affected, including physi-
• Spontaneous Pain—pain that occurs without a
cal impairment, mood dysfunction, and social
specific sensory stimulus (eg, the sudden lanci-
disruption. This is in keeping with the earlier bio-
nating pain described by those with postherpetic
psychosocial perspective of CPS.
neuralgia).
Guides6e_03_031-046.indd 34 2/17/09 2:24:07 PM

3.2 Controversies Surrounding Pain is the subjective factor that is considered in this
Pain-Related Impairment chapter for the practical reason that it is the one most
commonly encountered when impairment ratings
according to the Guides are performed. However, it
3.2a Practical Problems With Rating is not the only subjective factor that can contribute
Pain-Related Impairment to the burden of illness imposed by a medical condi-
tion. For example, in addition to pain, the burden
Subjectivity of Pain
of illness associated with medical disorders can be
Impairment is defined in Chapter 1 of the Guides as
increased by other subjective factors such as fatigue
“a significant deviation, loss, or loss of use, of any
or emotional distress. Moreover, psychiatric disor-
body structure or body function in an individual
ders are characterized by subjective processes such
with a health condition, disorder, or disease.” An
as anxiety or hallucinations that are not amenable to
impairment rating is defined as a “consensus-derived
assessment via objective methods such as laboratory
percentage estimate of loss, which reflects severity
or imaging studies. Thus, the challenge of assessing
Chapter 3
of impairment for a given health condition, and the
subjective factors is crucial to the determination of
degree of associated limitations in terms of ADLs”
impairment associated with mental illness.
as traditionally defined by the domains of personal
mobility and self-care.
Level of Analysis: Body Parts vs Whole Person
As these definitions indicate, impairments are Another conceptual problem with any PRI is that
viewed as biomedical abnormalities that can be pain and its effects need to be analyzed at the level
analyzed at the level of organs or body parts. Also, of the whole person, rather than at the level of a spe-
the implicit assumption throughout the Guides is cific organ or body part. People with chronic pain
that impairments should be assessed on the basis of typically attribute their pain and activity limitations
objective medical data, rather than on the basis of to dysfunction of an organ or body part. But these
the self-reporting of patients. Thus, for example, a subjective reports are difficult to assess precisely
physician could assess renal impairment on the basis because examination of the involved organ or body
of creatinine clearance or cardiac impairment on the part often does not identify abnormalities that make
basis of ejection fraction. the pain reports inevitable.17 It often appears to an
observer that the affected organ or body part is
A key feature of pain is its subjectivity. Physicians
capable of functioning, but that the patient does not
and other observers can make inferences about a
use it normally because of pain. In keeping with the
patient’s pain but cannot directly experience it. To
biopsychosocial perspective, the observer must con-
examine the significance of this feature of pain, it
sider the person as a whole in order to make sense of
is useful to conceptually divide factors that might
the situation. Thus, the assessment of incapacitation
be considered in impairment ratings into 2 groups:
secondary to pain violates the tenet that impair-
(1) objective factors such as atrophy of a limb or
ment evaluations should assess the functioning of
reduced ejection fraction and (2) subjective factors
organs or body parts, rather than the functioning of
such as pain. Whereas objective medical factors
an individual as a whole. However, this tenet, which
are assessed via methods (eg, laboratory assays or
is based on the outdated biomedical reductionist
imaging studies) that are unrelated to the subjec-
approach, needs to be seriously questioned in light of
tive experiences and communications of a patient,
the more recent heuristic biopsychosocial approach
the assessment of subjective factors requires an
to chronic pain.
examiner to interpret the communications of the
patient, and to use these communications to infer the
Pain as Isolated Problem vs
patient’s subjective experiences.
Component of Medical Conditions
In terms of the dichotomy between objective and Another conceptual challenge related to PRI is that
subjective factors, the Guides strive to base impair- pain is not something completely distinct from organ or
ment ratings on objective factors insofar as possible. body part dysfunction. Rather, it is usually most appro-
This principle is violated by any system that rates priate to construe pain as a “component” of a medi-
impairment associated with pain. Some experts cal disorder. From this perspective, it is arbitrary to
argue that such a violation represents a fundamental examine the significance of pain in isolation from the
deviation from the central purpose of the Guides medical condition underlying the pain, just as it would
and question why the basic logic of the Guides be arbitrary to evaluate shortness of breath in isolation
should be compromised in order to include pain in from congestive heart failure. It would be more concep-
impairment ratings. tually appropriate to evaluate a medical disorder as an
Guides6e_03_031-046.indd 35 2/17/09 2:24:08 PM

entity with characteristic signs, symptoms, pathophysi- the inclusion of PRI in the Guides is compatible with
ology, and potential organ or body part dysfunction. An the overall conceptualization of the AMA system
impairment rating based on such an evaluation would presented in Chapters 1 and 2.
take into account all the manifestations of the disor-
der, including pain. In fact, this edition of the Guides 3.2b Fundamental Concepts in
does, for the most part, construe pain as one of many Determining Pain-Related Impairment
manifestations of injuries or diseases, and impairment
Specious Issues
ratings attempt to take into account the pain that typi-
Even if one accepts the premise that PRI can be
cally occurs in various disorders. Unfortunately, this
construed as a type of impairment because pain can
intuitively plausible approach to incorporating pain
diminish an individual’s ability to perform ADLs,
into impairment ratings sometimes runs into either of
several arguments against the inclusion of a system
2 complicating situations. First, it may well be the case
for rating PRI can be raised. As discussed below, we
that pain severity does not correlate well with objective
consider some of these arguments to be specious,
indicators of organ or body part dysfunction. In fact,
Chapter 3
but others to be crucial. Arguments that have been

empirical scientific research has consistently demon-
raised by proponents and opponents of including PRI
strated that there is often a low concordance or correla-
in the Guides are described in Appendix 3-3 at the
tion among self-report of pain, behavioral functioning
end of this chapter.
such as ADLs, and physiologic indexes.3,18 In such a
situation, impairment ratings based strictly on objective • The argument that PRI should not be included in
factors are likely to fail to capture the burden of illness the Guides because of the subjectivity of pain is a
of the disorder. theoretical one, related to the fundamental purpose
of the Guides. If this purpose is solely to evaluate
A second and more difficult situation is that some
an abstract construct labeled “impairment,” the
conditions are associated with severe pain but are
argument is valid. However, we believe that the
not amenable to conventional impairment ratings
ultimate purpose of impairment rating is to deter-
because they are not associated with unequivocal
mine the burden of illness borne by individuals
objective factors. In these conditions, it is not possi-
with various medical problems, so that they can be
ble to make impairment ratings on the basis of objec-
compensated fairly. The burden of illness associ-
tive factors. Common examples include headache
ated with a medical condition is best approximated
disorders and fibromyalgia.
by the impact of the condition on an individual’s
ability to perform ADLs. From this perspective,
Resolution of Conceptual Conundrums
all factors that influence ADLs—including subjec-
Some people might conclude that the problems
tive ones—should, in principle, be included in the
listed in this section are conceptual conundrums that
AMA system.
preclude the incorporation of PRI into the Guides’
system. However, we believe that the conceptual • The argument that PRI should not be included in
foundation of the AMA Guides (as articulated in the AMA system because of a lack of empirical
Chapters 1 and 2) is compatible with the inclusion of evidence sounds plausible but is actually specious
PRI as long as certain clarifications are made. A key when one considers the Guides as a whole. The
to the resolution of the conceptual issues described key issue is that most of the conventional ratings in
earlier comes from close inspection of the definition the Guides are not validated by empirical research.
of an impairment rating as a “consensus-derived Although the goal of buttressing impairment rat-
percentage estimate of loss of activity reflecting ings on the basis of empirical research is laudable,
severity for a given health condition, and the degree this goal should not be applied selectively to the
of associated limitations in terms of ADLs” as tradi- assessment of PRI.
tionally defined by the domains of personal mobility
• Most pain specialists would challenge the argu-
and self-care. This definition implies that severity of
ment that PRI is unnecessary because conventional
impairment depends on 2 criteria: (1) the severity of
ratings in the Guides already include pain. As
dysfunction in the relevant organ or body part and
discussed below, we believe that the conventional
(2) the extent to which the condition being evalu-
rating system does provide appropriate ratings for
ated affects the ability of the individual to perform
many patients with chronic pain. However, the
ADLs. Chronic pain can reasonably be interpreted
problem of PRI cannot be dismissed completely,
as a factor that causes deficits in an individual’s abil-
because some painful conditions cannot be rated
ity to perform ADLs, even in settings where objec-
on the basis of the conventional system.
tive indicators of organ or body part dysfunction are
modest or even nonexistent. Thus, we believe that
Guides6e_03_031-046.indd 36 2/17/09 2:24:08 PM

• The argument that a PRI rating system might cause performed to determine the strength of the indepen-
problems for the insurance industry may well be dent contribution that pain makes to the burden of
valid, but we believe that the need for a system that illness borne by individuals with various medical
fairly compensates individuals with long-term func- conditions, and whether examiners can reliably and
tional deficits outweighs the desire of the insurance validly assess PRI. Considerable research has been
industry to simplify their benefit packages. done on the first issue, at least for some common
painful conditions such as disorders of the lumbar
• We agree with the argument that the PRI system
spine. Unfortunately, though, essentially no research
described in the Guides’ Fifth Edition was overly
has been done on the issue of determining the reli-
complex and believe that this practical concern
ability and validity of PRI assessments. Construct
should inform the development of the PRI assess-
validation research is greatly needed in this area. At
ment system for the Sixth Edition. However, we
this time, as a practical matter, decisions regarding
do not believe that this practical concern bears on
PRI for purposes of the Guides’ Sixth Edition must
the fundamental question of whether the Guides
be based on judgment rather than empirical data.
Chapter 3
should include a PRI rating.
How Much Weight Should Be Given to Pain
Crucial Issues
in Impairment Ratings?
In our opinion, the most powerful arguments
Whether or not to include PRI in the Guides can be
against the inclusion of PRI in the Guides are that
framed as a qualitative yes or no question. However,
(1) PRI assessments are likely to be unreliable and
it is more fruitful to frame the issue in quantitative
(2) they might lead to systematic errors in assess-
terms by asking the following question: How much
ment, such that persuasive patients can “game the
weight should be given to pain in impairment rat-
system” and get inappropriately high impairment
ings? Opponents of PRI, in effect, argue that pain
awards. Both of these arguments derive from the
(and other subjective factors) should be given zero
premise that it is very difficult for examiners to
weight, so that impairment ratings reflect only objec-
determine the extent to which patients are affected
tive factors. Many proponents of including PRI in the
by their pain. These difficulties were succinctly
Guides argue not only that pain should be considered
captured by Scarry19 when she said: “To have great
in impairment ratings but also that a PRI system
pain is to have certainty; to hear that another person
should permit patients with severe pain to receive
has pain is to have doubt.” The problem of reliabil-
impairment awards with high WPI percentages. An
ity and validity of PRI assessment is much more
impairment rating system could make a “cautious
than an academic problem in measurement theory.
foray into the difficult waters” of PRI assessment
The Guides serves the societal role of providing
by permitting awards to be made for PRI, but cap-
an equitable method of compensating individuals
ping these awards at a modest level. This describes
whose ability to function has been compromised
the strategy used in the Guides’ Fifth Edition, in
by a medical condition. For the Guides to carry out
which PRI was capped at 3% WPI. In the absence of
this role, it must be perceived as fair. To be per-
persuasive empirical research on the extent to which
ceived as fair, the Guides must employ assessment
pain affects the ability of people with medical condi-
procedures that are reliable and valid, rather than
tions to function or the measurement problems that
capricious ones that can be manipulated by persua-
arise when PRI is assessed, any decision about caps
sive patients. Thus, regardless of how severely pain
for PRI will be perceived as arbitrary.
affects individuals with various medical conditions,
a PRI assessment system must have reasonable reli-
ability and validity to accomplish the societal goal
of fairly compensating them.
3.3 The Rating System
In fact, the key issue separating proponents and
opponents of impairment due to pain is the weight
3.3a The Problem of Credibility and
they place on ease of measurement of PRI vs
Consistency in Rating Pain-Related
relevance of PRI. Advocates for PRI emphasize that
Impairment
pain has great relevance to the ability to function of
Whenever examiners conduct impairment evalu-
individuals who have various medical conditions,
ations, they must consider the consistency and
but these advocates tend to downplay the problems
interpretability of the clinical data for a patient. For
of measuring PRI. Opponents tend to emphasize
example, a primary step in radiographic interpreta-
problems in measurement but ignore the issue of
tion is an evaluation of the quality of the image.
relevance. In principle, empirical research could be
Guides6e_03_031-046.indd 37 2/17/09 2:24:09 PM

Incorrect exposure, motion artifact, and other techni- a patient would not watch television or read while
cal deficiencies (including poor interrater reliability waiting for a migraine to abate, and there would
between radiologists reading the radiographs) may be an expected response to ergots, triptans, or
weaken the conclusions that can be drawn from it. other antimigraine preparations. A patient with
More generally, examiners using the techniques neuropathic pain would likely, but not always,
described in Chapters 4 to 17 must consider whether show some response to certain antiepileptic drugs
diagnostic studies have been performed appropri- (eg, gabapentin, carbamazepine) or antidepressants
ately, and whether a patient presents with a coherent (eg, tricyclics). A person with persistent pain of
set of symptoms and signs that clearly point to the pancreatitis would be unlikely to gain weight.
diagnosis of a well-accepted medical condition.
Consistency Over Time and Situation
Most experts believe that the problem of interpreting
There is a risk of placing unwarranted confidence
clinical data is greater for patients undergoing PRI
in the validity of assessments that are numeri-
assessment than for ones being rated according to
cal and therefore often considered “objective” and
Chapter 3
principles in Chapters 4 to 17. The principal gauge

“scientific.” Such confidence is challenged by such
of pain is its associated behaviors, which include
observations as a person who can tolerate only 10°
verbal reports and nonverbal pain behaviors such as
forward flexion while standing, yet can sit with legs
limping. The challenge for an examiner is to decide
outstretched and touch his or her toes. Similarly,
whether these pain behaviors accurately reflect a
a person may demonstrate collapsing with pain on
patient’s experiences. Inappropriate pain behavior,
manual testing of plantar flexion, yet be able to
embellishment, and symptom magnification are not
tiptoe. Others may limp on one leg walking for-
uncommon, particularly in medicolegal circum-
ward, the other walking backward, and not at all
stances and entitlement programs. In evaluating the
on a treadmill. Grip strength may be measured
reliability and credibility of pain behaviors among
repeatedly and coefficients of variation calculated,
patients undergoing PRI assessments, examiners
although these methods have been criticized.20 Rapid
should consider the following:
exchange grip strength testing may provide similar
• Congruence with established conditions. information.21 Isokinetic strength testing may dis-
criminate between maximal and submaximal effort.17
• Consistency over time and situation.
Complaints and dysfunction should be relatively
• Consistency with anatomy and physiology. independent of the observers present and should
generally persist despite distraction.
• Agreement between observers.
• Inappropriate illness behavior. Consistency With Anatomy and Physiology
One would expect a patient who claims to be unable
Congruence With Established Conditions to use an arm at all to show some signs of atrophy
In phantom pain, the patient describes pain in an or decreased muscle tone. A patient with inability
absent extremity. While this might be expected to bear weight on one leg or who has a limp should
to evoke incredulity, it does not, because this show evidence of differential shoe wear patterns.
condition has been well described for decades, Although evaluating whether there is clear physical
long before its pathophysiology was understood. evidence of pain-related dysfunction is ideal, there
Similarly, the person with complex regional pain are also numerous “tests” that can be performed to
syndrome (previously called reflex sympathetic assess whether pain behaviors are more likely to
dystrophy, Sudek’s disuse atrophy, or causalgia) be accounted for by patient expectations than by
may describe exquisite pain on light touch of a organic pathology, with Waddell’s signs perhaps the
healthy appearing extremity following a trivial best known of these indicators.22,23 One example is
injury. A constellation of associated signs and that of axial rotation, in which the standing patient’s
symptoms, such as cold sensitivity, autonomic hips are rotated in each direction by the examiner.
changes, trophic changes, dystonic phenomena, This essentially affects only the hips and ankles,
and others help to confirm that the pain complaint leaving the pelvis and all above it to move as a unit.
is consistent with a known clinical syndrome. Exacerbation of back pain by this maneuver is con-
Intolerance of light touch over a region of the lower sidered abnormal. It is important, however, when
back in patients with mechanical low back pain is using this method to rate the patient not on one
not consistent with a defined disease process and abnormal test only, and to place the response in the
thus fails to meet this criterion. Most known condi- context of the totality of the patient’s history, physi-
tions have such expected concomitants. Typically, cal examination findings, and cultural background.
Guides6e_03_031-046.indd 38 2/17/09 2:24:09 PM

Interobserver Agreement seriously. Thus, symptom magnification can be an

Collateral information from relatives and other evalu- iatrogenic phenomenon that occurs when patients
ating professionals is of critical value in determining feel mistrusted or poorly cared for.
the consistency of patient behaviors. This information
may confirm that a patient’s pain behaviors reflect a 3.3b Rating Impairment When Pain
relationship to perceived pain, and that they vary lit- Accompanies Objective Findings of
tle with changes in observers. Alternatively, the infor- Injury or Illness That Permit Rating
mation may expose major inconsistencies that raise Using Another Chapter in the Guides
questions about the factors underlying the patient’s The PRI system that was developed for the Sixth
pain behaviors. Edition of the Guides makes a basic distinction
between assessing pain in conditions that can be
Inappropriate Illness Behavior rated according to principles outlined in Chapters
It may be difficult to judge whether behavior is 4 through 17, vs ones that cannot be rated. The
compatible with perceived pain. For example, since PRI system outlined in this chapter is used only
Chapter 3
one cannot know how much leg pain a patient expe- if a patient presents with a painful condition and
riences on walking, it is hard to know whether an cannot be rated according to principles outlined
antalgic gait is exaggerated. Inappropriate illness in Chapters 4 to 17. It should also be noted that
behavior may be suspected, however, if the patient patients’ subjective experiences regarding their
demonstrates dysfunction in unrelated domains. conditions are considered in the ratings described
For example, except in extreme situations, a patient in Chapters 4 to 17. Specifically, patients are asked
with back pain should not require that the spouse to fill out functional assessment instruments in
complete the patient’s questionnaire—or his or her which they indicate the impact of their condition
sentences. Chronic pain does not often preclude on their ability to function. Although responses to
making one’s own phone calls to the doctor, paying such instruments reflect a variety of factors, it is
bills, and so forth. When a person has delegated assumed that pain will influence them. Thus, we
these functions to others, abnormal illness behavior believe that the impairment ratings described in
is likely. the remaining chapters of this book can capture
the burden imposed by pain that is construed as
The PRI assessment system described in this chapter
a component of a ratable disorder. As discussed
assigns a presumptive impairment rating based on
in Chapter 1, patients’ responses on functional
self-report data by a patient. Examiners are asked
assessment instruments will act as modifiers of the
to modify this rating on the basis of their clinical
percentage impairment they are awarded, but the
judgment regarding the consistency and reliability
awards will, in general, primarily reflect objective
of these self-report data. Examiners are advised to
factors. This is in keeping with the general strat-
consider the issues outlined above when they make
egy of the Guides to consider PRI but to limit the
these judgments. A word of caution is in order here.
amount of impairment that is awarded for subjec-
Although no one would conclude that, because an
tive factors. In no circumstances should the PRIs
X ray was of poor quality, there was unlikely to be
developed using this chapter be considered as an
pathology of concern, this non sequitur frequently
add-on to impairment determinations based on the
occurs in the case of aberrant pain behaviors. Such
criteria listed in Chapters 4 to 17. In essence, the
behaviors should properly cause the physician to be
PRIs derived according to this chapter (see method-
uncertain but not automatically dismissive. Behavior
ology described in the next section) are determined
is affected by many factors. As discussed earlier, the
in a stand-alone fashion.
heuristic biopsychosocial approach to pain would
predict differences in pain behavior across individu-
3.3c Rating Impairment When Pain Is
als because of unique interactions among physical,
Not Accompanied by Objective Findings
psychological, and social factors that become even
In response to criticisms of the complexity of the
more complex when pain is chronic. The appear-
PRI system developed for the previous edition of
ance of symptom exaggeration can be created by
the Guides, the system to be used in the Guides’
fear or by having learned that certain actions or
Sixth Edition is simple. A patient is awarded a
positions provoke pain. “Nonphysiologic” signs may
presumptive percentage WPI on the basis of his or
occur in dementia. Excessive or exaggerated pain
her responses on the Pain Disability Questionnaire
behaviors can be a response to feeling discounted or
(PDQ; Appendixes 3-1 and 3-2 in Section 3.7).24
mistrusted, so that one must emphasize symptoms to
The PDQ was developed as a measure of func-
persuade the physician of their reality. Anyone might
tional status of patients with pain, such as those
dramatize a problem in an effort to have it taken
Guides6e_03_031-046.indd 39 2/17/09 2:24:10 PM

with chronic disabling musculoskeletal disorders. TA B L E 3 -1

The psychometric properties are excellent, demon- Pain-Related Impairment and Whole
strating strong reliability, validity, and responsive- Person Impairment Based on Pain Disability
ness, relative to many other existing measures of Questionnaire
functional status. The focus of the PDQ, much like Degree of Pain Disability
other health inventories, is primarily on how pain Pain-Related Questionnaire Whole Person
Impairment Score Impairment (%)
affects disabilities and ADLs. Moreover, it is based
on the earlier reviewed biopsychosocial approach None 0 0
to pain. Therefore, an important core of the PDQ Mild 1–70 0
will include psychosocial variables (which empirical Moderate 71–100 1
research has consistently shown to play an integral Severe 101–130 2
role in the development and maintenance of chronic
Extreme 131–150 3
pain and disability.)6
Chapter 3
The PDQ consists of 15 items that are scored on a

10-point scale, for a maximum total score of 150.
Instructions for scoring the PDQ appear in
In a subsequent study by Gatchel and colleagues,25
Appendix 3-2.
total PDQ score was broken down into 4 categories
based on the maximum score (high pain and disabil- 4. Determine the patient’s presumptive WPI percent-
ity) of 150 and a minimum score of 0: mild (0–70); age by consulting Table 3-1. As can be seen, by
moderate (71–100); severe (101–130); and extreme using the categorization of PDQ scores reviewed
(131–150). Results of this categorization showed a in Section 3.3c, one can quantify the functional
linear trend for decreasing positive outcomes (eg, status of the patient.
return-to-work and work retention) as the PDQ score
5. Make a clinical judgment about the reliability and
categories increased.
credibility of the patient’s presentation, and mod-
Using the PDQ scoring method, the examiner can ify the presumptive award accordingly, within the
then modify this presumptive award on the basis of range available for PRI (0% to 3% WPI). Usually,
his or her clinical assessment of the reliability of the the modification will be in the direction of lower-
patient’s self-reports and assigns a final PRI award. ing the award for a patient whose credibility is
A cap of 3% WPI is used for conditions that are suspect. However, the examiner has the option
rated with the PRI system. of increasing the award (within the limits of the
allowable cap) if he or she concludes that a patient
3.3d Steps of Assessment has understated the burden of illness.
1. Determine that the patient meets the general
criteria for performing an impairment rating, as
described in Chapter 2. In particular, determine
that the patient is medically stable (ie, has reached 3.4 Future Directions—Need
Maximum Medical Improvement, or MMI). for Research and Dialogue to
2. Determine that the patient meets eligibility crite- Establish the Validity of Rating
ria for rating PRI. They are:
Pain-Related Impairment
a. Pain has been determined to have a reasonable
medical basis, for example, can be described by Based on responses to Chapter 18 of the Guides’
generally acknowledged medical syndromes. Fifth Edition, we anticipate that responses to the PRI
system outlined here will fall into familiar patterns.
b. Pain has been identified by the patient as a
Skeptics of any system for rating PRI will attack
major problem.
the system for being unscientific and for violat-
c. The patient’s condition cannot be rated according the principle that impairment ratings should be
ing to principles described in Chapters 4 to 17. based on objective indexes of organ dysfunction.
Proponents of PRI will attack the system for capping
d. The PRI rating is not specifically excluded by
the size of PRI awards. In order to move past this
relevant jurisdiction.
fruitless dichotomy of opinion, we believe that it is
3. If the patient meets criteria for PRI assessment, crucially important to consider the issues underly-
have him or her fill out the PDQ (Appendix 3-1). ing the dichotomy in a systematic way before the
Guides6e_03_031-046.indd 40 2/17/09 2:24:11 PM

Seventh Edition of the AMA Guides is developed. Everything about rating impairment in those with
Specifically, we recommend the following: chronic pain engenders controversy except that the
suffering of these individuals is real. Our view is
1. Empirical research could be performed to deter-
that an enormous number of people are limited by
mine the strength of the independent contribution
“unbearable sensations” as they attempt to engage in
that pain makes to the burden of illness borne
activities27 and that these subjective factors cannot
by individuals with various medical conditions
be fully assessed by any system that relies strictly
and the ability of examiners to assess PRI reli-
on objective factors. The issue for the future will
ably and validly. Considerable research has been
be to develop impairment rating systems that take
done on the first issue, at least for some common
into account both the importance of subjective fac-
painful conditions such as disorders of the lumbar
tors and the difficulties inherent in the evaluation of
spine.26 In contrast, we are not aware of system-
another person’s subjective experiences.
atic research on the reliability of the PRI system
developed for the Fifth Edition of the Guides, or
Chapter 3
of any other system for evaluating PRI. This issue
should be explored empirically before another
edition of the Guides is published.
3.6 Examples
2. As noted above, a striking feature of the “debate”
EXAMPLE 3-1 NON-SPECIFIC PAIN AFFECTING
over the appropriate role of PRI in the AMA
RIGHT LOWER EXTREMITY
Guides system is that, to date, there has been no
real debate. We are not aware of any published A 43-year-old man reported ongoing burning pain
article or symposium in which enthusiasts and in his right foot and ankle following an ankle sprain
skeptics have debated the appropriateness of PRI. 3 years earlier. At the time of the initial injury, plain
It is time for such a debate to occur, so that the X rays of the ankle revealed no evidence of fracture.
issues separating proponents and opponents can Subsequent plain X rays, a 3-phase bone scan, elec-
be articulated and methods of assessing the valid- tromyography (EMG) and nerve conduction velocity
ity of the arguments can be developed. (NCV) testing, and magnetic resonance imaging
(MRI) of the ankle are all without identifiable
abnormalities. The man indicates that his symptoms
become worse with weight-bearing activities and that
3.5 Conclusion he is significantly limited with respect to walking,
climbing stairs, and prolonged standing. He reports
The stakes in deciding how and whether to include ongoing, intermittent swelling associated with color
PRI in the Guides’ system are high. Discussions and temperature asymmetries between the left and
about PRI need to be framed within the broader right ankles. He has no other pain complaints and no
context of discussions about the appropriate role general medical problems. His physical examination
of subjective factors in the evaluation of impair- is normal; there are no identifiable sensory abnor-
ment and disability. Although pain is a commonly malities, swelling, or color or temperature asym-
reported cause of activity limitation among indi- metries when the affected and unaffected ankles are
viduals undergoing rating of impairment with the compared. The examiner judges him to be credible
AMA Guides, various other subjective experiences with respect to his pain complaints. His score on the
(eg, fatigue or fear of reinjury) can also act as bar- Pain Disability Questionnaire is 72. The examiner
riers to activity. If these subjective factors are to concludes that the patient has moderate PRI and
be considered in impairment ratings, examiners awards 1% WPI.
have no choice but to rely at least in part on com-
Comment: The pathophysiologic basis of this man’s
munications by patients about their experiences.
pain is unknown; however, he reports a constellation
Moreover, the assessment of psychiatric impairment
of symptoms that are suggestive of complex regional
relies heavily on communications by patients. Taken
pain syndrome, type 1. He does not, however, meet
together, the above groups represent an enormous
the diagnostic criteria for this as specified elsewhere
number of individuals whose activity limitations
in the Extremity Chapters. On physical examination
are incomprehensible if an impairment system
and in all laboratory testing and imaging studies,
relies strictly on objective medical factors and
there are no identifiable abnormalities. The exam-
excludes reports by patients about their subjective
iner judges him to be credible, but there are no
experiences.
identifiable objective findings of organ or body
part derangement. Thus, if he is to receive any
Guides6e_03_031-046.indd 41 3/3/09 4:48:53 PM

impairment rating, it is via the PRI system described lasting a couple of hours at a time, and described as
in this chapter. squeezing. Her primary treating physician has diag-
nosed post-concussive headaches. She denies any
history of prior headache and review of the medical
EXAMPLE 3-2 POST-CONCUSSIVE HEADACHE records reveals no documentation of headaches prior
to the accident. At the evaluation she reports that the
A 34-year-old woman was involved in a motor
headaches are very disabling when they occur and
vehicle accident 2 years ago. She struck her head
do appear to be stable in frequency and duration.
against the windshield and reports that she awoke
a “few seconds” later and felt “dazed.” She was Her physical examination is normal; there are no
taken by ambulance to an emergency room and neurological deficits and mental status is normal.
was diagnosed with a “mild concussion.” Review She was felt to be very credible. The score on the
of the emergency department records reveals a Pain Disability Questionnaire is 120. The examiner
normal neurological assessment, including normal concludes that the patient has severe PRI and awards
Chapter 3
mental status. With the extent of the trauma and 2% WPI.

her reported loss of consciousness a head CT was
Comment: Post-concussive headaches can be of mul-
performed which showed no evidence of fracture or
tifactorial origin and may take many forms. In addition
intracranial pathology. Conservative management
to post-traumatic muscle tension-type headaches, they
was recommended. Within the week following the
may mimic migraine. Post-traumatic migraine is not
accident she experienced difficulties with head-
uncommon. This is thought to be due to injury to the
aches, felt “dizzy” at times, was irritable, felt her
vasonervorum and autonomic vascular instability.
memory was not as sharp, and had difficulties with
sleep. She returned to the emergency room 2 weeks Mixed tension and migraine is also commonly seen
post accident, had a normal examination and a in patients with post-traumatic headache.
repeat CT was normal. Her symptoms continued and
Other proposed causes have included direct or indi-
she was referred to a neurologist six months post
rect traction injury to nerves, such as the occipital
injury. The neurological assessment was normal. An
nerves. This may result in a more classically neuritic
MRI, cervical spine imaging, and neuropsychologi-
pain quality. She had no documented intracranial
cal evaluation were ordered; these studies were nor-
pathology and there have been no documented neu-
mal. Over time her symptoms have improved, with
rological deficits. There are no factors that would
the exception of her headaches. She reports having
result in ratable impairment other than for pain.
problems with headaches two to three times a week,
Guides6e_03_031-046.indd 42 3/3/09 4:48:53 PM

3.7 Appendixes
Appendix 3-1 Pain Disability Questionnaire
Patient Name: Date:
Instructions: These questions ask for your views about how your pain now affects how you function in everyday activi-
ties. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.
1. Does your pain interfere with your normal work inside and outside the home?
Work normally Unable to work at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely Need help with all my personal care
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
3. Does your pain interfere with your traveling?

Travel anywhere I like Only travel to see doctors
Chapter 3
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
4. Does your pain affect your ability to sit or stand?

No problems Cannot sit / stand at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
No problems Cannot do at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
7. Does your pain affect your ability to walk or run?

No problems Cannot walk / run at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
8. Has your income declined since your pain began?

No decline Lost all income
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
9. Do you have to take pain medication every day to control your pain?
No medication needed On pain medication throughout the day
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors See doctors weekly
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?
No problem Never see them
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
12. Does your pain interfere with recreational activities and hobbies that are important to you?
No interference Total interference
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home
and housework) because of your pain?
Never need help Need help all the time
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression / tension Severe depression / tension
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
15. Are there emotional problems caused by your pain that interfere with your family, social, and / or work activities?
No problems Severe problems
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
Examiner
Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability Questionnaire: A New Psychometrically Sound Measure for Chronic Musculoskeletal Disorders.
Spine 2004; 29 (20): 2290-2302.
Guides6e_03_031-046.indd 43 2/17/09 2:24:12 PM

Appendix 3-2 Pain Disability Questionnaire (PDQ)
Administering the Pain Disability Questionnaire

Follow these instructions for administering and scoring the PDQ:
1. Reproduce the PDQ (Appendix 3-1) and ask the patient to complete all items on the questionnaire.
2. If necessary, the patient may complete the form with the assistance of a translator or reader. Be certain all 15
questions are answered. If the patient is unable to complete the PDQ, no functional assessment score will be given.
3. The evaluating doctor will score the PDQ by adding together the marked integer in each question.
4. If the patient fails to mark a question, the default score for that question is 0.
5. Apply the final score to Table 3-1 and consider this in the Steps of Assessment as described in Section 3.3d.
The PDQ scores can be divided into 5 distinct categories: no disability (score of 0); mild (scores of 1 to 70); moderate (scores
of 71 to 100); severe (scores of 101 to 130); and extreme (scores of 131 to 150).
Chapter 3
Guides6e_03_031-046.indd 44 2/17/09 2:24:12 PM

Appendix 3-3 Additional Pain Considerations

The American Medical Association’s Guides to the Evaluation of Permanent Impairment, Sixth Edition is intended to
provide a valid and clinically relevant source for assessing and rating an individual’s permanent impairment. With each
edition, a group of clinical experts, representing various medical organizations, mounts a collective effort to update the
Guides and refine its validity and practical clinical application. This effort is applied to each chapter to enhance the rel-
evancy of impairment ratings, improve internal consistency, promote greater precision and simplify the rating process.
However, in some situations marked by a lack of scientific evidence on which to base recommendations, Guides’ contribu-
tors rely on clinical expertise. At times, clinical opinions differ, creating a situation where consensus is lacking.
The assessment of impairment associated with chronic pain is a clear example of the difficulties that arise when such
differences in clinical opinion exist. Experts have disagreed about the usefulness and questioned the validity of the rating
systems for pain-related impairment (PRI) described in previous editions of the Guides, and these difficulties have contin-
ued throughout the development of the current chapter.
Here, the pain chapter authors provide a snapshot of the existing differences between proponents and opponents of
developing a pain-related impairment (PRI) rating system and call for a comprehensive approach to address future devel-
opment of a reliable Guides’ pain rating system.
Chapter 3
Criticism of Earlier Editions of the Guides
Arguments in Favor of Including PRI
Pain specialists have advanced several reasons for including PRI in the Guides system, and for permitting high impairment
percentages to be awarded on the basis of chronic pain:
• Pain affects a person’s ability to perform Activities of Daily Living (ADLs). This effect is to some extent independent
of objective factors. Thus, even when a person has a condition associated with objective factors, statistical theory
dictates that predictions regarding his/her ability to perform ADLs, based on an evaluation of both objective factors
and pain, will be more accurate than predictions based on objective factors alone.
• Although chronic pain can sometimes be conceptualized as a “component” of a disorder with objective factors, it
can also reflect a neurobiologic disease that is independent of a measurable organ/body part dysfunction. In sup-
port of this conceptual model, proponents of PRI note that recent research on the pathophysiology of pain has
cast doubt on the hypothesis that chronic pain is usually closely associated with tissue damage of dysfunction of
organs/body parts. In particular, they cite research demonstrating nervous system sensitization, and note that clini-
cal phenomena that are often dismissed as “not real” can be explained in terms of altered functioning at the level
of the dorsal horn, thalamus, and sensory cortex. Congruent with this theoretical model, experience demonstrates
that there are medical conditions with no associated objective factors in which pain influences a person’s ability to
perform ADLs. Thus, it is appropriate to assess pain and its effects, even in individuals with no objective factors.
• The independent contribution of pain to ADL deficits can be substantial. Thus, the Guides should not only include a
system for assessing PRI, but the system should permit examiners to award high whole person impairment percent-
ages to patients on the basis of their pain.
Arguments Against the Inclusion of PRI in the Guides

We are not aware of any published manuscripts in which arguments against the inclusion of PRI have been articulated.
Thus, we must construct these arguments on the basis of informal discussions with critics of PRI.
• The purpose of the Guides is to evaluate impairment on the basis of objective factors. Pain is a subjective factor, and
is not a kind of impairment. Therefore, PRI should not be included in the Guides.
• There is no empirical evidence that demonstrates the reliability and validity of any system to rate PRI.
• It is redundant to develop a system for assessing pain, because pain has already been factored into the ratings that
are described throughout the Guides.
• The PRI system described in Chapter 18 of the Guides, fifth edition was excessively complex and difficult to use.
• Assessing PRI is difficult; therefore, the inter-examiner reliability and validity of such assessments are likely to be
low. The assessment of pain insinuates unscientific, subjective methods of impairment assessment into a system that
is otherwise objective.
In light of the current controversy related to pain-related impairment, the Guides, 6th edition Editorial Panel determined
that a 3% whole person impairment will be used for conditions that are rated with the PRI system. This decision was based
on the tenet that in the absence of objective data, recommendations will be based on precedent. In this case, the 3% WPI
is based on that used in the fifth edition of the Guides.
The authors of the Pain chapter have made various recommendations for research and collaboration between opponents
and proponents of PRI, in order to build a foundation for the pain chapter in the Guides seventh edition. We hope that
these recommendations are implemented to form a common ground based on objective evidence.
Guides6e_03_031-046.indd 45 2/17/09 2:24:13 PM

14. Elliott AM, Smith BH, Penny KI, et al. The

References epidemiology of chronic pain in the community.
Lancet. 2000;355:233–234.
1. Merskey H, Bogduk N. Classification of Chronic 15. Andersson HI, Ejlertsson G, Leden I, Rosenberg C.
Pain: Descriptions of Chronic Pain Syndromes and Chronic pain in a geographically defined general
Definitions of Pain Terms. 2nd ed. Seattle, Wash: IASP population: studies of differences in age, gender,
Press; 1994. social class, and pain localization. Clin J Pain.
1993;9:174–182.
2. Siddall PJ, Cousins MJ. Persistent pain as a disease
entity: implications for clinical management. Anesth 16. Aronoff GM. Chronic pain and the disability epidemic.
Analg. 2004;99:510–520. Clin J Pain. 1991;7:330–338.
3. Gatchel RJ. Comorbidity of chronic mental and physical 17. Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS.
health disorders: The biopsychosocial perspective. Am Chronic pain disability exaggeration/malingering
Psychol. 2004;59:792–805. and submaximal effort research. Clin J Pain.
1999;15:244–274.
4. Gatchel RJ. Clinical Essentials of Pain Management.
Washington, DC: American Psychological Association; 18. Flores L, Gatchel R, Polatin PB. Objectification of
2005. functional improvement after nonoperative care. Spine.
Chapter 3
1997;22:1622–1633.
5. Gatchel RJ, Okifuji A. Evidence-based scientific data
documenting the treatment and cost-effectiveness of 19. Scarry E. The Body in Pain. New York, NY: Oxford
comprehensive pain programs for chronic nonmalignant University Press; 1985:7.
pain. J Pain. 2006;7:779–793.
20. Mannerkorpi K, Svantesson U, Broberg C.
6. Turk DC, Gatchel RJ, Eds. Psychological Approaches Relationships between performance-based tests and
to Pain Management: A Practitioner’s Handbook. 2nd patients’ ratings of activity limitations, self-efficacy,
ed. Guilford, NY: Guilford Press; 2002. and pain in fibromyalgia. Arch Phys Med Rehabil.
2006;87:259–264.
7. Turk DC, Monarch ES. Biopsychosocial perspective
on chronic pain. In: Turk DC, Gatchel RJ, eds. 21. Westbrook AP, Tredgett MW, Davis TR, Oni JA. The
Psychological Approaches to Pain Management: rapid exchange grip strength test and the detection
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Guilford Press; 2002. 2002;27:329–333.
8. Meyer RA, Ringkamp M, Campbell JN, Raja SN. 22. Waddell G, McCulloch JA, Kummel E, Venner RM.
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McMahon SB, Koltzenburg M, eds.Textbook of Pain. 1980;5:117–125.
5th ed. Philadelphia, Pa: Elsevier Churchill Livingstone;
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HL, Rosomoff RS. A structured evidence-based review
9. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, on the meaning of nonorganic physical signs: Waddell
symptoms, mechanisms and management. Lancet. signs. Pain Med. 2003;4:141–181.
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24. Anagnostis C, Gatchel RJ, Mayer TG. The pain
10. Bennett GJ, Kajander KC, Sahara Y, et al. disability questionnaire: a new psychometrically sound
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functional and psychosocial rehabilitation outcomes.
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Guides6e_03_031-046.indd 46 2/17/09 2:24:13 PM

CHAPTER 4
The Cardiovascular
System
4.1 Principles of Assessment
4.2 Valvular Heart Disease
Chapter 4
4.3 Coronary Artery Disease
4.4 Cardiomyopathies
4.5 Pericardial Heart Disease
4.6 Dysrhythmias
4.7 Hypertensive Cardiovascular Disease

Introduction
This chapter describes criteria for evaluating
4.8 Vascular Diseases Affecting the
permanent impairment of the cardiovascular
Extremities
system and their effects on the individual’s abil-
ity to perform activities of daily living (ADLs).
4.9 Diseases of the Pulmonary Artery
The chapter has changed from the previous edi-
tion, reflecting a combined approach to all aspects
4.10 Cardiovascular Impairment Evaluation
of the cardiovascular system. For the purpose of
Summary
this impairment rating scheme the cardiovascular
system will be divided into the following compo-
nents: Valvular Heart Disease, Coronary Artery
Disease, Cardiomyopathies, Pericardial Disease,
Dysrhythmias, Hypertensive Cardiovascular
Disease, Peripheral Vascular Disease (both
upper and lower extremities), and Diseases of the
Pulmonary Artery.
This chapter provides a brief overview of principles
of cardiovascular assessment. The most recently
published guidelines from the American Heart
Association and the American College of Cardiology
are the primary references used in this chapter. The
reader is also encouraged to review other publica-
tions from the American Medical Association.1
Additionally, a brief discussion will be provided
on the use of contemporary diagnostic testing,
47
Guides6e_04_047-076.indd 47 2/17/09 2:31:27 PM

including the use of specific laboratory data such as Society for grading of angina pectoris, which can be
B-type natriuretic peptide (BNP) and use of myocar- useful in the angina table.2
dial imaging.
4.1a Exercise Testing
Functional capacity is objectively determined and
should be used for impairment ratings. There are
4.1 Principles of Assessment several standard exercise protocols, which estimate
energy expenditure (METs). Table 4-2 outlines the
Substantial transformation is apparent throughout usual treadmill protocols. Although METs may be
this edition of the AMA Guides. The reader must estimated from treadmill testing, it is preferable to
read Chapters 1 and 2 in their entirety and must measure energy expenditure using a metabolic sys-
understand the key concepts and philosophy of the tem that employs protocols such as bicycle ergome-
Guides before attempting to use this chapter. The try (Table 4-3). In addition to functional capacity
functional impairment classes have been standard- based on exercise protocols, most stress testing is
ized, and each cardiovascular disease entity will combined with myocardial imaging. Myocardial
include its own functional impairment table, main- perfusion imaging uses nuclear isotopes to evaluate
taining a standard format. A new concept, “Burden perfusion defects in the myocardium, representing
of Treatment,” has been introduced in the Sixth previous infarction or current myocardial ischemia.
Edition and relates well to impairment ratings from Myocardial perfusion imaging when used with stress
cardiovascular disease. As the data shows, the inci- testing provides additional evidence for the degree
dence of death due to coronary artery disease (CAD) of myocardial damage or ischemia.3,4 Stress echocar-
is declining; however, secondary to the survival suc- diography is also an objective measure that could be
Chapter 4
cess, the incidence of heart failure (HF) continues to used as an alternative.2-4 Stress testing is preferably
increase. Please note that heart failure is the recom- accomplished by exercise, but when needed, phar-
mended term, as there are many causes of HF, not macologic-induced testing can be employed.
all of which are congestive. Most disease survivors
are therefore receiving treatment and lead productive 4.1b Left Ventricular Function Evaluation
lives, but absent treatment they would have limited Left ventricular function is an important component
function, leading to greater impairment. in assessing impairment in an individual with virtu-
ally any form of cardiac assessment. It is equally
The New York Heart Association (NYHA) func-
important to recognize that both systolic and dia-
tional classification remains a mainstay reference for
stolic dysfunction can lead to HF. Both systolic and
functional impairment (Table 4-1). It is noteworthy
diastolic dysfunction may be measured and quanti-
that a more recent, albeit similar, classification has
fied by standard echocardiography.5
been published by the Canadian Cardiovascular
Left ventricular ejection fraction (LVEF), a mea-
sure of systolic function, is the percentage of blood
contained in the ventricle at end diastole that is
TA B L E 4 -1 ejected in systole. Ejection fraction (EF) may be
NYHA Functional Classification of Cardiac Diseasea measured by echocardiography, radionuclide angi-
Class Function of Patients ography (multiple gated acquisition, or MUGA), left
I Patients with no limitation of activities; they ventriculography during diagnostic left-sided heart
suffer no symptoms from ordinary activities catheterization, computed tomography (CT), and car-
II Patients with slight, mild limitation of diac magnetic resonance imaging (MRI). An EF is
activity; they are comfortable with rest or considered normal if it is greater than 50%. Ejection
with mild exertion fraction values can be described as mild dysfunc-
III Patients with marked limitation of activity; tion of 41% to 50%, moderate dysfunction of 30% to
they are comfortable with rest or with mild 40%, and severe dysfunction of less than 30%.
exertion
IV Patients who should be at complete rest, Both diastolic and systolic dysfunction can result
confined to bed or chair; any physical activity in significant difficulties, which may range from
brings on discomfort and symptoms occur mild dyspnea to pulmonary edema. Quantifying the
at rest
degree of diastolic dysfunction can be problematic;
a
A functional and therapeutic classification of physical activity however, it is manifest clinically as symptoms of HF
for cardiac patients.
Source: New York Heart Association. Heart Failure Society of
in the face of normal systolic function and no signifi-
America cant valvular disease. Standard imaging protocols
Guides6e_04_047-076.indd 48 2/17/09 2:31:27 PM

The Cardiovascular System 49
TA B L E 4 -2
Relationship of METs and Functional Class According to 5 Treadmill Protocols a
METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TREADMILL TESTS
Ellestad
Miles per hour 1.7 3.0 4.0 5.0
% grade 10 10 10 10
Bruce
Miles per hour 1.7 2.5 3.4 4.2
% grade 10 12 14 16
Balke
Miles per hour 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4
% grade 2 4 6 8 10 12 14 16 18 20 22 24 26
Balke
Miles per hour 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0
% grade 0 2.5 5 7.5 10 12.5 15 17.5 20 22.5
Naughton
Miles per hour 1.0 2.0 2.0 2.0 2.0 2.0 2.0
% grade 0 0 3.5 7 10.5 14 17.5
METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
CLINICAL STATUS
Chapter 4
Symptomatic
patients
Diseased,
recovered
Sedentary healthy
Physically active
Functional class IV III II I and Normal
a
Adapted from: Fox SM III, Naughton JP, Haskell WL. Physical activity and the prevention of coronary heart disease. Ann Clin Res.
1971;3:404–432.
TA B L E 4 -3
Energy Expenditure in METs During Bicycle Ergometrya
Body Weight Work Rate on Bicycle Ergometer, kg m —1 min —1 (W)
kg (lb) 75 150 300 450 600 750 900 1050 1200 1350 1500 1650 1800
(12) (25) (50) (75) (100) (125) (150) (175) (200) (225) (250) (275) (300)
20 (44) 4.0 6.0 10.0 14.0 18.0 22.0

30 (66) 3.4 4.7 7.3 10.0 12.7 15.3 17.9 20.7 23.3
40 (88) 3.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0
50 (110) 2.8 3.6 5.2 6.8 8.4 10.0 11.5 13.2 14.8 16.3 18.0 19.6 21.1
60 (132) 2.7 3.3 4.7 6.0 7.3 8.7 10.0 11.3 12.7 14.0 15.3 16.7 18.0
70 (154) 2.6 3.1 4.3 5.4 6.6 7.7 8.8 10.0 11.1 12.2 13.4 14.0 15.7
80 (176) 2.5 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0
90 (198) 2.4 2.9 3.8 4.7 5.6 6.4 7.3 8.2 9.1 10.0 10.9 11.8 12.6
100 (220) 2.4 2.8 3.6 4.4 5.2 6.0 6.8 7.6 8.4 9.2 10.0 10.8 11.6
110 (242) 2.4 2.7 3.4 4.2 4.9 5.6 6.3 7.1 7.8 8.5 9.3 10.0 10.7
120 (264) 2.3 2.7 3.3 4.0 4.7 5.3 6.0 6.7 7.3 8.0 8.7 9.3 10.0
a
Source: American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. Philadelphia, Pa: Lea &
Febiger; 1975:17.
Guides6e_04_047-076.indd 49 2/17/09 2:31:28 PM

utilizing both 2-dimensional and Doppler imaging either a higher or lower severity than the default. For
can now identify diastolic dysfunction with clear each impairment rating grid in this chapter, classes
criteria.6,7 1 through 4 will include 5 potential grades.
A recent laboratory test has been developed that is In order to consistently determine the appropriate
useful for determining the presence or absence of impairment grade for a given class, the following
HF. B-type natriuretic peptide or the closely related procedure is recommended:
N-terminal pro-B-type natriuretic peptide (NT-
1. Determine the impairment class (IC) first,
proBNP) is released when ventricular wall tension
according to the “key factor” for that particular
is increased. Clinically, the value is used to deter-
impairment grid.
mine whether shortness of breath is, in fact, due to
actual congestive HF (CHF) or to other processes.8-10 2. Default to the middle (“C”) grade position for
Assays for BNP vary for each laboratory. The BNP that IC.
also varies by age, sex, and body size. The degree of
3. For the first remaining (non-key) factor, deter-
elevation needs to be assessed in the context of the
mine the most appropriate IC position and record
normal values for each particular laboratory. The
the number difference to the key factor IC.
BNP level is now included in the impairment tables
as an objective measure of active HF. 4. Repeat step 3 for each remaining (non-key)
factor.
Methodology for Determining the Grade
5. Summate the IC column differences and add or
in an Impairment Class
subtract the final number from the default identi-
This chapter employs impairment grids for use in
fied in step 1 to determine the final impairment
Chapter 4
determining the appropriate impairment class (class)

grade.
and severity grade (grade) in a class for the condi-
tion or conditions being rated at Maximum Medical To illustrate, if the key factor identifies IC 3 (default
Improvement (MMI). As was stated in Chapter 1, the to 3C), and non-key factors identify IC 1 and 4, this
decision regarding which key factor is the primary would produce differences of −2 and +1, respectively.
determinant of impairment will be clearly stated for These summate to −1. Subtracting 1 grade from
each organ system impairment grid selected. The IC/grade 3C gives a final IC/grade of 3B.
examiner will use this key factor to determine the
In this example, if the non-key factors both identi-
appropriate class. Once the class has been deter-
fied IC 1, you would summate the diffrerences to −4.
mined, based on this key factor, the final impairment
Since this procedure does not allow jumping from
grade in that class must then be determined by non-
one IC to a lower (or higher) IC, you would subtract
key factors, and it is not possible to move upward or
the maximum allowable 2 grades, for a final
downward between classes based on these non-key
IC/grade of 3A.
factors. For most impairment rating scenarios, the
middle grade (integer) in a class will serve as the If the key factor indicated class 4C, and both non-
initial (default) rating (Table 4-4). key factors were also IC 4, the differences would
summate to zero, and IC/grade 4D or 4E would not
In many situations, the examiner will then use the
be possible. In order to correct this deficiency, if the
non-key factors to determine the grade as being
TA B L E 4 - 4 Methodology for Determining the Grade in an Impairment Class
IMPAIRMENT
SEVERITY GRADE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
(A B C D E) (A B C D E) (A B C D E) (A B C D E)
(%)
c c c c
Class 1 Default Class 2 Default Class 3 Default Class 4 Default
Guides6e_04_047-076.indd 50 2/17/09 2:31:28 PM

key factor identifies IC 4C, automatically add +1 as the objective factor, so there is no change in the
difference to the value of each non-key factor. For rating. The physical examination shows no mini-
example, if the key factor identifies IC 4, and the mal changes, consistent with a class 1 examination.
first non-key factor was IC 3, the second was IC 4, This examination, being from a lower class than the
the differences are −1 and zero. Adding +1 to each original objective test, moves the impairment rating
of these yields zero and +1, which summates to +1. down 1 grade, in this case to 14%. The final impair-
Consequently, the final IC/grade is 4D. ment rating will come from 1 of these 5 integers
(they are not an open range of numbers), but the
The process of assigning impairment according to
examiner must specifically identify 1 impairment
the generic template is as follows:
number.
1. The examiner should note that throughout this
chapter the objective test results are used as the
primary, or key factor in the impairment rating
for the condition, as well-validated functional 4.2 Valvular Heart Disease
test measures exist for the cardiovascular system.
Using the key impairment factor (objective test
4.2a Criteria for Rating Impairment due
results), the patient is assigned an impairment
to Valvular Heart Disease
class, with the median as the default position.
Causes of valvular heart disease include calcific or
2. Each impairment class has a corresponding range age-related changes, congenital disease, rheumatic
of available impairment grades. The examiner disease, and infectious endocarditis. Trauma is rarely
should consider the range in each class as divis- a factor. Valvular heart disease may be asymptom-
Chapter 4
ible into 5 subsections. The first is the lowest atic or may produce signs or symptoms of CHF or
impairment rating that could be assigned for the dysrhythmia. Left or right ventricular hypertrophy,
class; the fifth is the highest. ventricular dilation, or ventricular dysfunction may
occur.
3. The NYHA class is the primary basis for his-
tory. For the sake of simplicity and consistency, Doppler echocardiography is a noninvasive, effective
the authors have elected to use the NYHA tool for evaluation of valvular heart disease. Doppler
classification throughout the various tables. echocardiography estimates valvular gradients to
However, it must be recognized that there are quantify severity of stenosis,5,13 enables cardiac
other validated functional instruments for car- chamber measurements, and can also help quantify
diovascular disorders, such as the Canadian regurgitation. However, the degree of regurgitation
Cardiovascular Society classification system for is also dependent on the hemodynamic status of the
angina pectoris,2 Seattle Angina Questionnaire,11 individual, which may vary sequentially between
and the Minnesota Living With Heart Failure 2 studies.14 Standard echocardiography and degree
Questionnaire.12 If examiners opt to use any other of dilation, which are crucial to the evaluation of
assessment tool, they must justify their decision severity, can be applied to the functional impairment
explicitly. Table 4-5 to formulate an impairment estimate.
4. When secondary factors such as history, physi- Diagnostic left-sided heart catheterization is usually
cal exam, or ADLs are reviewed, they move the not necessary to evaluate patients with either stenotic
impairment rating up or down within the same or regurgitant valvular heart disease. The main indi-
class only if they are from a different class. The cations for such evaluation would be discrepancies
grade level may be moved to reflect the impact between the clinical presentation or examination and
of each secondary factor. The impairment rating the echocardiographic assessment, if the echocardio-
will never move out of the class to which it was graphic assessment were technically deficient, or for
initially assigned by the objective key factor. planned surgical intervention.
For example, a patient has an echocardiogram that Valvular replacement is common for advanced
places his or her heart disease in class 2. The default, valvular heart disease. Valvular repair is also cur-
median (midposition) value is 17%. The range of rently a proven option for many patients and has
impairment grades is 11% to 23%, with this range become the procedure of choice for most patients
being defined by the specific integers of 11, 14, 17, with isolated mitral valve insufficiency. Valvular
20, 23. The patient in our hypothetical example operations may result in class 1 or class 2 degrees of
has a NYHA class of II. This is in the same class impairment.
Guides6e_04_047-076.indd 51 2/17/09 2:31:29 PM

Valvular heart disease resulting in HF typically Clinical Studies: Echocardiogram: Bicuspid aortic
requires dietary modifications and medications valve; mean gradient of 22 mm Hg; valve area
to minimize symptoms. Such modifications are 1.6 cm2. ECG: Normal except for bradycardia. Chest
included in the impairment classification table radiograph: Normal.
(Table 4-5).
Diagnosis: Asymptomatic mild aortic stenosis.
Impairment Rating: 6% (class 1C). According to
Table 4-5, the objective test results, physical find-
CLASS 0 ings, and history all place the patient in class 1,
0% Impairment of the Whole Person impairment rating 6%.
EXAMPLE 4 -1: VALVULAR HEART DISEASE
Subject: 22-year-old woman. CLASS 3

24% to 40% Impairment of the Whole Person
History: Asymptomatic, echocardiogram done as
part of a health fair.
Current Symptoms: None. No signs of cardiac
enlargement, HF, or cardiac dysrhythmia. Plays Subject: 50-year-old man.
tennis regularly.
History: Mitral valve replacement 2 years earlier;
Physical Exam: Slight pectus excavatum. Cardiac advanced symptoms and signs of CHF causing pul-
Chapter 4
auscultation normal. monary and systemic congestion. Activities remain

limited by dyspnea on minimal exertion despite
Clinical Studies: Electrocardiogram (ECG): nor-
restriction of activities and salt intake. Digoxin and
mal. Echocardiogram: mild mitral valve prolapse,
diuretics did not relieve symptoms. Vigorous diuretic
normal left atrial, and left ventricular (LV) size and
use eliminated peripheral edema but resulted in
function. No mitral regurgitation.
chemical evidence of prerenal azotemia.
Diagnosis: Mitral valve prolapse.
Current Symptoms: Walks a city block at a slow
Impairment Rating: 0% (class 0) pace, drives, sleeps comfortably; breathless after
According to Table 4-5, the objective test results, climbing 1 flight of stairs.
physical findings, and history all place the patient in
Physical Exam: Comfortable at rest; BP 110/70 mm
class 0, impairment rating 0%.
Hg; heart rate at 80 BPM; jugular venous pressure
normal; no peripheral edema; auscultation of lungs
indicates rales at the left base; apical impulse nor-
mal; parasternal heave; prosthetic valve sounds are
CLASS 1
normal; I/VI holosystolic murmur at the apex.
Clinical Studies: ECG: normal sinus rhythm
(NSR), heart rate of 80 BPM, low T-wave amplitude.
Chest radiograph: Cardiomegaly with enlarged left
Subject: 38-year-old woman. ventricle, right ventricle, and left atria. Prominent
pulmonary vascularity in all lung fields with no
History: She played collegiate sports and is cur-
Kerley B lines. Properly positioned prosthetic valve.
rently a marathon runner. She has always taken anti-
Echocardiogram: Enlarged ventricles and left atrium.
biotics for dental work. NYHA class I.
Moderate global reduction of LV systolic function;
Current Symptoms: Denies dyspnea, angina, palpi- LVEF of 35%. Well-seated prosthetic valve. Normal
tations, and fatigue. mean gradient across the prosthetic valve. Normal
degree of regurgitation. Cardiac catheterization and
Physical Exam: Blood pressure (BP) is normal.
angiography: LV pressure 110/18 mm Hg. Mean
Pulse rate: 52 beats per minute (BPM); midpeaking
left atrial pressure 20 mm Hg. Pulmonary artery
systolic ejection murmur.
pressure 45/18 mm Hg. LV angiogram: mild mitral
regurgitation; reduction of ventricular contraction.
Level of BNP moderately elevated.
Guides6e_04_047-076.indd 52 2/17/09 2:31:30 PM

TA B L E 4 - 5 Criteria for Rating Permanent Impairment due to Valvular Heart Diseasea
Valvular Heart Disease

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4b
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
GRADE (%) (A B C D E) (A B C D E) (A B C D E) (A B C D E)
(Minimal) (Mild) (Moderate) (Severe)
HISTORY Asymptomatic No continuous Moderate dietary Heart failure and/ Heart failure
and no therapy—except changes or drugs or other symp- and/or other
medications antibiotic to remain free toms on symptoms at rest
prophylaxis of HF, syncope, medications- regardless of
chest pain, or moderate medication
NYHA class I
emboli
or Intermittent
NYHA class II decompensation
intermittent
of HF symptoms
severe HF
symptoms NYHA class IV
Chapter 4
NYHA class III
PHYSICAL No abnormality Auscultation Auscultation Auscultation Auscultation

FINDINGS by auscultation identifies stenotic identifies stenotic identifies stenotic identifies stenotic
or regurgitant or regurgitant or regurgitant or regurgitant
murmur murmur murmur murmur
Signs of mild HF Signs c of Signsc of severe HF
moderate HF
OBJECTIVE TEST No ventricular No ventricular Mild ventricular Moderate ven- Severe ventricular
RESULTSd dysfunction or dysfunction or dysfunction or tricular dysfunc- dysfunction or
dilation dilation chamber dilation tion or chamber chamber dilation
dilation
Trace regurgi- Mild stenosis or Moderate steno- Moderate or
tation or mild regurgitation on sis or regurgita- Moderate or severe stenosis or
mitral valve pro- echo tion on echo severe stenosis or regurgitation
lapse with trace regurgitation on
METs ≥7; Bruce METs <7 but ≥5; Surgical correc-
regurgitation on echo
protocol ≥6 min; Bruce protocol tion not feasible
echocardiogram
VO2max >20 >3 min; VO2max Surgical correc-
(echo) METs <2; Bruce
16-20 post- tion not feasible
Normal function- protocol <1 min;
valvular surgery
ing prosthetic METs <5 but ≥2; VO2max <10
and meets above
valve Bruce protocol ≥1
criteria BNP >500 e; AVA
min but <3 min
<1.0; AVG >50;
BNP <100 e; AVA post-valvular sur-
MVA <1.0;
>1.5; AVG <25; gery and meets
MVG >10
MVA >1.5; above criteria;
MVG <5 VO2max 10-15
BNP >100 but
<500 e; AVA 1.0-
1.5; AVG 25-50;
MVA 1.0-1.5;
MVG 5-10
a
NYHA indicates New York Heart Association; HF, heart failure; VO2max, maximum oxygen uptake (in mL/min/kg); BNP,
B-type natriuretic peptide (in pg/mL); AVA, aortic valve area (in cm2); AVG, aortic valve gradient (in mm Hg); MVA, mitral
valve area (in cm2); and MVG, mitral valve gradient (in mm Hg).
b
If all 3 factors are class 4, the impairment rating is 65%.
c
For example, rales, JVD, S3, or peripheral edema.
d
Key factor.
e
Alternatively, one could test for N-terminal pro-B-type natriuretic peptide (also in pg/mL with the same reference range).
Guides6e_04_047-076.indd 53 2/17/09 2:31:30 PM

Diagnosis: Mitral valve replacement with a prosthe- 4.3 Coronary Artery Disease
sis; LV dysfunction, probable rheumatic origin.
Impairment Rating: 32% (class 3C). Refer to Table 4.3a Criteria for Rating Impairment due
4-5; the objective test results, physical findings, and to Coronary Artery Disease
history all place the patient in class 3C impairment Coronary artery disease relates specifically to dis-
rating 32%. eases of the coronary arteries, most commonly arte-
riosclerotic in nature. The degree of arteriosclerosis
will vary from mild luminal irregularities causing no
impairment to severely narrowed coronary arteries
CLASS 4 impairing daily activities. In addition, plaque rupture
45% to 65% Impairment of the Whole Person may occur, resulting in acute myocardial infarction
with resultant significant LV impairment. Additional
etiologies of coronary artery narrowing include
EXAMPLE 4 - 4: VALVULAR HEART DISEASE
vasospasm, embolic events, congenital abnormali-
Subject: 45-year-old woman. ties, Kawasaki disease, trauma, a connective tissue
disorder such as lupus, or prior radiation therapy.
History: Congestive HF for 10 years; breathless-
ness and fatigue with minimal exertion; diuretics, Angina pectoris results from an imbalance in
digoxin, and, for the past year, peripheral vasodilator myocardial oxygen demand in the presence of chron-
did not relieve symptoms. Sleeps on 3 pillows. Long- ically reduced coronary blood flow. Medication
term ankle edema. Protuberant abdomen for last can often control the symptoms; however, if fixed
year. Unable to do most ADLs without assistance. obstructive disease is severe, angina may also be
Chapter 4
present even at rest. Myocardial infarction is diag-

Physical Exam: Pale and weak; thin; jaundiced face
nosed if 2 of the 3 following clinical conditions
showed temporal depression; respiratory rate 22
are met: acute ECG changes, elevated myocardial
breaths per minute; BP 110 /70 mm Hg; heart rate
enzyme levels including troponin,15 or evidence of
irregular at 80 BPM. Patient prefers sitting position.
myocardial damage by imaging studies. Symptoms
Neck veins distended. Prominent V waves. Lung
of chest pain are not required for myocardial infarc-
sounds: rales at both lung bases; parasternal heave.
tion, as at least 25% of myocardial infarctions are
III/VI harsh long systolic murmur in the second
“silent” with no evidence of chest pain. The degree
right intercostal space that lasts to late systole, fol-
of the patient’s impairment can be evaluated based
lowed by a long loud decrescendo diastolic murmur,
on Table 4-6.
blowing holosystolic murmur at the lower sternal
border, middiastolic rumble at the apex. Diminished Stress testing, preferably with cardiac imaging
S1; S2 loud at the second left intercostal space. Liver techniques, serves as the mainstay in evaluating
was large, pulsatile, approximately 12-cm ascites. the degree of damage and thus impairment due to
Pitting edema of thighs, sacral area, and legs. CAD. Left ventricular function must be determined
in these individuals as an objective basis for impair-
Clinical Studies: ECG: NSR, irregular ventricular
ment rating. Coronary angiography is also included
response, 80 BPM, low voltage QRS and T waves.
in the impairment classification tables, as it enables
Chest radiograph: Massive cardiomegaly. Vascular
the quantitative assessment of atherosclerotic dis-
prominence and Kerley B lines on both sides of the
ease.2,16 Newer imaging techniques, such as cardiac
upper lobes. Echocardiogram: Enlargement of all
MRI and CT angiography, also accurately quantify
chambers; LVEF 20%. Two-dimensional echocar-
atherosclerotic disease and may be used for impair-
diography identifies heavy calcification of the aortic
ment rating purposes.
and mitral valves. Doppler studies identify severe
aortic stenosis, mitral regurgitation, tricuspid regur- Impairment can be markedly altered with treatment
gitation, moderate aortic regurgitation, and mitral programs such as cardiac rehabilitation, smoking
stenosis. Pulmonary artery pressure 70 mm Hg. cessation, and compliance with medications. Patients
often require intervention for their CAD that may be
Diagnosis: Aortic and mitral stenosis and regurgita-
percutaneous (ie, percutaneous transluminal coro-
tion, tricuspid regurgitation.
nary angioplasty [PTCA] and/or stent placement), or
Impairment Rating: 65% (class 4E). All 3 factors they may require coronary artery bypass grafting.
are class 4; therefore, the highest rating is given. Impairment ratings should be determined after these
Guides6e_04_047-076.indd 54 2/17/09 2:31:31 PM

TA B L E 4 - 6 Criteria for Rating Impairment due to Coronary Artery Diseasea
Coronary Artery Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Equivocal history History of docu- History of History of

of chest pain mented MI or documented MI, documented MI,
exertional angina angina with exer- angina can occur
NYHA class I
tion or signifi- at rest
Requires medi-
cant changes to
cation to limit Requires marked
ADLs to prevent
symptoms changes to ADLs
frequent angina
and medication
NYHA class II and/or HFc
to remain free of
NYHA class III symptoms at rest
Chapter 4
NYHA class IV
PHYSICAL Normal physical Normal physical Normal physical Signs of HF c

Signs of HFc with
FINDINGS exam exam exam with maxi- with moderate minimal exertion
mal exertion exertion
OBJECTIVE TEST Normal coronary Luminal irregu- Obtained HR Stress testing Stress testing
RESULTSd angiography larities on coro- >90% maximum shows 1-2mm ST- shows >2 mm ST-
nary angiogram predicted with segment changes segment changes
Normal
(<50% stenosis) no ST-segment
echocardiography Coronary angio- Coronary angio-
changes, VT, or
Normal grams show grams show
Equivocal or low- hypotension
echocardiography ≥70% fixed ≥70% fixed
riske myocardial
METs ≥7 (may be obstruction obstruction
perfusion scan or Normal or low-
omitted if unable
stress echo risk myocardial and and
to walk)
perfusion scan or
EBCT 0-100 METs <7 but ≥5; METs <5;
stress echo Coronary angio-
grams shows VO2max 10-15 VO2max <10
EBCT >100
≥50%-70% fixed or or
VO2max>20 obstruction
moderate (25%- severe (>50%)
VO2max 16-20 50%) reversible reversible defect
No or mildly defect on myo- on myocardial
reversible defect cardial perfusion perfusion scan or
(<25%) on myo- scan or stress stress echo
cardial perfusion echo
Recovered from
scan or stress Recovered from CABG or PCI,
echo CABG or PCI, continues
Recovered from continues treatment
CABG or PCI; con- treatment
tinues treatment
a
NYHA indicates New York Heart Association; HF, heart failure; MI, myocardial infarction; CABG, coronary artery bypass
grafting; PCI, percutaneous coronary intervention; EBCT, electron beam computed tomography calcium score; VO2max,
maximum oxygen uptake (in mL/min/kg); and VT, ventricular tachycardia.
b
c
For example, rales, JVD, S3, and peripheral edema; for HF resulting from CAD, consult Table 4-7 and use worst impairment
estimate of the 2 tables as final result.
d
Key factor.
e
Mild reversible defect or fixed defect with normal EF.4
Guides6e_04_047-076.indd 55 2/17/09 2:31:32 PM

procedures have been completed and the patient is at High-density lipoprotein cholesterol (HDL-C)
MMI, generally 3 to 6 months later. 1.17 mmol/L (45 mg/dL). Triglycerides 2.54 mmol/L
(225 mg/dL). Low-density lipoprotein cholesterol
(LDL-C) 7.12 mmol/L (275 mg/dL). Cardiac
catheterization: 50% lesions in proximal and distal
CLASS 0 LAD, right coronary artery and left circumflex.
0% Impairment of the Whole Person Scattered 20% and 30% luminal irregularities
throughout. Ejection fraction is 65%.
EXAMPLE 4 -5: CORONARY ARTERY DISEASE Diagnosis: Asymptomatic CAD.
Subject: 48-year-old asymptomatic woman. Impairment Rating: 11% (class 2B).
According to Table 4-6, the objective test findings
History: No cardiac history; underwent treadmill
place the patient in class 2C, impairment rating 17%;
stress test for an insurance physical and was found
however, both the history and physical exam are con-
to have inferior electrical changes, with normal
sistent with class 1. His functional capacity is excel-
exercise tolerance.
lent; therefore, the final impairment rating is 11%,
Symptoms: None. the initial median of 17% adjusted to 14% based on
history followed by additional adjustment to 11%
Physical Exam: Normal.
according to the physical exam.
Clinical Studies: ECG: Normal.
Cardiac Catheterization: Normal coronary
EXAMPLE 4 -7: CORONARY ARTERY DISEASE
Chapter 4
anatomy and no evidence of atherosclerotic coronary

disease. Normal EF. Subject: 52-year-old woman.
Diagnosis: No evidence of coronary disease, History: Service specialist for an insurance firm.
false-positive treadmill stress test. Coronary artery bypass grafting 6 months earlier.
LIMA to left anterior descending artery and RIMA
Impairment Rating: 0% (class 0) (Table 4-6).
to right coronary artery. Preoperative coronary angi-
ography identified no significant obstructive disease
in the left circumflex artery. Preoperative LV func-
tion was normal. Sedentary job. Previous exertional
CLASS 2
angina.
Current symptoms: Did well after surgery and
worked for 14 months. Asymptomatic. Avoids heavy
physical exertion. Only medication is daily aspirin.
Subject: 58-year-old man.
Physical Exam: Well-healed scar. Normal cardio-
History: Referred to a cardiologist because of an vascular exam at rest.
abnormal myocardial perfusion scan. Denies any
Clinical Studies: Bruce protocol exercise 10 days
significant chest pain or dyspnea.
earlier to a heart rate of 160 BPM. No ST-T wave
Current Symptoms: Plays golf and tennis regularly. changes or dysrhythmias after 10 minutes of exer-
States he has the same level of endurance he had in cise. Achieved greater than 7 METs. Shows exer-
college. Nonsmoker. No history of hypertension, dia- tional tachycardia with delayed recovery to baseline.
betes mellitus, or family history of CAD. Concerned Concurrent metabolic study shows VO2max 18 mL/
because his friend just died unexpectedly of a heart kg/min/. Baseline ECG showed no Q waves. Chest
attack 2 months earlier. Wanted to know definitely radiograph: Normal.
if he had any significant CAD because he was on a
Diagnosis: CAD, post–coronary artery bypass
short list of possible High Court nominees.
grafting.
Physical Exam: Normal, including vital signs.
Impairment Rating: 17% (class 2C). According
Clinical Studies: Exercise echocardiogram: Normal to Table 4-6, the objective test findings, physical
exercise tolerance (9 minutes per Bruce protocol). findings, and history place the patient in class 2C,
Peak heart rate of 180 BPM. Nine METs. No ECG impairment rating 17%.
changes. Mild anterior wall hypokinesis. Lab
studies: Total cholesterol 9.45 mmol/L (365 mg/dL).
Guides6e_04_047-076.indd 56 3/3/09 6:29:12 PM

EXAMPLE 4 -8: CORONARY ARTERY DISEASE and an angiotensin-converting enzyme (ACE)

inhibitor.
Physical Exam: Evidence of weight loss. Prefers
History: Chest pain for 2 years interrupted his work-
sitting position. Blood pressure 110/70 mm Hg.
day. Pain accompanied by diaphoresis and dyspnea.
Heart rate 92 BPM. Distended neck veins with
Slightly elevated cholesterol: 6.34 mmol/L (245 mg/
abdominal hand pressure even when upper part of
dL). Family history: His 66-year-old father is living
the exam table is at 45 degrees. Apical impulse is
with CAD.
enlarged, sustained, and displaced. A parasternal
Current Symptoms: Chest pain. Palpitations. heave is noted. Rales at both lung bases. Dullness
at the right lung base. Auscultation reveals a soft S1,
Physical Exam: Blood pressure 140/90 mm/Hg.
prominent S3, II/VI holosystolic murmur at the apex.
Heart rate 76 BPM. Occasional ectopic beats; other-
wise normal heart sounds. Clinical Studies: ECG: QS in V1 – V4; prominent
Q waves in V5 and V6; poor R-wave progression
Clinical Studies: Exercise stress test was completed
throughout; inverted T waves in leads I, aVL, and
to 14 minutes; maximum heart rate 172; no exercise-
V1 – V5. Chest radiograph: Marked cardiomegaly;
induced ischemia. Due to persistence of seeking a
increased vascular markings; small right-sided pleu-
second opinion, he was referred to a cardiologist and
ral effusion. Coronary angiogram: Total occlusion
underwent cardiac catheterization which showed
of the left anterior descending artery; 90% lesion
50% stenosis in the right coronary artery, 60% EF.
in both the right coronary and circumflex arteries.
He returned to work. Symptoms persisted for another
Patent saphenous vein graft to the right coronary
6 months. Holter monitor showed no ST-segment ele-
and 1 circumflex artery branch. No visualization
Chapter 4
vation during pain. A second cardiologist suspected
of graft to the left anterior descending artery. Left
coronary artery spasm. He received ergonovine
ventricular fraction is 20%, with akinesis of the
testing documenting coronary spasm of the right
entire anterior wall.
coronary artery. He was placed on a calcium channel
blocker and has no current symptoms. Diagnosis: Angina pectoris and LV failure after
coronary artery bypass grafting.
Diagnosis: Vasospastic angina pectoris; coronary
artery vasospasm induced with significant mental Impairment Rating: 65% (class 4E). According to
stress only. Table 4-6, the objective findings, physical findings,
and history all place the patient in class 4C, impair-
ment rating 65%. Examination of the cardiomyopa-
Table 4-6, the objective test findings place patient in
thy Table 4-7 would yield the same result.
class 2C. The history of no further symptoms
and physical examination are both consistent with
class 2.
4.4 Cardiomyopathies
4.4a Criteria for Rating Permanent
CLASS 4 Impairment due to Cardiomyopathies
45% to 65% Impairment of the Whole Person Cardiomyopathy is a disease that affects the heart
muscles. The standard means of quantifying car-
diomyopathy involves measuring left systolic and
diastolic function as well as right ventricular (RV)
Subject: 46-year-old woman. function using echocardiography. The BNP mea-
surements provide additional objective evidence of
History: Coronary artery bypass surgery 11 months
classic CHF. The causes of cardiomyopathy are quite
earlier; daily pain, weakness, and breathlessness
diverse7 and may include the following:
after minimal exertion. Often experiences angina at
rest. 1. Systolic dysfunction secondary to myocardial
infarction.
Current Symptoms: Uses 3 pillows. Awakens
short of breath. Commonly sleeps sitting in a chair. 2. Diastolic dysfunction secondary to long-standing
Symptoms continue despite treatment with digitalis, hypertension.
diuretics, nitrates, calcium channel blocking agents,
3. Hypertrophic cardiomyopathy.
Guides6e_04_047-076.indd 57 2/17/09 2:31:33 PM

4. Cardiomyopathy of obesity. Diagnosis: Syncope secondary to alcohol intoxica-

tion and asymptomatic LV dysfunction, presumably
5. Cardiomyopathy secondary to systemic causes,
due to alcoholic cardiomyopathy.
such as hyperthyroidism or chronic alcohol
exposure. Impairment Rating: 2% (class 1A). According to
Table 4-7, the objective test results place the patient
Cardiomyopathy may be described according to
in class 1, for a median impairment rating of 6%. The
3 basic pathophysiologic types:
history and physical findings place the patient in class
1. Dilated or congestive. 0, so the final rating grade is adjusted down to 2%.
2. Hypertrophic.
3. Restrictive.
CLASS 3
Impairment should be evaluated in the context
of medication use and surgical intervention. For
example, hypertrophic cardiomyopathy may war-
rant myectomy, resulting in complete resolution of EXAMPLE 4 -11: CARDIOMYOPATHY
symptoms.
Subject: 54-year-old woman.
Brief mention should be made of the expanded
History: Treated for symptoms of HF and inad-
recommendations for use of automatic implantable
equate cardiac output for past 3 years. Cardiac
cardiac defibrillators (AICDs).17 Most patients with
catheterization and cineangiography 2 years ago;
significantly impaired LV function will meet crite-
no evidence of coronary artery or valvular disease.
Chapter 4
ria for AICD implantation, and this intervention is

Depressed ventricular function; elevated end-dia-
included in the impairment classification table
stolic pressure 28 mm Hg; 0.32 EF. Subsequently
(Table 4-7). Biventricular pacing is also a new tech-
treated with ACE inhibitors.
nology used in classes 3 and 4 patients with HF that
has been shown to improve functional status.18 Current Symptoms: Condition stable for past year;
able to do light housework and sedentary work.
Breathlessness upon climbing a flight of stairs;
prefers 2 pillows.
CLASS 1
Physical Exam: BP: 110/70 mm Hg; pulse rate
(PR): regular—70 BPM. Venous pressure normal;
rales that clear with coughing. Apical impulse
EXAMPLE 4 -10: CARDIOMYOPATHY markedly enlarged, sustained, displaced laterally
to anterior axillary line.
Clinical Studies: ECG: low T waves in all leads.
History: Admitted to hospital after syncope attack
QS pattern in V1, V2. Chest roentgenogram: marked
at detoxification center. Admitted to “a problem with
cardiomegaly; some distention of pulmonary ves-
alcohol”; refused chemical dependency treatment.
sels in upper lobes. Echocardiogram: LV moderately
Current Symptoms: Denies exertional dyspnea, dilated; LVEF 0.32; enlarged LA. BNP 210 pg/mL.
fatigue, angina, nocturnal dyspnea.
Diagnosis: Idiopathic cardiomyopathy.
Physical Exam: Vital signs: normal; cardiovascular
exam: normal.
Clinical Studies: Echocardiogram: 0.51 LVEF; in class 3C, which is supported by the history.
minimal global hypokinesis of all LV wall seg- However, the physical findings are class 2, so the
ments. Normal chamber dimensions and function, final rating is moved down 1 grade to 3B.
heart size, and estimated pulmonary artery pressure
(PAP). Overnight telemetry monitoring: no dysrhyth-
mias to explain syncope. Normal BNP level.
Guides6e_04_047-076.indd 58 2/17/09 2:31:33 PM

TA B L E 4 -7 Criteria for Rating Impairment due to Cardiomyopathies a
Cardiomyopathies
WHOLE PERSON
IMPAIRMENT
RATING (%) b 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Asymptomatic Mild HF symp- Moderate HF Severe symptoms

on continuous toms on therapy symptoms on of HF at rest or
No medication
treatment or or intermittent therapy or inter- intermittent HF
occasional, mild moderate HF mittent severe decompensation
HF symptoms on symptoms on HF symptoms on on treatment
treatment treatment treatment
NYHA class IV
NYHA class I NYHA class II NYHA class III
PHYSICAL Normal physical Minimal signs c Mild signs of HF Moderate signs Severe signs of HF
FINDINGS exam of HF of HF
Chapter 4
OBJECTIVE TEST Normal Minimally Mildly impaired Moderately Severely impaired
RESULTSd echocardiography impaired LV func- LV function (EF impaired LV func- LV function (EF
tion, minimal 41-50%), or slight tion (EF 30-40%), < 30%), or severe
BNP level normal
septal (< 1.1 cm) septal hyper- or moderate sep- gradient across
hypertrophy or trophy (1.1-1.2 tal hypertrophy septal hyper-
evidence of mini- cm), evidence of (1.3-1.4 cm) with trophy (> 1.4
mal restrictive restriction, or moderate gradi- cm), evidence
disease on echo- mild diastolic dys- ent, or evidence of restriction or
cardiography function (E > A) e of restriction or severe diastolic
(echo) on echo moderate dia- dysfunction
stolic dysfunction (E < A) on echo
Present on Present on
(E=A) on echo
therapy therapy Present on
Present on therapy
and and
therapy
and
at least 1 of: at least 1 of:
and
at least 1 of:
BNP level normal VO2max 16-20
at least 1 of:
VO2max > 20 METs ≥ 7 VO2max < 10
METs ≥ 7 BNP < 100 VO2max 10-15 METs < 5
METs < 7 but ≥5 BNP > 500
BNP 100-500
Malignant ven-
Malignant ventricular dysrhyth-
tricular dysrhythmias (post-AICD
mias (post-AICD or biventricular
or biventricular pacemaker)
pacemaker)
a
NYHA indicates New York Heart Association; HF, heart failure; BNP, B-type natriuretic peptide (in pg/mL); LV, left
ventricular; EF, ejection fraction; VO2max, maximum oxygen uptake (in mL/min/kg); and AICD, automatic implantable
cardiac defibrillator.
b
c
For example, rales, JVD, S3, and peripheral edema.
d
Key factor.
e
E and A are wave forms detected on the echocardiogram.
Guides6e_04_047-076.indd 59 2/17/09 2:31:34 PM

CLASS 4 Clinical Studies: ECG: normal sinus rhythm—

45% to 65% Impairment of the Whole Person 90 BPM; low-amplitude QRS complex throughout all
leads. QS complexes present in II, III, and aVF. Chest
roentgenogram: moderate cardiomegaly; mild pul-
EXAMPLE 4 -12: CARDIOMYOPATHY
monary venous hypertension. Echocardiogram shows
Subject: 62-year-old woman. reduced LV function (0.28 EF), with a scintillation
pattern consistent with amyloidosis. BNP 720 pg/mL.
History: Increasing dyspnea and chest pressure
with exertion for 2 years. No other medical prob- Diagnosis: Cardiac amyloidosis with CHF.
lems. Heart murmur, hypertrophic cardiomyopathy;
Impairment Rating: 65% (class 4E). According to
treated with large dosages of both a ß-blocker and a
Table 4-7, the objective test results, physical findings,
calcium channel blocker.
and history all place the patient in class 4, impair-
Current Symptoms: Still severely limited by ment rating 65%.
symptoms; unable to walk up a half flight of stairs
or do daily activities. Although dual-chamber pace-
maker placed 6 months earlier, minimal change in
symptoms. 4.5 Pericardial Heart Disease
Physical Exam: BP: 150/90 mm Hg; HR: 50 BPM.
Venous pressure: normal; carotid brisk with bifid 4.5a Criteria for Rating Impairment due
quality. LV impulse: sustained with a triple impulse. to Pericardial Disease
Lungs: few rales. Moderate peripheral edema. Pericardial disease is not nearly as common as
Chapter 4
the previous entities discussed; however, it will

Clinical Studies: Echocardiogram: severe septal
occasionally warrant an evaluation of impairment.
hypertrophy 1.5 mm; 0.30 EF; 70 mm Hg outflow
Inflammation of the pericardium may occur due to
tract obstruction. Severe mitral regurgitation
infection (most commonly viral), or may occur fol-
secondary to systolic anterior motion of mitral valve.
lowing coronary artery bypass grafting (after peri-
Chest roentgenogram: cardiomegaly with clear
cardiotomy syndrome) or after myocardial infarction
fields. ECG: sinus bradycardia with paced rhythm.
(Dressler’s syndrome). In addition, connective tissue
BNP 600 pg/mL.
disorders such as lupus, radiation-induced pericardi-
Diagnosis: Severe hypertrophic cardiomyopathy tis, and tumor etiologies must be considered. There
with outflow obstruction. is very rarely tumor involvement in the pericardium
as well. Often, the cause remains idiopathic.
Table 4-7, the history and objective test results place Recurrent pericarditis can be quite disabling.
the patient in class 4. The physical exam, however, is Although echocardiography is helpful to diagnose
class 3; therefore, the final impairment rating is 55%, a pericardial effusion, such effusion is not essential
class 4C. for the diagnosis of pericarditis. Laboratory values
are helpful, most specifically an elevated erythrocyte
sedimentation rate (ESR).
EXAMPLE 4 -13: CARDIOMYOPATHY
Constrictive pericarditis is an unusual entity and
Subject: 47-year-old man. deserves brief discussion. True constrictive pericar-
ditis often requires surgical intervention and removal
History: 3 months ago developed exertional
of the pericardium. Constrictive pericarditis may be
dyspnea, orthopnea, and edema.
quite disabling and characterized by persistent
Current Symptoms: Evaluation for cardiac trans- symptoms of CHF.
plantation: dyspnea on exertion with 1 flight of stairs
Cardiac tamponade is a rare but life-threatening
or ambulating more than 7.5 m(25 ft). Medications:
complication of pericarditis, often associated with
ACE inhibitor, diuretics, and ß-blocker. Unable to do
the presence of carcinoma, or a history of chest
most ADLs.
trauma. Cardiac tamponade generally requires
Physical Exam: Elevated venous pressures and rales pericardiocentesis, which may be curative, with no
in both lung fields. Cardiac examination: laterally resulting permanent impairment.
displaced, sustained apical impulse; 2/6 apical holo-
The physical examination findings can be variable
systolic murmur. Severe peripheral edema.
or absent. The examiner may hear a pericardial fric-
tion rub or pericardial “knock”; these findings are
Guides6e_04_047-076.indd 60 2/17/09 2:31:35 PM

TA B L E 4 - 8 Criteria for Rating Impairment due to Pericardial Heart Diseasea
Pericardial Heart Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) b 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Asymptomatic Intermittent Chest pain or HF Chest pain or HF

with ordinary chest pain or symptoms with symptoms at rest
No medication
activity on HF on chronic normal exertion despite HF or
NSAID or diuretic NSAID or diuretic NSAID therapy
On long-term
therapy therapy
NSAID or HF NYHA class IV
or Symptoms with therapy
moderate activity
intermittent, NYHA class III
mild chest pain or NYHA class II
HF on no therapy
NYHA class I
Chapter 4
PHYSICAL Normal physical Minimal HF Mild HF Moderate HFc Severe HF
FINDINGS exam presence of
Presence of friction rub
friction rub
OBJECTIVE TEST Normal echocar- One or more of One or more of One or more One or more of
RESULTSd diography and the following: the following: of the follow- the following:
ECG small pericar- mild effusion ing: moderate Severe effu-
dial effusion, or evidence of effusion or sion, evidence
Normal ESR
evidence of peri- constrictive peri- evidence of of tamponade
carditis on ECG, carditis on echo- constrictive peri- or constrictive
minimally ele- cardiography, carditis on echo- pericarditis with
vated ESR (< 30), ECG evidence cardiography, severe LV dys-
of pericarditis, ECG evidence of function on echo-
and
mildly elevated pericarditis, mod- cardiography,
at least 1 of: ESR (30-50) erately elevated ECG evidence
BNP level normal ESR (51-70), of pericarditis,
and
significantly ele-
VO2max > 20 and
at least 1 of: vated ESR (> 71),
METs ≥ 7 at least 1 of:
BNP < 100 and
or BNP 100-500
VO2max 16-20 at least 1 of:
status post- VO2max 10-15
METs ≥ 7 BNP > 500
pericardiectomy METs < 7 but ≥ 5
or VO2max < 10
or surgical peri-
and
cardial window status post- METs < 5
pericardiectomy failed surgi-
and
or surgical peri- cal attempt or
cardial window no response to failed surgi-
surgery cal attempt or
no response to
surgery
a
NSAID indicates nonsteroidal anti-inflammatory drug; NYHA, New York Heart Association; HF, heart failure; ECG,
electrocardiogram; ESR, erythrocyte sedimentation rate (in mm/h); BNP, B-type natriuretic peptide (in pg/mL); VO2 max,
maximum oxygen uptake (in mL/min/kg); and LV, left ventricular.
b
c
For example, rales, JVD, or peripheral edema.
d
Key factor.
Guides6e_04_047-076.indd 61 2/17/09 2:31:35 PM

pathognomonic of pericarditis. The pericardium may Diagnosis: Acute benign idiopathic pericarditis.
require more thorough evaluation such as CT or MRI
Impairment Rating: 2% (class 1A). According to
to evaluate thickness of the pericardium. See Table
Table 4-8, the objective test results would place the
4-8 for impairment rating criteria.
patient at class 1C. The physical examination and his-
tory are normal, which moves the grade down to A.
CLASS 0
0% Impairment of the Whole Person
CLASS 3
EXAMPLE 4 -14: PERICARDIAL HEART DISEASE
Subject: 64-year-old woman. EXAMPLE 4 -16: PERICARDIAL HEART DISEASE
History: Had successful pericardiocentesis for Subject: 62-year-old man.

idiopathic pericardial effusion. Moderate symptoms
History: Profound ascites, peripheral edema, weight
resolved after treatment.
loss, signs of pulmonary congestion attributed to a
Current Symptoms: Asymptomatic from rigorous pericardial effusion. Effusion drained, temporarily
traveling to South America. relieved severe ascites and peripheral edema. Fatigue
and breathlessness continue with ordinary activity;
Physical Examination: Normal.
unable to climb 1 flight of stairs without resting.
Clinical Studies: Chest roentgenogram: normal. Refuses further intervention. Has taken NSAID and
Chapter 4
Echocardiogram: normal. Normal ESR. low-dose diuretic long term.

Diagnosis: Resolved pericardial effusion following Current Symptoms: Edema, ascites returned. Able
percutaneous pericardiocentesis, with no recurrence. to walk on a level surface and do light ADLs.
Impairment Rating: 0% (class 0). According to Physical Exam: Comfortable. Neck veins elevated 20
Table 4-8, the objective test results, physical find- cm H2O; 2+ peripheral edema and ascites. Evidence of
ings, and history all place the patient in class 0, 0%. marked weight loss remained. No ventricular heaves,
thrills, or taps in the precordium. Diminished heart
sounds; no murmurs or extra sounds.
Clinical Studies: ECG: low voltage of the QRS and
CLASS 1
T waves. Chest roentgenogram: marked cardiomeg-
aly; some upper lobe pulmonary vasculature disten-
tion. Echocardiogram: systolic ventricular function:
EXAMPLE 4 -15: PERICARDIAL HEART DISEASE normal; 0.55 LVEF. Doppler: constrictive pericar-
ditis. Recurrence of moderate pericardial effusion.
ESR 55 mm/h.
History: Acute pericarditis 15 months ago.
Diagnosis: Constrictive pericarditis following peri-
Symptoms: acute, self-limited, febrile illness, with
cardial drainage.
anterior chest pain and a pericardial friction rub.
Current Symptoms: Asymptomatic; returned to
work and leading a normal life.
ings, and history all place the patient in class 3C,
Physical Exam: Normal. impairment rating 32%.
Clinical Studies: Echocardiogram: small pericardial
effusion. Illness resolved with aspirin treatment.
Normal ESR.
Guides6e_04_047-076.indd 62 2/17/09 2:31:36 PM

CLASS 4 Dysrhythmias are somewhat difficult to evaluate

45% to 65% Impairment of the Whole Person because they vary in frequency as well as severity.
Symptoms may be limited to brief palpitations or
may result in life-threatening syncope. The symp-
EXAMPLE 4 -17: PERICARDIAL HEART DISEASE
toms also may, unfortunately, be vague and limited
Subject: 47-year-old woman. to dyspnea, weakness, or fatigue.
History: Pericardiectomy for constrictive pericar- Impairment evaluation for both tachydysrhythmias
ditis 2 years ago. Continued dyspnea with minimal and bradydysrhythmias relates directly to degree of
activities and at rest; dependent on others for self- organic heart disease, and often one must use the
care. Daily furosemide (160 mg twice a day), digi- coronary heart disease, valvular heart disease, or
talis, and nitrates. Compression stockings caused cardiomyopathy impairment rating tables for the
symptomatic improvement. most appropriate impairment determination.
Current Symptoms: Waking at night with The treatment of dysrhythmias has advanced signifi-
breathlessness. cantly in the past few years. Many patients receive
AICD after myocardial infarction to prevent sudden
Physical Exam: BP: 115/80 mm Hg; fell to 85/45 mm
death from cardiac dysrhythmias. The presence of
Hg with inspiration. Neck veins elevated; did not fall
an AICD may specifically affect disability in certain
with inspiration. Inspiratory and expiratory wheezing;
occupations (ie, welding).
distant heart sounds; audible S3. Abdomen: moderate
ascites and hepatomegaly. 2+ pitting edema in lower Permanent pacemakers are extremely common,
extremities and lower back region. particularly for bradydysrhythmias. Impairment
Chapter 4
should be evaluated post-pacemaker implantation
Clinical Studies: Echocardiogram: enlarged heart
with reassessment of symptoms.
with reduced function; 0.30 EF. Constrictive physi-
ology. No pericardial effusion. Laboratory studies: Many dysrhythmias are controlled with medication
mild anemia; liver enzymes elevation consistent with and, in fact, may be completely stabilized, resulting
congestive hepatomegaly. Severely elevated BNP in class 1 impairment estimations. See Table 4-9 for
870 pg/mL. ESR 80 mm/h. Treadmill METs 3. the impairment rating criteria.
Diagnosis: Constrictive pericarditis following surgi-
cal pericardiectomy and biventricular dysfunction
with HF.
CLASS 0
Impairment Rating: 65% (class 4E). According to 0% Impairment of the Whole Person
ings, and history all place the patient in class 4,
EXAMPLE 4 -18: DYSRHYTHMIA
impairment rating 65%.
History: Frequent premature beats during annual
physical examination.
4.6 Dysrhythmias
Current Symptoms: None. Able to perform all
ADLs. Exercises regularly.
Impairment due to Dysrhythmias Physical Exam: Normal.
Cardiac dysrhythmias vary in severity from completely
Clinical Studies: ECG: frequent premature atrial
benign to life-threatening, and include tachydysrhyth-
complexes.
mias and bradydysrhythmias. Echocardiography and
Holter monitoring remain a mainstay for evaluation Diagnosis: Atrial premature complexes.
of affected individuals. In general, cardiac dysrhyth-
Impairment Rating: 0% (class 0). According
mias are markedly less severe when they occur in the
to Table 4-9, the objective test results, physical
absence of organic heart disease than in the presence of
findings, and history place the patient in class 0,
structural heart disease.
Guides6e_04_047-076.indd 63 2/17/09 2:31:37 PM

TA B L E 4 -9 Criteria for Rating Impairment due to Dysrhythmias a
Dysrhythmias
CLASS CLASS 0 CLASS 1 CLASS 2b CLASS 3b CLASS 4b
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Asymptomatic Asymptomatic Symptoms c Symptoms c

or occasional during daily despite drug despite therapy
No medication
palpitations or actions, palpita- therapy or at rest, espe-
isolated syncopal tions or isolated pacemaker with cially recurrent
episode syncope, but minimal activity syncope
requires drug or intermittent,
NYHA class I NYHA class IV
therapy or severe symptoms
pacemaker
NYHA class III
NYHA class II
PHYSICAL Normal physical Normal physi- Auscultation Auscultation Auscultation

Chapter 4
FINDINGS exam cal exam or of irregularity of irregularity of irregularity

occasional unless pacer unless pacer unless pacer
extra systole on dependent dependent dependent
auscultation
OBJECTIVE TEST Normal Normal Abnormal echo- Abnormal echo- Abnormal echo-
RESULTSd echocardiography echocardiography cardiography cardiography cardiography
with small ASD with moderate documenting
Normal ECG or and
or VSD, mildly ASD or VSD, mod- large ASD or VSD,
occasional PACs
ECG documen- impaired LV or erately impaired severely impaired
or PVCs
tation of dys- RV function, LV or RV func- LV or RV func-
rhythmia but no diastolic dys- tion, diastolic tion, diastolic
ECG or Holter function, mild dysfunction, dysfunction,
documentation chamber enlarge- moderate cham- severe chamber
of ≥ 3 consecutive ment, or mild val- ber enlargement, enlargement,
ectopic beats or vular stenosis or or moderate val- or severe valvu-
pauses > 2 s regurgitation vular stenosis or lar stenosis or
Atrial and ven- regurgitation regurgitation
or
tricular rate or or
ECG or Holter
50-100 beats per
documentation ECG or Holter ECG or Holter
minute
of malignant documentation documentation
Post-ablation or dysrhythmia of malignant of malignant
pacemaker with dysrhythmia dysrhythmia
Post-ablation,
above criteria
pacemaker, or Post-ablation, Post-ablation,
Medications may AICD with above pacemaker, or pacemaker, or
be required criteria AICD with above AICD with above
criteria criteria
a
NYHA indicates New York Heart Association; ECG, electrocardiogram; PAC, ; PVC, ; ASD, ; VSD, LV, left ventricular; RV, right
ventricular; and AICD, automatic implantable cardiac defibrillator.
b
For classes 2, 3, and 4, use the same criteria under objective test results as identified in Tables 4-6, 4-7, or 4-8 for each
respective class to look for evidence of organic heart disease.
c
For example, severe palpitations, syncope, or near syncope.
d
Key factor.
Guides6e_04_047-076.indd 64 2/17/09 2:31:37 PM

CLASS 1 Impairment Rating: 32% (class 3C). According to

2% to 10% Impairment of the Whole Person Table 4-9, the objective findings, physical examina-
tion, and history all place the patient in class 3. Note
that this example also easily applies to the cardiomy-
EXAMPLE 4 -19: DYSRHYTHMIA
opathy impairment rating, and either classification
Subject: 52-year-old man. table may be used.
History: Recurring syncope 8 months ago; treated
with insertion of a permanent pacemaker for com-
plete heart block.
CLASS 4
Current Symptoms: Asymptomatic. 45% to 65% Impairment of the Whole Person
Physical Exam: Appeared well. BP: 120/80 mm Hg;

PR: 72 BPM. Normal heart sounds; no murmurs. EXAMPLE 4 -21: DYSRHYTHMIA
Clinical Studies: ECG: complete capture of the Subject: 42-year-old man.

heart by artificial pacemaker at 72 BPM. Pacemaker
History: Medications, pacemaker for syncope for past
sensed and properly inhibited rare premature ven-
8 years. Syncope continued daily without warning
tricular beat.
despite all efforts. Work limited; unable to conduct
Diagnosis: Adams-Stokes attacks in individual with business meetings because of embarrassment about
complete heart block; managed with properly func- syncope unpredictability. Could not legally drive an
tioning artificial pacemaker. automobile or use any power equipment that might
Chapter 4
endanger his safety if spell occurred.
Table 4-9, the objective findings of pacemaker and Physical Exam: S1S2 normal. RV heave.
occasional extra systoles, normal physical exam and
Clinical Studies: Echocardiogram demonstrates
no current symptoms place the patient in class 1C,
severely dilated right ventricle. Holter monitoring: PSVT.
functional impairment rating 6%.
Diagnosis: Recurrent syncope despite maximal
therapy due to underlying congenital ASD.
CLASS 3
Table 4-9, the objective findings place the patient in
class 4. History and physical findings are also con-
sistent with class 4. This results in final impairment
EXAMPLE 4 -20: DYSRHYTHMIA IMPAIRMENT grade 4E for 65%.
History: Without prior symptoms, suffered out-
of- hospital cardiac arrest 3 months ago. Returned 4.7 Hypertensive Cardiovascular
for evaluation of implanted AICD. No syncope; Disease
5 instances of profound palpitations followed by
internal firing of the AICD 45 seconds after symp-
tom onset. Palpitations with minimal activity. 4.7a Criteria for Rating Impairment due to
Hypertensive Cardiovascular Disease
Current Symptoms: Internal shocks were “mildly
The Seventh Report of the Joint National
disconcerting.” No HF or angina symptoms. Is con-
Committee on Prevention, Detection, Evaluation,
cerned with performing any heavy tasks around the
and Treatment of High Blood Pressure (JNC 7)
house.
changed the classification of BP for adults in 2004
Physical Exam: PR: 80 BPM, normal pacing. (see Table 4-10).19 The committee introduced a new
category defined as “pre-hypertension,” which
Clinical Studies: AICD with appropriate function,
warrants therapeutic lifestyle changes as defined
interrogation reveals multiple episodes of sustained
in this document.19 Hypertension in and of itself is
ventricular tachycardia. Echocardiogram demon-
difficult to assess as far as functional impairment;
strates LVEF 0.35.
however, hypertension continues to be a primary
Diagnosis: Sustained VT. risk factor for CAD, cerebrovascular accidents
and, very importantly, renal failure.
Guides6e_04_047-076.indd 65 2/17/09 2:31:38 PM

TA B L E 4 -1 0
Classification of Blood Pressure for Adults CLASS 3
Classification Systolic Diastolic 24% to 40% Impairment of the Whole Person
Normal < 120 < 80%

Pre-hypertension 120-139 80-89 EXAMPLE 4 -23: HYPERTENSIVE
Stage 1 hypertension 140-159 90-99 CARDIOVASCULAR DISEASE
Stage 2 hypertension ≥ 160 ≥ 100 Subject: 48-year-old man.
History: Severe hypertension; intermittent therapeu-
tic drugs. Current triple therapy: ß-blocker, vasodi-
lator, and diuretic.
The impairment secondary to hypertension is based Current Symptoms: None. Remains mildly active.
largely on the evidence of end-organ damage;
Physical Exam: BP: 170/95 mm Hg in both arms;
however, hypertension independently exacerbates
PR: 64 BPM. No signs of CHF. Fundus: increased
angina and may contribute to an aortic dissection.
light reflexes from arterioles and arteriovenous
Hypertension causes LV hypertrophy, which when
crossing depressions; no hemorrhages or exudates.
left untreated ultimately leads to diastolic and sys-
Optic disk flat. Enlarged, sustained LV impulse in
tolic HF (Table 4-11). Hypertension may be treated
normal position. Normal S1; S2 increased in intensity;
with significant control of symptoms and frequent
S4 present.
reversal of LV hypertrophy. Again, if end-organ
cardiovascular, renal, or other organ system disease Clinical Studies: ECG: LV hypertrophy; tall R and
has developed due to hypertension, other impairment inverted T waves in lateral chest leads. Chest roent-
Chapter 4
tables appropriate to these organ systems should genogram: mild cardiomegaly; pulmonary vascula-
be used and combined for the final impairment ture normal. Serum electrolyte levels and urinalysis:
evaluation. normal. ECHO shows definite LVH.
Diagnosis: Essential hypertension and hypertensive
heart disease with documented LV hypertrophy.
CLASS 1 Impairment Rating: 36% (class 3D). According
2% to 10% Impairment of the Whole Person to Table 4-11, the LVH places the patient in class 3.
The physical findings (BP 170/95) place the patient
in class 4, which would move the patient up 1 grade
EXAMPLE 4 -22: HYPERTENSIVE
to D. The history reflects no HF, and this leaves the
CARDIOVASCULAR DISEASE
rating unchanged. The final impairment rating is
Subject: 55-year-old woman. therefore class 3D, 36%.
History: Essential hypertension 5 years ago.
Medication: diuretic. Normal BP readings before
visit.
Current Symptoms: Asymptomatic; denies medica-
tion side effects.
History: Hypertension; ß-blocker and ACE inhibi-
Physical Exam: Normal; BP: 105/78 mm Hg.
tor. Well-controlled BP remained in normal range.
Clinical Studies: ECG: normal.
Current Symptoms: None. Remains mildly active.
Diagnosis: Essential hypertension with adequate
Physical Exam: Normal except for S4; sustained api-
control.
cal impulse. BP 140/90 mm Hg.
Clinical Studies: ECG: LV hypertrophy.
Echocardiogram: concentric LVH. Normal systolic
function; some diastolic dysfunction noted.
Diagnosis: Hypertensive heart disease with LV
hypertrophy and early diastolic dysfunction.
Guides6e_04_047-076.indd 66 2/17/09 2:31:39 PM

TA B L E 4 -11 Criteria for Rating impairment due to Hypertensive Cardiovascular Diseasea
Hypertensive Cardiovascular Disease

CLASS CLASS 0b CLASS 1b CLASS 2 CLASS 3 CLASS 4
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Asymptomatic Asymptomatic Asymptomatic or Asymptomatic or

chest pain HF symptoms
NYHA class I
NYHA class II NYHA class III
or IV
PHYSICAL Normal BP with Normal BP on Pre-hypertension Stage 1 hyper- Stage 2 hyper-

FINDINGS dietary modifica- single drug or stage 1 on mul- tension despite tension despite
tion only therapy or pre- tiple drug therapy multiple drug multiple drug
hypertension therapy therapy
Normal physical Possible hyper-
without therapy
exam, includ- tensive changes Definite hyper- Definite hyper-
ing funduscopic Normal physical on funduscopic tensive changes tensive changes
Chapter 4
exam exam, including exam c on funduscopic on funduscopic
funduscopic exam exam exam
OBJECTIVE TEST Normal lab val- Normal lab val- Normal BUN/ Proteinuria or Proteinuria or
RESULTSd ues, no evidence ues, no evidence creatinine urinary sediment urinary sediment
of end-organ of end-organ abnormalities abnormalities
Proteinuria or
damage damage
urinary sediment Elevated BUN and Elevated BUN and
Normal echocar- Normal echocar- abnormalities serum creatinine serum creatinine
diography and diography and
Normal to Creatinine clear- Creatinine
ECG ECG
borderline ance 20%-50% of clearance < 20%
LVH on normal normal
echocardiography
Echocardio- Episodic
graphic hypertensive
Echocardiographic encephalopathy
evidence of LVH
Hypertensive
cerebrovascular
damage
Echocardiographic
evidence of severe
LVH, diastolic dys-
function, and/or
signs of HFe
a
NYHA indicates New York Heart Association; HF, heart failure; BP, blood pressure; ECG, electrocardiography; BUN, serum
urea nitrogen; and LVH, left ventricular hypertrophy.
b
Use physical findings to distinguish class 0 vs class 1.
c
Copper wiring or arteriovenous nicking with or without hemorrhages or exudates.
d
Key factor.
e
Apply same class 4 criteria as in Tables 4-6, 4-7, etc.
Guides6e_04_047-076.indd 67 2/17/09 2:31:39 PM

Impairment Rating: 28% (class 3B). According to

4.8 Vascular Diseases Affecting
in class 3. The history places the patient in class 2, the Extremities
and moves the grade down to a B. The physical
examination is a class 3, which leaves the rating
4.8a Criteria for Rating Impairment due
unchanged. Therefore, the final impairment rating is
to Vascular Diseases of the Extemities
28% (class 3B).
The presence of peripheral vascular disease is more
common than previously suspected. Peripheral vas-
cular disease that contributes to permanent impair-
ment may include the following:
CLASS 4
45% to 65% Impairment of the Whole Person 1. Atherosclerosis of the arterial system may result
in intermittent claudication, atrophic changes,
ulceration, gangrene, and ultimately extremity
loss. Raynaud’s phenomenon must also be con-
sidered when evaluating arterial disorders of the
Subject: 62-year-old woman. extremities.
History: 10 years’ BP treatment. Elevated BP despite 2. Venous disorders such as chronic deep vein throm-
medication, salt restriction, and weight control. CHF 2 boses resulting in pain, edema and ulceration.
years ago; improved with digitalis and diuretics.
3. Lymphatic disorders often leading to chronic
Current Symptoms: 6 months’ marked tiredness lymphedema and recurrent infections.
Chapter 4
and breathlessness with ordinary activity; ankle

Atherosclerosis remains the number one cause
edema. Difficulty in performing most ADLs.
of arterial disorders. Raynaud’s phenomenon and
Physical Exam: BP: 180/100 mm Hg in arms and thromboangiitis obliterans must also be considered
legs. Lower extremity edema. Fundus: increased when evaluating arterial disorders. Varicose veins
arteriole light reflexes, arteriovenous crossing com- and deep venous thromboses must be evaluated
pressions, no hemorrhages or exudates; flat optic when considering the venous system. The lymphatic
disks. Apical impulse: enlarged, sustained, displaced system is most commonly impaired by an infectious
to anterior axillary line. Normal S1; increased S2; S3 or neoplastic process.
and S4 present. Rales at both lung bases.
Impairment secondary to diseases of the extremities
Clinical Studies: ECG: deep S wave in V2; normal has been divided into lower and upper extremities
R waves in V5 and V6. Low T waves in I, L, and V4 with two separate impairment classification tables.
through V6. Chest roentgenogram: cardiomegaly;
In evaluating occlusive peripheral arterial disease of the
pulmonary vasculature prominent in upper lung
lower extremity, ankle-brachial indices are an excel-
fields. Creatinine μmol/L (3.0 mg/dL), serum urea
lent non-invasive standard measurement. ABI values
nitrogen (BUN) mmol/L (40 mg/dL), marked pro-
are mildly to moderately diminished between 0.41 and
teinuria. Echocardiogram: increased wall thickness;
0.90, severely decreased when less than or equal to
dilated LV cavity with global hypokinesis; 0.30 EF.
0.40. These values have been validated to have prog-
Diagnosis: Essential hypertension with CHF. nostic value.20 If the ABI’s are not felt reliable second-
ary to advanced age or diabetes, the toe-brachial index
should be considered.20 Duplex ultrasound can estab-
lish the diagnosis of lower extremity peripheral arterial
ings, and history place the patient in class 4, impair-
disease and establishing severity.20
ment rating 65%.
Guides6e_04_047-076.indd 68 2/17/09 2:31:40 PM

Raynaud’s phenomenon is described as the clini- is evaluated by objective testing including arterial
cal scenario that begins with blanching of one or pressure ratios between the digits and the brachial
more fingers, cyanosis, and subsequent erythema. pressure. A ratio of less than 0.8 suggest obstructive
It is important to note that pain on exposure to physiology. Obstructive physiology in both upper and
cold alone does not necessarily indicate Raynaud’s lower extremities can also be accurately identified
phenomenon. Raynaud’s needs to be differentiated using doppler techniques. Criteria for rating vascular
from obstructive physiology. Obstructive physiology diseases are shown in Tables 4–12 and 4–13.
TA B L E 4 -12 Criteria for Rating Impairment due to Peripheral Vascular Disease – Lower Extremity
Lower Extremity Peripheral Vascular Disease

UNILATERAL LE
IMPAIRMENT
RATING (%)a 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
Chapter 4
HISTORY No claudication Intermittent Intermittent clau- Intermittent clau- Severe and

or pain at rest or claudication on dication walking dication walking consistent pain
transient edema severe lower 25-100 yards at < 25 yards or pain at rest
extremity usage average pace or intermittent at
or persistent marked edema rest or marked
edema edema
Partially con-
Controlled by trolled by elastic Not controlled by
elastic supports supports elastic supports
PHYSICAL No findings Vascular damage Vascular damage Vascular damage Vascular damage
FINDINGS except loss such as healed, such as healed such as amputa- such as amputa-
of pulses or painless stump of amputation of tion at or above tion at or above
minimal loss of digit two or more ankle or amputa- the ankles of
subcutaneous digits or one tion of two or two extremities
Healed ulcer
tissue or venous extremity more digits with or amputation
varicosities with evidence evidence of per- of all digits with
of persisting sistent vascular evidence of per-
vascular disease disease or persis- sistent vascular or
or superficial tent widespread deep ulceration
ulceration or deep ulcer- involving two
ation involving extremities
one extremity
OBJECTIVE TEST Normal ABI’s c Normal or mildly Abnormal ABI’s c Moderately Markedly
RESULTSb abnormal ABI’s c (0.71-0.90) or abnormal ABI’s c abnormal ABI’s c
(> 0.90) mildly abnormal (0.41 - 0.70), mod- (≤ 0.40), severely
arterial or venous erately abnormal abnormal arterial
duplex ultra- arterial or venous or venous duplex
sound or periph- duplex or periph- or peripheral
eral angiograms eral angiograms angiograms doc-
documenting documenting umenting severe
mild PADa . moderate PADa PADa
a
Peripheral arterial disease.
b
Key factor.
c
Ankle-brachial indices.
Guides6e_04_047-076.indd 69 2/17/09 2:31:41 PM

TA B L E 4 -13 Criteria for Rating Impairment due to Peripheral Vascular Disease – Upper Extremity
Upper Extremity Peripheral Vascular Disease

UNILATERAL UE
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY No intermittent Intermittent Intermittent Intermittent Severe and con-

claudication or claudication with claudication with claudication sistent pain at
pain at rest or heavy upper moderate upper with mild upper rest or severe
transient edema extremity usage, extremity usage extremity usage edema
persistent edema or mild edema or moderate
No curtailment of
or pain with cold edema
activity
exposure
PHYSICAL No findings Vascular damage Vascular damage Vascular dam- Vascular damage
FINDINGS except loss evidence such evidenced by a age as evidenced as evidenced by
of pulses or as healed, pain- healed amputa- by signs such amputation at
minimal loss of less stump of tion of two or as amputation or above both
Chapter 4
subcutaneous amputated digit more digits of at or above the wrists or amputa-

tissue of with evidence one extremity wrist or amputation of all digits
fingertips of persistent with evidence tion of two or with evidence of
vascular disease of persistent more digits of persistent wide-
or a healed ulcer vascular disease both extremities spread or deep
or Raynaud’s or superficial with evidence of ulceration involv-
phenomena ulceration persistent vas- ing both upper
with obstructive cular disease or extremities
physiology that persistent wide-
incompletely spread or deep
responds to life- ulceration of one
style change or extremity
medical therapy
OBJECTIVE TEST Arterial Finger/brachial Mildly abnormal Moderately Markedly

RESULTS a calcification by indices < 0.8 or upper extrem- abnormal abnormal
radiography low digital tem- ity arterial or upper extrem- upper extrem-
peratures with venous Doppler ity arterial or ity arterial or
decreased laser study (excludes venous Doppler venous Doppler
Doppler signals amputation) study (excludes study (excludes
that do not amputation) amputation)
normalize with
warming
a
Key factor.
CLASS 0 further symptoms. Mild edema 1 year ago when he

0% Impairment of the Whole Person forgot stocking.
Physical Exam: Normal, currently no edema.
EXAMPLE 4 -26: LOWER EXTREMITY
Clinical Studies: Normal venous duplex.
PERIPHERAL VASCULAR DISEASE
Diagnosis: Mild incompetence of the left lower
extremity venous system.
History: Left leg edema after coronary artery
Impairment Rating: 0% (Class 0). According
bypass graft (CABG) surgery. No DVT or lower
to Table 4-12, the objective test results, physical
extremity cellulitis. Compression stocking; no
Guides6e_04_047-076.indd 70 3/3/09 6:29:13 PM

findings, and history place the examinee in Class 0, hypertension is typically diagnosed on echocardiogra-
impairment rating 0%. phy by estimated Doppler flow measurements across
the tricuspid valve,5 often with associated echocar-
diographic evidence of RV hypertrophy. Pulmonary
CLASS 4 hypertension may also be suspected from ECG
45%- 65% Impairment of the Lower Extremity changes. A right heart catheterization is rarely neces-
sary to make the diagnosis of pulmonary hypertension
due to the accuracy of Doppler echocardiography.13
EXAMPLE 4 -27: LOWER EXTREMITY
PERIPHERAL VASCULAR DISEASE, The criteria for rating impairment due to diseases of
IMPAIRMENT RATING the pulmonary artery are shown in Table 4-14.
History: Myocardial infarction; severe angina pec- CLASS 1
toris. Type 1 diabetic. Symptomatic PAD in lower 2% to 10% Impairment of the Whole Person
extremities for 9 years. Walking capacity < 25 feet
and calf pain at rest.
EXAMPLE 4 -28: PULMONARY HYPERTENSION
Current Symptoms: Pain worse at night.
Progressive renal insufficiency; creatinine 407
mmol/L (4.6 mg/dL). History: Moderate obesity with a body mass index
(BMI) of 32. No diet pill or illicit drug use.
Physical Exam: Cool extremity. Painful, nonheal-
Chapter 4
ing deep ulcerations right great toe and heel. Also, Current Symptoms: No symptoms.
infected deep ulceration left heel.
Physical Exam: Systolic ejection murmur.
Clinical Studies: Ankle brachial indices < 0.3.
Clinical Studies: Chest roentgenogram: normal.
Diagnosis: PAD with bilateral ischemic ulcerations ECG: normal. Echocardiogram: normal ventricular
and ischemic pain in diabetic man with severe CAD function. Mild pulmonary hypertension; estimated
and moderate renal insufficiency. PAP 45 mm Hg. Heart valves: normal.
Impairment Rating: 65% (Class 4E). According to Diagnosis: Mild pulmonary hypertension secondary
Table 4-12, the objective test results, physical find- to obesity.
ings, and history all place the examinee in class 4E,
Impairment Rating: 2% (class 1A). According to
impairment rating 65%, for each extremity, or 26%
Table 4-14, the PAP of 45 mm Hg places the patient
WPI for each lower extremity. As per the Combined
in class 1C. He has a normal physical exam and his-
Values Chart, page 604, whole person impairment
tory, which moves the impairment to grade A.
of 45%.
CLASS 2
4.9 Diseases of the Pulmonary

Artery EXAMPLE: 4 -29: PULMONARY HYPERTENSION

4.9a Criteria for Rating Impairment due History: Pulmonary embolism after arthroscopic
to Diseases of the Pulmonary Artery knee surgery 5 years ago.
Pulmonary arterial hypertension (PAH) is a progres-
Current Symptoms: Exertional dyspnea during
sive and debilitating disease whose true etiology often
doubles tennis; minimal (1+) pitting edema at end of
remains unknown. Causes of PAH include pulmo-
workday. Minimal ascites on close physical exam.
nary venous and capillary disorders, HF, pulmonary
emboli, pulmonary parenchymal disease, and obesity. Physical Exam: Parasternal heave left and right
Mitral Valve Disease can affect the presence of PAH lower sternal border; tricuspid regurgitation.
and must be considered in evaluating this impairment.
Clinical Studies: Echocardiogram: pulmonary hyper-
Classic findings of pulmonary hypertension on physi- tension. PAP: 55 mm Hg; systemic BP: 140/80 mm
cal examination include RV lift and an increased S2 Hg. Moderate RV enlargement; moderately severe
pulmonary component on auscultation. Pulmonary grade 3 of 4 tricuspid regurgitation. Started on a
Guides6e_04_047-076.indd 71 3/3/09 6:29:15 PM

TA B L E 4 -14 Criteria for Rating Impairment due to Diseases of the Pulmonary Artery
Pulmonary Artery Diseases

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY Asymptomatic Intermittent Mild dyspnea Moderate dys- Severe dyspnea

mild dyspnea and/or other pnea or other or other right-
not requiring right-sided right-sided heart sided heart fail-
treatment heart failure failure symptoms ure symptoms at
symptoms on on therapy or rest or intermit-
NYHA class I
therapy or inter- intermittent tent extreme
mittent moder- severe symptoms symptoms
ate dyspnea
NYHA class III NYHA class IV
NYHA class II
PHYSICAL Normal physical Minimal signs of Mild signs of Moderate signs Severe signs of
Chapter 4
FINDINGS exam right-sided heart right-sided of right-sided right-sided heart

failure heart failure heart failure failure (severe
No signs of
(peripheral (peripheral edema, asci-
right-sided heart
edema) edema, ascites) tes, pulmonary
failure
edema)
OBJECTIVE TEST Normal PAP Mild pulmonary Moderate pulmo- Severe pulmo- Severe pulmo-
RESULTS b by Doppler hypertension nary hyperten- nary hyperten- nary hyperten-
echocardiography (PAP 40-50) sion (PAP 51-75) sion (PAP > 75) sion (PAP > 75)
and and and and
at least 1 of: at least 1 of: moderate RV severe RV
enlargement on enlargement on
BNP level normal BNP < 100
echo 3–4 cm echo >4cm
VO2max > 20 VO2max 16-20
and and
METs > 7 METs > 7
at least 1 of: at least 1 of:
BNP 100-500 BNP > 500
VO2max 11-15 VO2max < 10
METs > 5 but < 7 METs < 5
a
NYHA indicates New York Heart Association; PAP, pulmonary artery pressure (in mm Hg); BNP, B-type natriuretic peptide (in
ng/mL); VO2max, maximum oxygen uptake (in mL/min/kg); and RV, right ventricular. No mitral valve disease present.
b
Key factor.
CLASS 3
regimen of nitrates, digitalis, and diuretics. After
3 months, dyspnea present; less peripheral edema.
Diagnosis: Moderate pulmonary hypertension and
EXAMPLE 4 -30: PULMONARY HYPERTENSION
RV failure.
Impairment Rating: 20% (class 2D). According
to Table 4-14, the objective test results place the History: History of Pulmonary Hypertension PAH.
patient in class 2; history and physical findings place Systemic BP: 120/75 mm Hg. Mild shortness of
the patient in classes 2 and 3, respectively. Final breath when pulling luggage at airport. Mild edema
impairment class/grade 2D, 20% impairment. and mild cyanosis with moderate exertion.
Guides6e_04_047-076.indd 72 2/17/09 2:31:43 PM

Current Symptoms: Performs some daily activi- History: Scleroderma; CREST syndrome.
ties without dyspnea; symptomatic with moderately Treatment: diuretics, nitrates, and digitalis.
severe exertion.
Current Symptoms: Exertional dyspnea with mild
Physical Exam: Increased right ventricular heave; to moderate exertion. Daily morning peripheral
increased P2. Moderate peripheral edema and mild edema. Very tired by midmorning.
ascites.
Physical Exam: Changes of scleroderma; systolic
Clinical Studies: Echocardiogram: increased heart murmur along lower left sternal border. Both
pulmonary pressure estimated at 80 mm Hg, lower extremities edematous, significant ascites,
moderate RV enlargement noted. Metabolic study rales on exam.
11 mm/min/kg.
Clinical Studies: Echocardiogram: large right ven-
Diagnosis: Idiopathic PAH. tricle with severely depressed function. Estimated
PAP: 80 mm Hg. Normal LV, left-sided heart valve
function. Exercise stress test: significant functional
impairment; 3.5 minutes on Bruce protocol before
stopping with severe dyspnea. METs 4.5. Peak
HR: 115 BPM.
Diagnosis: Pulmonary Hypertension PAH with
associated scleroderma and symptoms of moderate
CLASS 4 to severe functional limitation.
Chapter 4
Impairment Rating: 50% (class 4B). According to
Table 4-14, the objective test results place patient
EXAMPLE 4 -31: PULMONARY HYPERTENSION in class 4; history and physical findings place the
patient in classes 3 and 4, respectively, for a 4B
impairment rating of 50%.
Guides6e_04_047-076.indd 73 2/17/09 2:31:44 PM

4.10 Cardiovascular Impairment the patient’s functional history and physical findings
Evaluation Summary on examination serves to identify the proper impair-
ment grade within the impairment class established
by the key factor. The classification tables presented
In summary, emphasis is made in this chapter on the
in Table 4–15 have been restructured for greater
use of objective testing as the key factor in impair-
internal consistency and functional relevance.
ment estimations. Corroborative information from
TA B L E 4 –15 Cardiac Impairment Evaluation Summary

Disorder History, Including Selected Examination Record Assessment of Cardiac Function
Relevant Symptoms
General Cardiovascular symptoms Comprehensive Data derived from relevant studies

(eg, fatigue, palpitations, physical examination; (eg, ECG, echocardiography,
dyspnea, chest pain) and detailed cardiovascular echocardiogram, stress tests, cardiac
general symptoms; impact of system assessment catheterization)
symptoms on function and
ability to do daily activities
Prognosis if change anticipated
Review medical history
Valvular Discuss symptoms and any Note rate, rhythm, Doppler echocardiography or cardiac
Heart Disease resulting limitation of physical heart sounds, and catheterization
activity (eg, angina) other organ function
Chapter 4
Address cardiac output, pulmo-

nary and systemic congestion
Coronary Angina pectoris; reduced Detailed history Coronary angiography; chest x-ray; ECG; EF;
Artery ventricular function; limitation of studies may be obtained at rest and during
Note rate, rhythm,
Disease physical activity due to fatigue; and after exercise
heart sounds, and
palpitations; dyspnea; anginal
other organ function
pain
Cardio- Exertional dyspnea; angina; Note rate, rhythm, Echocardiography; ECG; chest
myopathies syncope; pulmonary or systemic heart sounds, and roentgenogram; abnormal ventricular
organ congestion other organ function function; dynamic outflow tract obstruction
Pericardial Chest pain Note rate, rhythm, ECHO-pericardial effusion, thickening, or

Heart Disease heart sounds (pericar- calcification; thickened pericardium on CT
Note active inflammation,
dial rub, early diastolic scan or MRI; cardiac catheterization
increase in ESR
pericardial knock), and
other organ function
Dysrhythmias Syncope; weakness and fatigue; Note rate, rhythm, ECG: frequent premature complexes,
palpitations; dizziness; chest heart sounds; docu- tachycardia
heaviness; shortness of breath ment dysrhythmias and
Echocardiogram: atrial enlargement
estimate its frequency
Holter monitoring
Hypertensive Determine symptoms that docu- Comprehensive; note ECG, echocardiogram, stress testing,
Cardio- ment cardiac, renal, and cere- end-organ conditions catheterization; serum BUN and creatinine,
vascular brovascular limitation urinalysis and urinary protein excretion,
Disease creatinine clearance or GFR assess-ment; renal
ultrasound; head CT or MRI scan; angiography
Peripheral Full history, including degree of Comprehensive Stress testing; ankle-brachial pressure indices
Vascular limitation of activities of daily examination and transcutaneous oximetry; peripheral
Disease living angiography; venous imaging with dye or
ultrasound/Doppler
Lymphatic assessment with contrast or tagged
markers
Pulmonary Detailed history with regard to Comprehensive Echocardiography; pulmonary angiography;

Artery functional impairment and prior examination CT or MRI imaging
Disease medical issues, medication usage,
and occupational exposure
Guides6e_04_047-076.indd 74 2/17/09 2:31:44 PM

End-Organ Diagnosis(es) Degree

Damage of Impairment
Include assessment of sequelae, including Record all pertinent diagnosis(es); note if they are at Criteria outlined
end-organ damage and impairment maximal medical improvement; if not, discuss under in this chapter
what conditions and when stability is expected
Assess relevant organs (eg, lungs, kidneys) Aortic or mitral valve stenosis; mitral valve prolapse; See Table 4-5
for congestion or dysfunction aortic or mitral valve regurgitation; aortic and/or
mitral valve disease; ventricular dysfunction
Chapter 4
Assess relevant organs (eg, brain, lungs, kid- MI; angina pectoris; coronary artery vasospasm; ven- See Table 4-6
neys, eyes, peripheral vascular system) tricular failure
Assess relevant organs (eg, brain, lungs, kid- Dilated or congested; hypertrophic; restrictive See Table 4-7
neys, peripheral vascular system)
Assess relevant organs (eg, brain, lungs, kid- Constrictive or idiopathic pericarditis; tamponade; See Table 4-8
neys, peripheral vascular system) tumor; pericardial effusion; pericardial damage
Assess relevant organs (eg, brain, lungs, kid- Syncope; VT; atrial fibrillation; copmplete heart block; See Table 4-9
neys, peripheral vascular system) premature complexes
Heart; eyes; kidney; brain; monitor for protein- Hypertension; left ventricular hypertrophy; hyper- See Table
uria, elevated creatinine, reduced creatinine tensive hypertrophic cardiomyopathy; hypertension- 4-10 and 4-11
clearance, and abnormal urinary sediment; related systolic heart failure; hypertension-related
funduscopic changes including silver-wiring diastolic heart failure; hypertensive nephrosclerosis;
and arterio-venous crossing changes hypertensive encephalopathy; stroke; TIA
Upper and lower extremities Raynaud’s phenomenon; arterial and venous ulceration; See Tables
claudication; arterial aneurysms excluding the aorta; 4-12 and 4-13
ischemic digital amputation, gangrene, and thromboan-
giitis obliterans
Venous disorders, including edema, induration, stasis
dermatitis, cellulitis, ulceration, and thrombosis
Lymphatic disorders, including lymphedema, lymphan-
gitis, and cellulitis
Assess cardiac and pulmonary damage Primary and secondary pulmonary hypertension; pul- See Table 4-14
monary embolism; pulmonary veno-occlusive disease;
pulmonary vein stenosis
Guides6e_04_047-076.indd 75 2/17/09 2:31:45 PM

11. Spertus JA, Winder JA, Dewhurst TA, et al.

References Development and evaluation of the Seattle Angina
Questionnaire: a new functional status measure
1. American Medical Association, Chicago Il. for coronary artery disease. J Am Coll Cardiol.
https://catalog.ama-assn.org/Catalog/ 1995;25:333-341.
home.jsp?checkXwho=done. Accessed 05/07. 12. Rector TS, Cohn JN. Minnesota Living With Heart
2. ACC/AHA 2002 guideline update for the management Failure Questionnaire. Available at:
of patients with chronic stable angina. J Am Coll http://www.mlhfq.org. Accessed May 21, 2007.
Cardiol. 2003;41:159-168. 13. Bonow, et al. ACC/AHA Task Force report.
3. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA J Am Coll Cardiol. 1998:32:1486-1588.
guidelines for exercise testing: a report of the American 14. Feigenbaum H, Armstrong WF, Ryan T. Feigenbaum’s
College of Cardiology/American Heart Association Echocardiography. 6th ed. Philadelphia, Pa: Lippincott
Task Force on Practice Guidelines (Committee on Williams & Wilkins; 2005:chaps 10-12.
Exercise Testing). J Am Coll Cardiol. 1997;30:260-311.
15. Van de Werf F. Cardiac troponins in acute coronary
4. Klocke, et al. ACC/AHA/ASNC guidelines for the syndromes. N Engl J Med. 1996;335:1388-1389.
clinical use of cardiac radionuclide imaging.
J Am Coll Cardiol. 2003. 16. ACC/AHA guidelines for the management of patients
with ST-elevation myocardial infarction. J Am Coll
5. ACC/AHA/ASE 2003 guideline update for the clinical Cardiol. 2004;44:671-719.
application of echocardiography. J Am Coll Cardiol.
2003;42:954-70; Circulation. 2003;108:114-662; and 17. ACC/AHA/NASPE 2002 guideline update for
J Am Soc Echocardiogr. 2003;16:1091-1110. implantation of cardiac pacemakers and antiarrhythmia
devices. J Am Coll Cardiol. 2002.
6. Nishimura RA, Tajik AJ. Evaluation of diastolic
filling of left ventricle in health and disease: Doppler 18. Leon AR, Abraham WT, Brozena S, et al. Cardiac
echocardiography is the clinician’s Rosetta Stone. resynchronization with sequential biventricular pacing
for the treatment of moderate-to-severe heart failure.
Chapter 4
J Am Coll Cardiol. 1997;30:8-18.

J Am Coll Cardiol. 2005;46:2298-2304.
7. ACC/AHA key data elements and definitions for
measuring the clinical management and outcomes of 19. National Institutes of Health, National Heart, Lung,
patients with chronic heart failure. J Am Coll Cardiol. and Blood Institute, National High Blood Pressure
2005;46:1179-1207. Education Program. The Seventh Report of the Joint
National Committee on Prevention, Detection,
8. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid Evaluation, and Treatment of High Blood Pressure
measurement of B-type natriuretic peptide in the (JNC 7). August 2004.
emergency diagnosis of heart failure. N Engl J Med
2002;347:161-167. 20. 2005 AHA/ACC guidelines for the management
of patients with peripheral arterial disease (lower
9. McCullough PA, Nowak RM, McCord J, et al. B-type extremity, renal, mesenteric, and abdominal aortic): a
natriuretic peptide and clinical judgment in emergency collaborative report from the American Association for
diagnosis of heart failure: analysis From Breathing Vascular Surgery/Society for Vascular Surgery, Society
Not Properly (BNP) Multinational Study. Circulation. for Cardiovascular Angiography and Interventions,
2002;106:416-422. Society for Vascular Medicine and Biology, Society
10. Mueller C, Scholer A, Laule-Kilian K, et al. Use of Interventional Radiology, and the ACC/AHA Task
of B-type natriuretic peptide in the evaluation Force on Practice Guidelines (Writing Committee to
and management of acute dyspnea. N Engl J Med. Develop Guidelines for the Management of Patients
2004;350:647-654. With Peripheral Arterial Disease). J Am Coll of
Cardiol. 2006.
Guides6e_04_047-076.indd 76 2/17/09 2:31:45 PM

CHAPTER 5
The Pulmonary System
5.1 Assessing the Pulmonary System
5.2 Clinical Presentation of Pulmonary Disease
5.3 Environmental Exposures, Lifestyle

Choices, and Pulmonary Disease
5.4 Clinical Evaluation, Imaging Studies, and

Other Tests for Evaluating Pulmonary
Disease
5.5 Methodology for Determining the Grade in

an Impairment Class
Introduction
Chapter 5
This chapter provides a framework for the recogni-
5.6 Asthma and Other Hyperreactive Airway
tion and assessment of pulmonary impairments that
Diseases
affect the individual’s ability to perform Activities
of Daily Living (ADLs). Pulmonary assessment
5.7 Hypersensitivity Pneumonitis
requires clinical evaluation, measurement of pul-
monary function, analysis of the relevant data and
5.8 Pneumoconiosis
then comparison of this clinical information to the
Guides’ criteria to arrive at an impairment rating.
5.9 Lung Cancer
This chapter provides a brief overview of the prin-
5.10 Sleep Disorders and Other Impairments ciples of pulmonary assessment. The most recently
Related to Pulmonary System published guidelines from the American Thoracic
Society (ATS) and the European Respiratory Society
5.11 Examples of Impairment due to Pulmonary (ERS) are the primary references used in this chap-
Disorders ter. Additionally, a brief discussion is provided on
the use of contemporary diagnostic testing, includ-
5.12 Pulmonary Impairment Evaluation ing the use of specific laboratory data and imaging
Summary studies. For a more detailed review of pulmonary
assessment, the reader should refer to the numerous
textbooks available on the subject.
Substantial transformation is apparent throughout
this edition of the Guides. The reader is encouraged
to read Chapters 1 and 2 in their entirety and under-
stand the key concepts and philosophy of the AMA
Guides before reading this chapter.
77
Guides6e_05_077-100.indd 77 3/3/09 6:29:52 PM

The functional impairment classes have been exposures may be associated with just one of the
standardized. In addition, the Table of Permanent many occupations in a workplace. A thorough his-
Pulmonary Impairment has been updated to reflect tory enables the examiner to direct the physical
consistency to the extent that is practical with the examination to areas of concern and identify the
common impairment rating grid and to comply with most appropriate diagnostic studies. The physician
the goal to create uniformity and internal consis- then evaluates the structural or movement abnormal-
tency across various chapters. ities of the chest and its contents. Important features
of the examination are detailed in Section 5.4.
A relatively new concept, “Burden of Treatment
Compliance,” has also been introduced into the Sixth Although imaging techniques provide information
Edition and relates well to impairment ratings for on the radiographic severity of a pulmonary abnor-
asthma and other pulmonary disorders. As the treat- mality, they are most helpful in identifying and diag-
ment options increase for a variety of pulmonary nosing lung disease. Radiologic techniques provide
disorders, individuals are able to live longer with visual evidence of internal anatomic abnormalities
less dysfunction, albeit at the expense of rigid com- that are not apparent by external inspection, palpa-
pliance with the treatment. Most disease survivors tion of the chest wall, or percussive or auscultatory
are therefore receiving treatment and lead produc- assessment. Advanced radiographic techniques
tive lives, yet without treatment, members of this may be necessary. For example, a high-resolution
group would have limited function leading to greater computed tomography (CT) scan of the chest may
impairment. Any Burden of Treatment for pulmo- help elucidate anatomic abnormalities recognized
nary disease is already accounted for in the various in interstitial lung diseases, and a CT scan with pul-
impairment tables in this chapter and must not be the monary embolism protocol may identify obstructive
basis for additional impairment. abnormalities in the larger pulmonary arteries.
Pulmonary function tests are the most reliable for
assessment of functional changes in the lungs and
pulmonary interstitium. The appropriate techniques
5.1Assessing the are discussed in Section 5.4. These tests are most
Pulmonary System helpful in addressing the category of respiratory dis-
ease and the extent of impairment.
The goals of the impairment assessment of the
Chapter 5
pulmonary system should be to determine if a per-

manent pulmonary impairment exists, quantify its
severity, assess its impact on the ability to perform 5.2Clinical Presentation of
ADLs, and, when possible, identify the cause of the Pulmonary Disease
abnormality and recommend measures to prevent
progression of impairment and ensure optimum
Symptoms and signs associated with pulmonary dys-
function.
function include dyspnea, cough, sputum production,
A detailed clinical evaluation of the pulmonary hemoptysis, wheezing, chest pain or tightness, and
system should begin with a comprehensive history. night sweats. Although quantification of some of
An inquiry into specific symptom severity, duration, these indicators of pulmonary abnormalities may
and manner of onset guides the initial evaluation. be difficult in view of their subjective nature, the
Personal habits, especially the use of cigarettes and severity, duration, and manner of onset of each of
drugs, must be ascertained. An individual’s child- these specific symptoms should be explored during
hood illnesses, previous chest diseases, surgery, history taking.
or trauma to the chest may be of consequence. A
detailed work history is of critical importance. 5.2a Dyspnea
Workplace exposures to potentially toxic substances Dyspnea is the most common presenting symptom in
might explain or contribute to respiratory symptoms. patients with pulmonary impairment. Its importance
When work exposures are thought to be a potential is matched only by its nonspecificity and resistance
cause for impairment, a systematic review of all jobs to objective quantification. Dyspnea can be caused
and their possible exposures beginning with employ- by deconditioning, anxiety, or diseases of cardiac,
ment during the worker’s teen years may well be hematologic, metabolic, or neurologic origin.
relevant. Each of a worker’s jobs should be described
Various schemes have been developed to grade dys-
in detail, because often specific environmental
pnea. The most widely used classification system
Guides6e_05_077-100.indd 78 2/17/09 2:34:32 PM

The Pulmonary System 79
TA B L E 5 -1
Impairment Classification of Dyspnea (Adapted)a Once nonpulmonary causes of cough are ruled out,
Severity Definition and Question an acute, self-limited cough most commonly is
Mild Do you have to walk more slowly on
reasonably attributed to infection or airway irrita-
level ground than people of your age tion. A subacute or recurrent non-productive cough
because of breathlessness? may be a manifestation of asthma and should be
Moderate Do you have to stop for breath when investigated further with pulmonary function test-
walking at your own pace on level ing. A chronic, productive cough is often a marker
ground? of bronchitis. According to ATS criteria, the term
Severe Do you ever have to stop for breath after chronic bronchitis is used to describe a cough
walking about 90 m (100 yd) or for a few
productive of sputum that occurs on most days for
minutes on level ground?
at least 3 consecutive months per year, for at least
Very severe Are you too breathless to leave the
house, or breathless on dressing or
2 years in succession.7 In some individuals with a
undressing? chronic productive cough, bronchiectasis should
a
be considered.8
Adapted from Ferris BG. Epidemiology standardization project:
American Thoracic Society. Am Rev Respir Dis. 1978;118(6, pt 2): Hemoptysis frequently accompanies bronchitis and
1–120. The person’s lowest level of physical activity and exertion
that produces breathlessness denotes the severity of dyspnea. pneumonia, usually in the form of blood-streaking of
the sputum. Although a common cause of hemoptysis
is bronchitis, hemoptysis may be life-threatening, with
serious causes including bronchogenic carcinoma,
pulmonary embolism, bronchiectasis, tuberculosis,
is based on the ATS Lung Diseases Pulmonary
vasculitis, and arteriovenous malformations. The pres-
Symptom Questionnaire1 (Table 5-1). This classifica-
ence of hemoptysis requires evaluation to determine
tion is an attempt to provide a reasonable means to
whether this finding indicates a disease that might
compare an individual’s symptoms with objective
lead to impairment. In particular, hemoptysis in male
measurements of pulmonary function. Although
smokers over the age of 50 years carries a high risk of
generally helpful,2 in some instances, there may be a
lung cancer, and bronchoscopy is indicated.9
poor correlation between lung function (as measured
by spirometry) and subjective complaints. Examples
5.2c Wheezing
when this might occur could include individuals
High-pitched, musical sounds often are described as
with normal lung function but with pulmonary vas-
Chapter 5
wheezing by patients who have partial airway obstruc-
cular disease, an asthmatic who has recovered from
tion. These sounds can be generated at any point
an acute episode, or an applicant for disability who
along the airway from the glottis to the bronchioles.
exaggerates his or her symptoms. If there is a great
Identification of the part of the respiratory cycle where
disparity between the subjective complaints and the
the wheeze is identified is important. Inspiratory
objective findings, a more complete and detailed
wheeze, or stridor, suggests laryngeal disease, whereas
investigation may be necessary.3
expiratory wheeze can be a feature of bronchospasm or
bronchitis and suggest airway secretions with localized
5.2b Cough, Sputum Production,
bronchial narrowing. Seasonal occurrence of wheez-
and Hemoptysis
ing suggests allergy. Intermittent wheezing suggests a
Although cough is considered to be an important
bronchospastic, allergic, or asthmatic cause,10 whereas
indicator of lung disease,2 there are other explana-
persistent wheezing raises the suspicion of a fixed bron-
tions for cough, including such non-pulmonary
chial obstruction. Wheezing and/or cough occurring
illnesses as gastroesophageal reflux,3 medica-
primarily in the workplace, or having a definite tempo-
tion,4 postnasal drip, and esophageal dysfunction.5
ral relationship to work, suggest occupational asthma.11
Although a recent review has suggested that comput-
Wheezing that follows several minutes of exercise
erized cough counting over a 24-hour period is an
suggests exercise-induced asthma.12 Finally, wheezing
effective way to determine the severity of cough, it
that usually accompanies pulmonary tract infections,
is a research tool and not widely available.6 For these
typically in an asthmatic, can be classified as asthmatic
reasons, the presence of cough is not considered an
bronchitis.13
objective determinant of pulmonary impairment.
Nonetheless, it is incumbent on the physician to Although these different varieties of asthma are
document its presence or absence, associated sputum commonly described as separate entities, the clinical
production, duration, and any associated hemoptysis. presentations are similar, attributable to the common
The purpose of this documentation is to identify underlying mechanism of airway hyperresponsiveness.
individuals who require further evaluation.
Guides6e_05_077-100.indd 79 2/17/09 2:34:33 PM

5.3 Environmental Exposures, of pulmonary protective devices is important and

Lifestyle Choices, and Pulmonary should be elicited. The number of years the devices
were used with each employer should be recorded.
Disease
In addition to information regarding workplace
environmental exposures, information should be col-
5.3a Tobacco Use lected about hobbies or leisure activities that might
The most common cause of pulmonary impairment involve exposure to potential respiratory toxins.
is cigarette smoking. Although there is variable indi- Home and environmental exposures (encountered in
vidual susceptibility to the adverse effects of cigarette the enjoyment of a hobby or during a leisure activity)
smoke, a discernible dose-response relationship is to organic and inorganic agents such as allergens,
commonly recognized.14 The examining physician bioaerosols, paints, glues, or pesticides may be more
should standardize data collection regarding cigarette potent causative agents of a pulmonary disorder
use by inquiring about the age when the patient started than the putative agents present in the workplace. As
smoking, age at quitting or current age if the smoking examples, in the home, exposure to pets and the use
continues, and the average number of packs smoked of cool-mist vaporizers, humidifiers, and indoor hot
per day. Multiplying the number of years of smoking by tubs may be associated with pulmonary disease.
the number of packs smoked per day produces a com-
There are a number of ways that the lung can be
monly expressed measure for cigarette use, pack-years.
injured and disabilities can develop. The outcome of
This information can be used in assessing the impact
the exposure to the toxic agent, irritant, or sensitiz-
of personal habits on pulmonary impairment and may
ing material varies based on whether the exposure is
aid in the apportionment of pulmonary abnormality
acute or chronic in nature, the amount of the agent
among various deleterious factors. Cigarette smoking
in the ambient environment at the time of exposure,
is the most significant causative factor in the devel-
and the physical characteristics of the agent.
opment of chronic bronchitis, emphysema, and lung
cancer. Chronic exposure to environmental tobacco An acute, excessive irritant gas exposure can be
smoke (ETS, or “second-hand” smoke) appears to be associated with several outcomes. Acute pulmonary
carcinogenic,15 promulgates adverse asthma outcomes parenchymal injury may result from the inhalation of a
in younger individuals,16 and potentiates the risks for highly irritant gas, fume, mist, or vapor. This is recog-
atherosclerotic vascular disease.17 Smoking cessation in nized as noncardiogenic pulmonary edema or the acute
Chapter 5
individuals with underlying lung disease can be a life- respiratory distress syndrome (ARDS). If the individual
saving intervention.18 survives the acute pulmonary injury, the healing pro-
cess may produce diffuse pulmonary fibrosis or obliter-
5.3b Occupational History ative bronchiolitis, both of which may lead to functional
Environmental exposure in the workplace often is impairment. If the outcome of such an exposure is per-
cited as a causative or contributory factor in the sistent cough and asthma, this is described as reactive
development of pulmonary impairment. To evaluate airways dysfunction syndrome (RADS).
the possible effects of such exposure, it is impor-
Recurrent inhalation of gases or fumes at irritant
tant to obtain a complete occupational history. A
exposure levels can result in persistent airway irrita-
major part of the history consists of a chronological
tion and cause chronic bronchitis. If the worker is
description of work activities beginning with the
exposed to agents with a sensitizing potential, airway
year of first employment. This description includes
hyperresponsiveness can develop and the signs and
the names of employers, the specific types of work
symptoms of asthma develop. An irritant exposure
performed, the material or materials used, and the
can also exacerbate (ie, cause a temporary worsen-
potentially toxic material that the worker is able to
ing that returns to baseline) a worker’s preexist-
identify in the workplace. Employers are required
ing, underlying condition such as asthma, chronic
to maintain a list of potentially toxic materials used
bronchitis, or emphysema. Inhalation of organic
in the workplace. This is available to the employee
material or certain types of reactive chemicals
and the treating physician in the form of Material
can cause hypersensitivity pneumonitis or asthma
Safety Data Sheets. Such information includes the
through an immune-mediated pulmonary mecha-
chemical descriptions of the agent under consid-
nism. Inhalation of fibrogenic dusts, typically over a
eration, and the physical and health hazards. This
protracted time, can cause pneumoconiosis (eg, sili-
information can aid the examiner in directing the
cosis, asbestosis, or coal workers’ pneumoconiosis).
assessment. An estimate of frequency, duration, and
Workplace exposures to a variety of carcinogens,
intensity of exposure to each substance is needed
such as asbestos, can cause lung cancer.
to assess its significance. Information about the use
Guides6e_05_077-100.indd 80 2/17/09 2:34:33 PM

5.4 Clinical Evaluation, Imaging changes in skin pigmentation, heart disease associ-
Studies, and Other Tests for ated with right to left shunt, and severe pulmonary
impairment. Poor lighting in the examination room
Evaluating Pulmonary Disease can interfere with assessing its magnitude. Suspicion
of cyanosis calls for measurement of oxygen satura-
tion by pulse oximetry or arterial blood gas analysis.
5.4a Physical Examination
Although less likely, also consider methhemoglo-
Although a thorough physical examination is impor-
binemia or carboxyhemoglobinemia.
tant in judging pulmonary impairment, it may not
be sensitive in early stages of pulmonary disease, or Hypercarbia may be suspected in an individual with
it may be normal in a disease such as asthma during a substantially impaired respiratory status; however,
the nonacute phase. A thorough physical examina- accurate assessment of this abnormality requires
tion should include: arterial blood gas determination. Alternatively, meta-
bolic testing can measure end-tidal CO2 and provide
• Vital signs measured after the patient has had an
a reliable assessment.
opportunity to relax and become accustomed to
the surroundings. Digital clubbing is characterized by loss of the angle
at the junction of the cuticle and the nail, softening
• A detailed chest examination. The physician
of the nail bed, increased curvature of the nail, and
should note the use of accessory muscles on
widening of the distal portion of the fingers or toes.
respiration and the patient’s body habitus. A
It is usually a sign of advanced disease. Diseases of
breathing pattern characterized by pursing the
the chest associated with clubbing include pulmo-
lips during expiration suggests chronic obstruc-
nary fibrosis, bronchiectasis, bronchogenic carci-
tive pulmonary disease (COPD). The thoracic
noma, pleural tumors, lung abscess, empyema, and
cage should be inspected for vertebral or rib cage
cyanotic congenital heart disease.
deformity, wasting of the intercostal muscles, fea-
tures of a barrel-shaped chest that may indicate
5.4b Imaging Studies of the Chest
hyperinflation, and adequacy of the movement of
the ribs with inspiration and expiration. Chest Roentgenograms
The initial chest radiographic examination should
• Percussion of the chest is carried out to ascertain
include posteroanterior and lateral views of the chest
hyperresonance or consolidation and to assess
Chapter 5
taken in full inspiration. Chest radiographic find-
diaphragmatic motion.
ings often correlate poorly with physiologic findings
• In a healthy chest, auscultation reveals vesicular in diseases with airflow limitation, such as asthma
breath sounds throughout the lung, with broncho- and emphysema, particularly in the tall and slender
vesicular sounds over the trachea. Adventitious individual. Persistent abnormalities of the chest radio-
sounds include decreased breath sounds, crack- graph may be classified as parenchymal, vascular,
les, wheezes, and rhonchi. The intensity, qual- pleural, or osseous. Inspection of the mediastinum and
ity, and location of wheezing, rhonchi, and rales trachea and the major airways may identify abnor-
should be described, as well as whether they are malities. Terms used to describe parenchymal changes
heard during inspiration, expiration, or both. In include hyperinflation, fibrosis, cavitary, or cystic.
bronchitis, coarse sounds attributable to airway
Briefly, airway obstruction as seen in asthma, emphy-
secretions change location with cough. Crackles
sema and bronchitis may show hyperinflation of the
are typically present in individuals with inter-
lungs with accentuated bronchi. Asthma and emphy-
stitial disease; these usually occur during late
sema are associated with parenchymal destruction
inspiration. Early inspiratory crackles may be
identified as flattening of the diaphragms, vascular
heard in bronchiolitis obliterans. The presence of
attenuation, an increased anteroposterior diameter of
wheezing cannot be excluded until the physician
the chest, and increased retrosternal airspace. In addi-
performs auscultation during both quiet breathing
tion, the plain chest radiograph can provide evidence
and forced expiration. Diffuse, bilateral, expira-
of pulmonary vascular abnormalities associated with
tory wheezing indicates generalized broncho-
chronic pulmonary disease. Pulmonary hypertension is
spasm, whereas unilateral or localized wheezing
indicated by bilateral enlargement of the main pulmo-
may be caused by partial bronchial obstruction.
nary arteries and rapid tapering of the peripheral ves-
Cyanosis, indicated by a bluish discoloration of the sels. Cor pulmonale is suggested by enlargement of the
lips, is a striking but unreliable indicator of impair- right ventricle and the changes of pulmonary hyperten-
ment. Its presence can be attributed to anemia, sion. The presence of pulmonary hypertension and cor
Guides6e_05_077-100.indd 81 2/17/09 2:34:34 PM

pulmonale should be confirmed by additional clinical Computed Tomography

and laboratory tests. Computed tomography and high-resolution com-
puted tomography (HRCT) scans are radiographic
The radiographic features of fibrotic lung diseases
techniques that may augment the standard chest
may be localized or diffuse, reflecting the distribu-
radiograph. A conventional CT scan is obtained
tion of such anatomic features in the lung. Because
by averaging the signals of 10-mm-thick sections
of the redundancy of pulmonary tissue in the normal
through various lung fields. This technique is good
individual, diffuse fibrotic disease is much more
for identifying anatomic features and for recognizing
likely to cause impairment than is localized disease.
nodules with high radiographic attenuation. Because
Diffuse, fibrotic abnormalities assume the charac-
HRCT consists of 1- to 2-mm-thick sections through
teristic radiologic appearance of rounded (nodular)
the affected part of the lung, it provides a clearer
or linear (reticular). Specific diagnostic information
definition of the parenchyma; it is most useful for
is obtained by describing both the type and the pre-
addressing interstitial lung disease. There is no stan-
dominant location of fibrotic changes observed on
dardized process for the evaluation of interstitial
the chest radiograph. As examples, sarcoidosis, coal
abnormalities found by HRCT comparable to that
workers’ pneumoconiosis, the miliary distribution of
used in the evaluation of the chest radiograph.22 The
fungal or acid-fast organisms (eg, miliary tuberculo-
standard CT and/or HRCT can provide greater accu-
sis), and silicosis all may present with a distribution
racy as part of a thorough assessment of the pulmo-
of small lung nodules (typically in the upper zones
nary parenchyma. With its fewer sections, the HRCT
with silicosis) and not infrequently with additional
delivers significantly less whole body effective dose
radiographic abnormalities. Interstitial lung diseases
radiation than does the standard CT.
with irregular or linear abnormalities are typically
distributed in the lower zones and include sclero- Also, HRCT is helpful in the detection of early
derma, idiopathic pulmonary fibrosis, and asbesto- changes in the lung consistent with focal emphy-
sis. Pleural abnormalities, such as pleural plaques or sema; regional air trapping associated with small
diffuse pleural thickening, may also be identified in airway disease, such as obliterative bronchiolitis;
individuals with asbestosis or may be the sole mani- and large airway abnormalities, such as bronchiec-
festation of past asbestos exposure. In the absence of tasis. For example, air trapping of the type seen with
pulmonary fibrosis, asbestos pleural plaques are not obliterative bronchiolitis is best demonstrated by
associated with pulmonary impairment unless exten- comparing full inspiratory and full expiratory scans.
Chapter 5
sive, diffuse, massive pleural thickening causes lung Prone and supine position scans also are helpful in
entrapment. distinguishing hydrostatic changes related to blood
volume that are transient and can occur in the depen-
A standardized scheme of classifying radiographic
dent position of the lungs from fixed parenchymal
abnormalities associated with fibrotic diseases
abnormalities.23
caused by the pneumoconioses was adopted by
the International Labor Office (ILO) in 1950 and
5.4c Spine and Other Musculoskeletal
was most recently revised in 2000.19 Although not
Abnormalities Affecting Pulmonary
designed to be used in the context of impairment
Function
assessment, this radiograph evaluation and grad-
Thoracic cage and osseous spine abnormalities may
ing process has become a key part of the medical
produce pulmonary impairment due to mechanical fac-
legal system. It is worth noting that the purported
tors that affect the size of the chest cavity and restrict
objective nature of the ILO classification system
rib motion. Kyphoscoliosis, the most common of these
notwithstanding, the correlation of interpretations
abnormalities, is characterized by curvature of the
and readings with physiologic measures of impair-
vertebral column from side to side in the frontal plane
ment is poor. Some reports address the interrater and
(scoliosis) and from the dorsal to the ventral aspect in
even intrarater reliability of the ILO classification
the sagittal plane (kyphosis). Although not always inter-
system, particularly in the medicolegal context.20 The
preted in a uniform manner, the Cobb method is a com-
US National Institute for Occupational Safety and
monly used measurement tool for curvature severity.24
Health (NIOSH) regularly administers an examina-
With this method, the posteroanterior and lateral spinal
tion to certify knowledge and proficiency in the use
radiographs measure the curvature angles. Only severe
of this method.21 Those competent in this evaluation
curvature angles—Cobb angles that are greater than
process are identified as “B” readers. In association
100°—are likely to lead to pulmonary failure. Even
with the American College of Radiology, NIOSH
when there are severe spinal deformities, pulmonary
provides hands-on training seminars as well as a
decompensation usually does not occur until middle
self-study program.
age or later.
Guides6e_05_077-100.indd 82 2/17/09 2:34:34 PM

With severe spinal abnormalities, pulmonary com- forced expiratory volume in the first second (FEV1),
promise is produced by the combined effects of and the ratio of these measurements (FEV1/FVC).
restricted lung volume, decreased cross-sectional
Interpretation of lung function tests involves 2 tasks.
area of the vascular bed, and age-related decrease in
The first is the comparison of the tested individual’s
chest wall compliance. Progressive stiffness of the
values to a set of reference values, and the second is
chest wall with advancing age increases the work of
an interpretation of the values that were measured.
breathing and leads to hyperventilation, which pro-
Recommendations for selecting reference values
duces hypoxia and hypercapnia. Hypoxia is a power-
include the following: sex (gender), matching age-
ful pulmonary vasoconstrictor and further decreases
range height, and racial or ethnic background. There
the vascular cross-sectional area, eventually leading
should be similar lung function instruments and
to cor pulmonale. Judge the severity of pulmonary
lung function testing protocols in the tested groups
impairment on the criteria described in the sections
compared with the reference group. All parameters
on forced pulmonary maneuvers, diffusing capac-
should be taken from the same reference source.
ity for carbon monoxide, and the criteria for rating
Differences in the assessment of lung function using
impairment due to pulmonary disease in this chapter.
different sets of reference equations have been rec-
ognized.27 A difference in prediction values for dif-
5.4d Physiologic Tests of
ferent races has been identified.28 Specifically, North
Pulmonary Function
American whites have larger spirometric values for
Pulmonary function studies including spirometry,
a given age, height, and sex than North American
diffusing capacity of the lung for carbon monoxide
blacks, with a similar tendency noted for Hispanics,
(DLco) and measurements of exercise capacity such
Native Americans, and Asians; in the past, adjust-
as oxygen consumption per unit time (Vo2), per-
ments were made in the prediction equations based
formed on standardized equipment with validated
on race. Currently, the Third National Health and
administration techniques, provide the quantitative
Nutrition Examination Survey (NHANES III) has
measurement on which the pulmonary impairments
ethnically appropriate reference equations that
tables are based in this chapter. It is critical that the
are recommended for people aged 8 to 80 years.29
technician be appropriately trained and knowledge-
Reference values for whites, African Americans, and
able regarding the contraindications of performing
Mexican Americans aged 8 to 80 years were devel-
spirometry, optimally measuring patient features
oped from 7429 asymptomatic, lifelong nonsmokers.
such as height and weight, knowing how to position
Chapter 5
Reference values and lower limits of normal were
the individual to optimally perform lung function
derived using a model with age and height as pre-
tests, and protecting the patient from infection.25
dictors. These reference values encompass a wide
Spirometric testing equipment, calibration, age range for 3 racial or ethnic groups and make it
and administration techniques must conform unnecessary to use adjustments for race.
to the guidelines presented in the ATS/ERS
Measurement of total lung capacity can be an impor-
Standardization of Spirometry26 report. When the
tant part of lung function assessment. A number of
clinician desires to document reversible airway
different approaches to measuring lung volumes have
obstruction, the subject should undergo baseline
been put forward, including body plethysmography
testing if not taking any drugs before the test. Short-
(using various methods), nitrogen washout, gas dilu-
acting drugs (albuterol, salbutamol, and ipratropium)
tion, and radiographic imaging. More recently, mea-
should not be used within 4 hours of testing. Longer
surement of lung volumes using imaging techniques
acting -agonists (salmeterol, formoterol), oral ami-
such as CT or magnetic resonance imaging (MRI)
nophylline, leukotriene receptor antagonists, tiotro-
have been added. There are inadequate data to rec-
pium, or slow-release -agonists should be withheld
ommend one approach over another.30 The readers
for at least 12 hours. Cigarette smoking should be
are reminded that a restrictive ventilatory defect is
avoided for at least 1 hour before testing.
characterized by the reduction in total lung capac-
ity below the fifth percentile of the predicted value,
Forced Pulmonary Maneuvers on Ventilatory
and a “normal” FEV1/FVC. Although a restrictive
Study (Simple Spirometry)
defect can be suspected when the FVC is reduced
An acceptable forced expiratory maneuver has a
and the FEV1/FVC is normal or increased, this is
maximal inspiration, a satisfactory start of test, a
not always the case. A reasonable approach to the
smooth expiratory effort, and a plateau at the end of
clinical indications for the measurement of total lung
test. Measurements available from the forced expi-
capacity is presented by Aaron et al31 and Gladys and
ratory maneuver and relevant to the assessment of
colleagues.32
impairment include the forced vital capacity (FVC),
Guides6e_05_077-100.indd 83 2/17/09 2:34:35 PM

Although there is no clear consensus as to when to predicted normal FVC and FEV1 by 0.88, and for
measure lung function after bronchodilator inhalation, normal single-breath DLco by 0.93.33
reasonable indications would include an FEV1/FVC
The NHANES III, reported in 1999, was the first
below 0.70, wheezing on physical examination, or a
report to compare a large number of lung function
history suggestive of asthma. When the pre- broncho-
values for healthy whites, Mexican Americans, and
dilator spirometry demonstrates airway obstruction
African Americans. It measured FVC, FEV1, forced
(FEV1/FVC below 0.70, an FEV1 <80% predicted)
expiratory volume in 6 seconds (FEV6), peak expira-
wheezing on physical examination, or a history sug-
tory flow rate (PEF), and forced expiratory flow rate
gestive of asthma, then albuterol should be given and
at 25% to 75% of FVC (FEF25-75). No adjustments
spirometry repeated 10 to 15 minutes later (post-BD).
for race were needed. Since that time, the reference
A total of 400 mcg of albuterol should be inhaled by
values for spirometry have become the standard-
the patient, one deep inhalation at a time, with 30-60
ized reference values in US pulmonary function
seconds between each of the four puffs. A volume
laboratories.34
spacer should be used between the metered dose
inhaler and the person. At least 3 acceptable FVC The NHANES prediction equations for men and
maneuvers should be repeated post-BD. To demon- women of the different age groups and 3 races are
strate repeatability, the second highest FEV1 should readily available34 if hand calculation is desired;
match the highest FEV1 within 0.15 liters. The highest however, we recognize that this set of prediction
FEV1 should be reported. Increments of less than 8% equations is often used as the “computerized”
of 150 mL are likely to be within measurement vari- comparison values when lung function tests are
ability. A change exceeding 12% or 200 mL compared performed. In addition, we recognize that few
with baseline suggests a “significant” bronchodilation. physicians will hand calculate the relationship
Changes in postbronchodilator FEV1 and FVC values between the values generated by the patient and
can be helpful in understanding the potential medica- compare the patient’s values to predicted values.
tion responsiveness and prognosis, but it is not reason- Data from NHANES prediction equations as
able to assume that the absence of a significant change tables could be entered in a spreadsheet, and the
means that bronchial responsiveness is absent (eg, in computer quickly and accurately generates the
the well-controlled asthmatic patient there may be no comparison of the patient’s values to the reference
responsiveness). value. Most of the standard spirometers currently
in use have the associated software with the abil-
Chapter 5
A comprehensive interpretation of lung function tests

ity to compute the predicted values for various
is beyond the scope of this discussion, and the reader
pulmonary functions. For the purpose of deter-
is advised to read any of a number of books that
mining pulmonary impairment using Table 5-4,
address this topic. However, the following discussion
pulmonary impairment classification, such use
would be helpful in understanding the current litera-
of computer-assisted comparison values for lung
ture on the topic.
function tests is useful and appropriate.
Use of Predicted Values From NHANES III
Diffusing Capacity for Carbon Monoxide
In the past, reliable population data were not avail-
The single-breath DLco method is the most accepted
able for ethnic groups, such as Hispanics, Native
method used in addressing carbon monoxide (CO)
Americans, and Asians. Studies recognized that
uptake in the lung. The DLco measurement provides
whites had greater mean FVC and FEV1 value than
information about gas transfer efficiency across the
did Mexican Americans and African Americans
lungs. The CO uptake is determined by the alveolar-
across the entire age range. For these ethnic groups,
capillary interface. This is dependent on the struc-
the values for North American whites had been
tural and functional properties of the alveolar and
used, yet adjustments were necessary.28 For the same
vascular walls, available gas exchange surface area,
height, the lung function of African Americans was
gas solubility, pulmonary capillary blood volume,
less, resulting in adjustments in predicted FVC and
hematocrit, CO concentration gradient across the
FEV1 because African Americans had a smaller
alveolar-capillary membrane, and hemoglobin-bind-
trunk-to-leg ratio compared with whites. Whites and
ing site availability, as well as other parameters.35 In
Mexican Americans had similar FEV1 and FVC val-
addition, ventilation and perfusion matching in the
ues with respect to height. The ATS Task Force for
lung plays an important role in determining the abil-
Interpretation of Pulmonary Function recommended
ity of CO to transfer from the alveolar space into the
an adjustment on a population basis for predicted
vasculature.
lung function in blacks by multiplying values for
Guides6e_05_077-100.indd 84 2/17/09 2:34:35 PM

Measurement of DLco is technically difficult, and measurement of oxygen consumption, carbon

it may take numerous efforts to gain reproducibility. dioxide (CO2) production, minute ventilation, and
As an example, the DLco is considered reproducible heart rate allows determination of whether exercise
if 2 test values are within 3 units, whereas the FEV1 capacity limitation is due to cardiac, pulmonary,
and FVC tests must be within 5% to be considered peripheral vascular, or coexisting impairments. More
reproducible. Mechanical factors that affect DLco invasively, measuring arterial blood gases and lactate
results include test gas inhalation speed, inspiration levels can aid in patient evaluation. When properly
depth, period of breath holding, and expiration speed. performed and interpreted, these tests can help
Although mechanical factors generally are controlled differentiate pulmonary impairment from cardiac
by DLco test automation, extrapulmonary factors impairment or physical deconditioning effects.
are important to ascertain proper interpretation. For
Exercise capacity is measured by Vo2 in milliliters
example, cigarette smoking can elevate the blood’s CO
per kilogram multiplied by minutes (mL/[kgmin]) or
levels, causing as much as 10% to 12% hemoglobin
in metabolic equivalents (METs), a unit of expended
saturation and decreasing DLco. It is reasonable that
energy equal to 3.5 mL/(kgmin) oxygen consump-
the test subject not smoke for at least 8 hours before
tion. METs are discussed in Chapter 4, in Section
the test. Regardless, the time of the last cigarette
4.2. Generally, an individual can sustain a work level
smoked should be noted and adjustments in CO back
equal to 40% of his or her measured maximum Vo2
pressure made for heavy or recent cigarette smoking.
for an 8-hour period.39
Anemia also decreases the DLco by reducing CO
uptake. When the DLco is reduced, corrections should Table 5-2 shows the relationship between work inten-
be made for anemia and carboxyhemoglobin.35 sity and oxygen consumption.40
Selecting reference values for DLco is more complex Exercise testing is infrequently needed in the inves-
than selecting values for spirometry because inter- tigation of pulmonary impairment. These studies
laboratory differences are much larger for DLco.36,37 can be difficult to perform, add considerable cost
Commonly used DLco prediction equations include to the assessment, and may be more invasive than
those of Crapo and Morris.38 It is the recommenda- conventional tests. Typically, the clinical assessment
tion of the authors that the Crapo reference values of the individual, spirometry and diffusion capacity,
for DLco be used for Caucasians, American Indians, and specialized cardiac tests, if necessary, usually
and Hispanic-Americans. For African-Americans provide sufficient information to determine whether
Chapter 5
and Asian-Americans, a correction factor of 0.93 impairment is present and the apparent explanation
should be applied to the DLCO predicted values for this. Exercise testing has traditionally been most
from Crapo (until studies of DLCO from healthy useful in addressing the clinical situation where
samples of these ethnic groups become available). It the individual’s complaints are out of proportion to
is reasonable for laboratories to compare their mea- his or her static lung function test abnormalities. In
sured values against the published reference values addition, exercise testing is used in situations where
for population-based predicted normal diffusing additional information is needed to clarify the nature
capacity. and severity of impairment,41, 42 where concurrent
illnesses (heart disease)43 or other factors (smoking)
Cardiopulmonary Exercise Testing
Diseases that affect the heart, lungs, circulation, or
blood will cause an abnormal response to exercise. TA B L E 5 -2
Exercise testing is useful to help evaluate the cause Impairment Classification for Prolonged Physical
of shortness of breath that otherwise cannot be deter- Work Intensity by Oxygen Consumptiona
mined at rest (heart vs lungs). It also may be diag- Work Excess
nostic in recognizing myocardial ischemia, abnormal Intensity Energy
blood pressure response to exercise, poor circulation, for 70-kg Oxygen Expenditure
Persona Consumption (METs)
loss of the vasculature of the lung (eg, pulmonary
embolism or other vasculature obliterative diseases), Light 7 mL/kg; 0.5 L/min 2
exercise-induced asthma, lack of fitness, and hyper- Moderate 8–15 mL/kg; 0.6–1.0 L/min 2–4
ventilation syndromes. Heavy 16–20 mL/kg; 1.1–1.5 L/min 5–6
The cardiopulmonary exercise gas-exchange mea- Very heavy 21–30 mL/kg; 1.6–2.0 L/min 7–8
surement, often referred to as metabolic studies, Arduous 30 mL/kg; 2.0 L/min 8
can be an additional means of assessing the sever- a
Adapted from Astrand and Rodahl. 47 METs indicates metabolic
ity and cause of exercise intolerance. Simultaneous equivalents (multiples of resting oxygen uptake).
Guides6e_05_077-100.indd 85 2/17/09 2:34:36 PM

may limit exercise,44 or when an understanding of 1. Determine the impairment class (IC) first,
the job-related energy requirements are needed to according to the “key factor” for that particular
determine whether the worker can meet the energy impairment grid.
demand of employment.45
2. Default to the middle (“C”) grade position for
Not surprisingly, an individual’s cardiac and condi- that IC.
tioning status must be considered in performing the
3. For the first remaining (non-key) factor, deter-
test and in interpreting the results. Do not use exercise
mine the most appropriate IC position and record
capacity measurements to study patients with medical
the number difference to the key factor IC.
contraindications such as unstable cardiac disease.
4. Repeat step 3 for each remaining (non-key) factor.
5. Summate the IC column differences and add or sub-
tract the final number from the default identified in
5.5 Methodology for Determining step 1 to determine the final impairment grade.
the Grade in an Impairment Class
To illustrate, if the key factor identifies IC 3 (default
to 3C), and non-key factors identify IC 1 and 4, this
The largely uniform impairment rating grid devel-
would produce differences of 2 and 1, respec-
oped for this edition of the Guides is designed to cre-
tively. These summate to 1. Subtracting 1 grade
ate a standard platform across which organ systems
from IC/grade 3C gives a final IC/grade of 3B.
can be rated in a consistent reproducible manner.
Pulmonary impairment ratings in this chapter fol- In this example, if the non-key factors both identi-
low the International Classification of Functioning, fied IC 1, you would summate the differences to 4.
Disability, and Health (ICF) scheme of 5 functional Since this procedure does not allow jumping from
classes (0 to 4). Each impairment class will have one IC to a lower (or higher) IC, you would subtract
an assigned range of the whole person impairment the maximum allowable 2 grades, for a final IC/
percentage values based primarily on the severity grade of 3A.
of the pulmonary function loss on various objective
If the key factor indicated class 4C, and both non-
test results (the key factor used in this chapter) for
key factors were also IC 4, the differences would
each condition being rated. In each class there are
summate to zero, and IC/grade 4D or 4E would not
5 different possible impairment grades. The median
Chapter 5
be possible. In order to correct this deficiency, if the

grade is the default rating for initial impairment
key factor identifies IC4C, automatically add 1
determination and may be adjusted on either side of
difference to the value of each non-key factor. For
the median but only in the same impairment class,
example, if the key factor identifies IC 4, and the
based on the non-key factors according to history
first non-key factor was IC 3, the second was IC 4,
and physical exam. The general steps for determin-
the differences are 1 and zero. Adding 1 to each
ing impairment class, and grade within class are out-
of these yields zero and 1, which summates to 1.
lined according to the example in Table 5-3.
Consequently, the final IC/grade is 4D.
In order to consistently determine the appropriate
impairment grade for a given class, the following
procedure is recommended:
TA B L E 5 -3 Methodology for Determining the Grade in an Impairment Class
IMPAIRMENT
SEVERITY GRADE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
(A B C D E) (A B C D E) (A B C D E) (A B C D E)
(%)
c c c c
Guides6e_05_077-100.indd 86 2/17/09 2:34:36 PM

Most pulmonary impairments can be rated according of discrepancy of impairment classes between the
to Table 5-4, which is the Standard Impairment key factor and non-key factors, the impairment rat-
Classification Table. ing should never move out of the class to which it
was initially assigned, using only the key factor.
The examiner should note that throughout this chap-
ter the objective test results are used as the primary The classification of objective test results for FVC,
or “key” factor in the impairment rating for the FEV1, FEV1/FVC, and DLco is given in Table 5-4.
condition, or range of conditions. Well-validated The DLco is primarily of value for persons with
organ-specific functional test measures exist for the parenchymal lung disease. In evaluating the cause of
pulmonary system that correlate well with levels abnormality in any of the listed measures, the physi-
of impairment. It is therefore appropriate to choose cian should also consider the extrapulmonary factors
“objective test results” as the primary determinant of contributing to pulmonary system impairment. For
the impairment class rating in this chapter. example, chest wall muscle weakness or obesity may
decrease the FVC, and anemia may decrease the
1. Each impairment class in Table 5-4 has a cor-
DLco. However, only the valid pulmonary dysfunc-
responding range of available impairment ratings
tion consistent and concordant with the validated
for each of grades A to E; for example, class 1
pathology should be considered in evaluating impair-
corresponds to a rating that ranges from 2% to
ment according to Table 5-4.
10% of whole person impairment. The examiner
should consider the range in each class as divis- Table 5-4 presents criteria for estimating the extent of
ible into 5 subsections, each equidistant from permanent impairment. Spirometry and DLco must be
the bottom and top of the range. For example, performed on each individual being studied. The car-
if the examiner determines that the key impair- diopulmonary exercise study to measure V̇o2 max is not
ment factor places an examinee into class 1, the typically performed as it is not often necessary for iden-
choices for the impairment rating will be 2%, 4%, tifying classes of impairment. If the individual is to be
6%, 8%, or 10%, for grades A to E, respectively. considered to have no impairment, all the listed criteria
except for V̇o2 max must be met. For all other classes, at
2. Using the key impairment factor (objective test
least one of the listed criteria must be fulfilled.
results), the examinee is assigned an impairment
class, with severity grade in median as the default Impairments of other organ systems may be evalu-
position. This is midway between the top and bot- ated according to the criteria given in other Guides’
chapters and then combined with the pulmonary sys-
Chapter 5
tom of the range (C is midway between A and E).
Continuing with our example, class 1C 6%. After tem impairment using the Combined Values Chart
the key impairment factor has led to a preliminary (found in the Appendix).
impairment rating, it will be adjusted based on the
results from rating the other factors.
3. The examiner will then assign grades (A to E)
for factors other than that considered “key.”
5.6Asthma and Other
However, only the key factor can be used to assign Hyperreactive Airway Diseases
the impairment class (IC). When non-key factors
such as history and physical exam are relevant to
5.6a Diagnosis
the rating, they are each assigned a relative class
The diagnosis of asthma requires both relevant
value, which in turn is used to move the impair-
clinical symptoms (current or historic), consistent
ment rating up or down in the same class (class 1
features on the physical examination, and pulmo-
in this example). So in our example, if the exam-
nary function tests. The latter should reveal either
iner determines that the other factors affecting
the presence of airflow limitation that is partially or
the rating are in the same relative class (class 1)
completely reversible either spontaneously or with
that had been used as the baseline rating, the final
treatment, or the presence of airway hyperrespon-
rating will stay in the middle of that class. On the
siveness to methacholine or histamine in the absence
other hand, if the relative classes chosen by the
of airflow limitation. Most patients with asthma have
non-key factors such as history and physical exam
a significant postbronchodilator response on spirom-
are higher or lower than that used for the baseline
etry, indicating airway hyperresponsiveness, yet, as
impairment rating, the level will be moved propor-
a caution, the presence of such a response by itself is
tionally to the right or to the left to reflect the col-
not diagnostic of asthma.46,47
lective value of these non-key factors. Regardless
Guides6e_05_077-100.indd 87 2/17/09 2:34:37 PM

TA B L E 5 - 4 Criteria for Rating Permanent Impairment due to Pulmonary Dysfunctiona
Pulmonary Dysfunction
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
HISTORY No current Dyspnea con- Constant mild Constant mod- Constant severe
symptoms trolled with Dyspnea despite erate Dyspnea Dyspnea despite
intermittent continuous despite continu- continuous
and/or
or continuous treatment ous treatment treatment
intermittent treatment
or or or
Dyspnea that
or
does not require intermittent, mod- intermittent, intermittent,
treatment intermittent, erate Dyspnea severe Dyspnea extreme Dyspnea
mild Dyspnea despite continu- despite continu- despite continuous
despite continuous treatment ous treatment treatment
ous treatment
PHYSICAL No current signs Physical find- Constant mild Constant mod- Constant severe
FINDINGS of disease ings not present physical findings erate physical physical findings
with continuous despite continu- findings despite despite continuous
treatment ous treatment continuous treatment
treatment
or or or
or
intermittent, intermittent, mod- intermittent,
mild physical erate findings intermittent, extreme findings
findings severe findings
Chapter 5
OBJECTIVE
TESTS
FVC FVC 80% of FVC between FVC between FVC between FVC below
predicted 70% and 79% of 60% and 69% of 50% and 59% of 50% predicted
predicted predicted predicted
and or or or or
FEV1 FEV1 80% of FEV1 between FEV1 between FEV1 between FEV1 below 45%
predicted 65% and 79% of 64% and 55% of 45% and 54% of of predicted
predicted predicted predicted
and
FEV1 /FVC (%) FEV1 /FVC (%)
lower limits
of normal and/
or (75% of
predicted)
or or or or
and
DLco DLco between DLco between DLco between DLco below 45%
DLco 75% of 65% and 74% of 55% and 64% of 45% and 54% of of predicted
predicted predicted predicted predicted
or or or or
or
V̇o2 max between 22 and between 21 and between 17 and 15mL/(kgmin)
25mL/(kgmin) 25 mL/(kgmin) 18 mL/(kgmin) 15 mL/(kgmin)
or 7.1 METs
or or or or
6.1–7.1 METs 5.1–6.0 METs 4.3–5.0 METs 4.3 METs
a
FVC indicates forced vital capacity; FEV1, forced expiratory volume in the first second; DLco, diffusion capacity for carbon
monoxide; Vo2 max, maximum oxygen consumption; and METs, metabolic equivalents (multiples of resting oxygen uptake).
Guides6e_05_077-100.indd 88 2/17/09 2:34:38 PM

5.6b Evaluation of Impairment exacerbations requiring urgent intervention has been

and Disability suggested as a measure of severity of impairment.
Although the diagnosis of asthma may be straightfor- However, given the current knowledge of the patho-
ward, assessment of impairment and disability from physiology of asthma, many experts now believe that
asthma is complex due to the condition’s variable frequent exacerbations of asthma probably represent
nature. The ATS in 1993 provided the first guidelines suboptimal treatment, although ongoing exposure to
to classify impairment due to asthma. This classifica- an occupational or environmental trigger, or severe
tion was categorical and without numerical estimates. uncontrollable asthma despite maximal/optimal
The first numerical estimates for impairment from treatment are also possibilities. Given this, many
asthma were reported in 1997.48 We have again used specialists believe that the number and types of
this approach in putting forward the following proto- medications required for both Maximum Medical
col for the evaluation of disability in asthma: Improvement (MMI) and the best outcome (balanc-
ing side effects) are better indicators of the severity
1. Confirm the presence of asthma.
of asthma than the frequency of attacks. If frequent
2. Determine the severity of asthma. exacerbations persist, one should determine whether
the individual is receiving maximal medical therapy
3. Estimate the permanent whole person impairment.
(including, when possible, removal from asthma-
4. Assess work-related asthma. producing agents) before the impairment evaluation.
Confirm the Presence of Asthma Estimate Permanent Whole Person

Asthma usually can be confirmed by relevant symp- Impairment
toms (shortness of breath, wheezing, chest tightness, Table 5-5 lists the classes for whole person impair-
coughing, and sputum production) and by the pres- ment based on pulmonary impairment, incorporating
ence of reversible airflow limitation or by the pres- the parameters from the ATS “Guidelines”46 into
ence of airway hyperresponsiveness to methacholine those of the Guides. Prior to this current approach,
in the absence of airflow limitation.49 The physician physiologic measurements using standard techniques
should follow the national guidelines for the diagno- were required during the 12 weeks preceding medi-
sis of asthma.11 cal evaluation. However, the examiner must deter-
mine that the patient is receiving optimal therapy
Determine the Severity of the Asthma before considering the clinical parameters. The
Chapter 5
Physiologic measures and clinical parameters can patient must be clinically stable from a pulmonary
determine the asthma’s severity. The physiologic perspective. The framework of Table 5-5 has the
measures in Table 5-5 include maximum postbroncho- similar key elements as Table 5-4.
dilator FEV1. This should be measured after optimal
Note that in the absence of airflow limitation with
therapeutic goals are achieved (ie, minimum medica-
asthma treatment, Table 5-5 may not be used to deter-
tion that obtains the best overall outcome). The lower
mine impairment for airway hyperresponsiveness
the postbronchodilator FEV1, despite optimal treatment,
(specific or nonspecific) alone. The individual with
the greater the severity of asthma. A second measure
airway hyperresponsiveness may have no measurable
of asthma severity is the percentage of FEV1 change or
impairment (solely determined on the basis of lung
the extent of reversibility of FEV1. This percentage is
function test values) but may still have disability for
defined by subtracting the baseline FEV1 from the post-
specific jobs.
bronchodilator value, then dividing it by the baseline
FEV1, and multiplying it by 100.
Assess Work-Related Asthma
In the absence of reversible airflow limitation, the Although different categories of asthma can be
measurement of airway hyperresponsiveness should described, they all share an underlying commonality
be measured by histamine/methacholine inhalation of airway hyperresponsiveness. There are 3 recognized
challenge testing by standard methods. To measure variants of asthma in the workplace: occupational,
the degree of airway hyperresponsiveness, use the work-aggravated, and irritant-induced. Occupational
dose of methacholine (provocative concentration) asthma represents a special subset of asthma sub-
that results in a 20% decline in FEV1 compared with jects. Occupational asthma is defined as a reversible
the baseline value upon provocation with less than airflow limitation caused by a specific agent in the
or equal to 8 mg/mL of methacholine using the tidal workplace.50,51 Occupational asthma has now surpassed
breathing method.49 pneumoconiosis as the most commonly reported
occupational lung disease linked to a particular
Many clinical parameters have been used in the past
occupational or environmental agent. In addition,
to assess the severity of asthma in disability rating
besides directly causing occupational asthma de novo,
schemes. For example, the frequency of acute
Guides6e_05_077-100.indd 89 3/3/09 6:29:53 PM

TA B L E 5 - 5 Criteria for Rating Permanent Impairment due to Asthmaa
Asthma
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%-10% 11%-23% 24%-40% 45%-65%
SEVERITY 2 4 6 8 10 11 14 17 20 23 24 28 32 36 40 45 50 55 60 65
CLINICAL No medication Occasional Daily low-dose Daily medium or Asthma not

PARAMETERS required bronchodilator inhaled steroid high-dose (500 controlled by
(MINIMUM use (not daily to 1000 mcg per treatment
MEDICATION use) day) inhaled
(500 mcg per
NEED, steroid and/or
day of beclom-
FREQUENCY OF short periods of
ethasone or
ATTACKS, ETC) systemic steroids
equivalent)
and a long acting
bronchodilator
Daily use of
steroids, systemic
and inhaled,
and daily use
of maximum
bronchodilators
MAXIMUM 80% 70%–80% 60%–69% 50%–59% 50%

POSTBRONCHO-
DILATOR FEV1
PERCENTAGE
PREDICTED b, c
Chapter 5
OBJECTIVE TESTS
FOR DEGREE
OF AIRWAY
HYPERRESPON-
SIVENESS
PC 20 mg/mL b 6–8 3–5 3–0.5 0.5–0.25 0.24–0.125

a
Modified from Ranavaya, MI. The challenge of evaluating asthma impairment and disability. AMA Guides Newsletter. May-
June 1997:1-4. 48
b
The “key” factor PC 20 indicates and measures the degree of airway hyperresponsiveness. Alternatively the
postbronchodilator FEV1 percentage predicted is used as Key factor
c
Percent predicted FEV1 after albuterol therapy
work exposures can also acutely exacerbate a preexist- weight. High-molecular-weight sensitizers of animal
ing underlying asthmatic condition, which typically or plant origin include animal dander or grain dust.
returns to baseline status with removal from expo- Such agents are of similar molecular weight to the
sure. Such events are recognized as work-aggravated common antigens associated with exacerbations of
asthma. Although potentially very dangerous, this asthma outside of the workplace. Low-molecular-
exacerbation is temporary. Irritant-induced asthma, weight sensitizers, typically organic or inorganic
known as RADS (reactive airways dysfunction syn- chemicals, include diisocyanates. These agents are
drome),52 may result from a single massive high-level often peculiar to the workplace. Low-molecular
exposure to a highly irritating gas, mist, or vapor. weight sensitizers generally require a latency period
for the development of immunologic responsiveness.
A variety of sensitizers (allergens) or irritants can
This latency period may last from a few months to
cause occupational asthma. Sensitizers are classified
several years after first exposure.
as either high molecular weight or low molecular
Guides6e_05_077-100.indd 90 2/17/09 2:34:39 PM

There is substantial evidence to show that the best chemical antigens.53 A wide variety of antigenic sub-
prognosis is attained through early diagnosis and stances are known to cause this disease. The acute
prompt removal from further exposure as soon as disease is characterized by the onset of respiratory
possible after the diagnosis. Yet, not all workers leave and constitutional symptoms beginning 4 to 8 hours
the workplace after receiving a diagnosis of occu- after exposure to the offending material. Symptoms
pational asthma. In sensitized workers who remain include chest tightness, cough, dyspnea, fever, chills,
in the workplace, asthma typically persists, with the malaise, and myalgias.
potential for severe and even life-threatening exac-
Pulmonary function tests in the acute phase of the
erbations of asthma upon reexposure. Workers who
disease show volume restriction and decreased dif-
leave the workplace may improve, yet improvement
fusing capacity. Hypoxia may be demonstrated by
is not always predictable. More than 50% of workers
pulse oximetry or arterial blood gas testing. Chest
with occupational asthma fail to recover completely,
radiographs may be normal but often show diffuse
even after 2 or more years since the last exposure and
micronodular changes in the pulmonary paren-
complete avoidance of the workplace. In those work-
chyma. When the person is removed from exposure,
ers in whom asthma persists, a physician needs to
the symptoms, physiologic changes, and chest radio-
monitor the worker’s course of asthmatic symptoms.
graphic abnormalities begin to resolve in 1 to 2 days,
For individuals with occupational asthma that occurs although they may take 4 to 6 weeks for complete
de novo in the workplace—those with work-aggra- resolution. In the subacute and chronic presentations
vated asthma and in those with asthma after an acute of hypersensitivity pneumonitis, the predominant
inhalation injury (RADS) —the issues of employ- symptoms include exertional dyspnea and cough;
ability in certain jobs and job accommodation are some patients report sputum production, anorexia,
separate issues from an impairment rating. Follow-up fatigue, and weight loss. Pulmonary function studies
studies of occupational asthma cases document that often show mixed restriction and obstruction, with
recovery is gradual, but most people with asthma isolated obstructive changes in some individuals.
related to the workplace have a plateau in their symp-
With repeated exposures, pulmonary fibrotic
toms and lung function about 2 years after removal
changes may occur and the parenchymal abnormali-
from exposure to putative agents. It is prudent that
ties become chronic and irreversible with respira-
final recommendations for permanent impairment in
tory impairment and limitations on other types of
occupational asthma cases be made at least 2 years
employment.54 If pulmonary fibrosis has not yet
Chapter 5
after the initial diagnosis and removal from exposure.
occurred, normal pulmonary function may be rees-
Physicians struggle to manage individuals with occu- tablished. Once the acute episode has resolved and
pational asthma who refuse to leave the workplace. the condition is stable, the examiner may rate the
Continued exposures to sensitizing agents in the degree of permanent impairment according to the
work environment or irritants at work or otherwise criteria given in Table 5-4.
lead to a more permanent change (aggravation) in
Asthma, pneumoconiosis, and hypersensitivity pneu-
an asthmatic individual. This likely increases the
monitis may require that the person refrain from
chance for an impairment to develop, which persists
working in a specific occupational setting where he or
even after removal from exposure. If an individual’s
she is exposed to the offending agent. If reassigned to
asthma is worsening, it is important to remove the
a site where no ongoing exposure occurs, the individ-
individual from exposure at least temporarily or, at
ual may not have a permanent respiratory impairment.
a minimum, to reduce exposure and reevaluate the
worker’s condition when it has stabilized. Although
prevention is optimal, medication including inhaled
steroids can modify symptoms and the clinical
course of asthma.
5.8 Pneumoconiosis
Pneumoconiosis is a term used to describe diseases
resulting from the inhalation of inorganic dusts such
as silica, coal, asbestos, and metals such as cobalt
5.7 Hypersensitivity Pneumonitis and beryllium. The radiologic and pathologic pat-
terns of pneumoconiosis from these dusts are usually
Hypersensitivity pneumonitis, also known as extrinsic
quite distinct and beyond the scope of this chapter.
allergic alveolitis, is a granulomatous interstitial and
Latency between exposure to these dusts and devel-
bronchiolar lung disease caused by immune sensitiza-
opment of disease varies, but disease can occur any-
tion to organic dusts and some low-molecular-weight
where from 10 to 30 years after initial exposure.
Guides6e_05_077-100.indd 91 2/17/09 2:34:40 PM

The severity of impairment related to pneumoco- 5.10Sleep Disorders and

niosis depends on the characteristics of the specific Other Impairments Related to
dust inhaled, the dust burden retained in the lungs,
the susceptibility of the individual, and the length Pulmonary System
of time since first exposure. Under some circum-
stances, the parenchymal changes on chest radio- Certain pulmonary conditions may cause impairment
graphs may be progressive, even after removal from that is not readily quantifiable by measuring spirom-
exposure, and may or may not be associated with etry, diffusing capacity, or exercise testing. Sleep
physiologic impairment. Individuals in whom pneu- disorders are examples of conditions of this type.
moconiosis develops should limit further exposure
Although the pulmonary system may be structur-
to the offending agent, particularly if radiographic
ally and functionally normal while the individual is
changes have occurred at a relatively young age or if
awake, the breathing pattern during sleep is altered
there is associated physiologic impairment. In those
and periods of apnea occur throughout the night. In
with silicosis, there is an increased risk of mycobac-
the normal individual, alterations in respiratory drive
terial diseases. However, these individuals may be
and ventilatory mechanics occur during the vari-
capable of working at other jobs where the offending
ous stages of sleep. In normal non–rapid eye move-
dust is not present. Impairment due to pneumoconio-
ment (NREM) sleep, there is an overall reduction
sis should be addressed with the use of Table 5-4.
in respiratory drive. In rapid eye movement (REM)
sleep, the respiratory drive is irregular and the muscle
tone of the rib cage and upper airways is decreased.
In patients with disordered breathing during sleep,
5.9 Lung Cancer periods of apnea occur and can lead to episodes of
hypoxia and hypercapnia. Arousal from sleep under
All persons with lung cancer are severely impaired
these circumstances is effected by reticular and corti-
at diagnosis. At reevaluation 1 year after the diag-
cal activation in the brain. While arousal is a protec-
nosis is established, if the patient is found to be free
tive response, the result is fragmentation of normal
of all evidence of tumor recurrence, that person is
sleep, with a morning headache, daytime sleepiness,
evaluated according to criteria listed in Table 5-4.
intellectual impairment, and personality changes.
If there is still evidence of tumor, the patient is
Two major subgroups of sleep apnea are recognized:
Chapter 5
considered to be severely impaired (class 4 impair-

obstructive sleep apnea (OSA) and central sleep
ment); if the tumor recurs, the person will also be
apnea. Obstructive sleep apnea is characterized by
considered to be severely impaired (class 4 impair-
occlusion of the upper pulmonary tract by sleep-
ment). Table 5-6 (the Karnofsky scale), specifically
induced relaxation of the oropharyngeal muscles.
developed to describe the capabilities of individuals
This allows the tongue and palate to rest against
with cancer,55 may be used to further describe the
the posterior pharyngeal wall. Air ceases to flow
capabilities of a person with lung cancer and enable
through the nose and mouth despite continued pul-
categorization in a particular class.
monary efforts by muscles of the chest wall and dia-
phragm. Arousal from sleep leads to improvement
TA B L E 5 - 6 in muscle tone of the upper airway, which dilates
Scale for Judging Capabilities of Subjects the pharynx and allows passage of air into the lungs.
With Cancera The apneic period is usually terminated by loud
Grade Description
snoring. Approximately 75% of patients with OSA
are obese. The observation that weight loss decreases
0 Fully active; able to carry on all predisease
activities without restrictions
the severity of OSA supports the concept that obesity
narrows the upper airway.56
1 Restricted in physically strenuous activity but
ambulatory and able to carry out light tasks, The second major subgroup of these disorders is
such as light work in home or office
central sleep apnea. Episodic apneas during sleep
2 Requires occasional to considerable care for are characterized by a total cessation of pulmonary
most needs and frequent medical care
effort rather than an obstruction to airflow. Although
3 Capable only of limited self-care and confined the genesis of the disorder is in the central nervous
to bed or chair at least half of waking hours
system, the clinical and physiologic effects of sleep
4 Almost totally impaired; cannot care for self, disruption are similar to the effects seen in OSA.
and totally confined to bed or chair
The manifestations of the abnormality are chronic
a
Adapted from Moossa et al. 55
alveolar hypoventilation with persistent arterial
Guides6e_05_077-100.indd 92 2/17/09 2:34:41 PM

blood gas abnormalities, pulmonary hypertension, earlier he had been hospitalized for treatment of an
and cor pulmonale. It is possible to see the obstruc- anteroseptal myocardial infarction. He was allowed
tive and central types of sleep apnea in the same to return to work after beginning a progressive exer-
individual. cise program. He had smoked cigarettes since age
18 years, averaging 1 pack per day (total exposure,
Untreated sleep apnea is a cause of impairment.
32 pack-years), but he stopped soon after the myocar-
Daytime sleepiness, intellectual impairment, and
dial infarction.
personality changes can affect an individual’s gain-
ful employment. People affected by OSA are at sig- Current Symptom: Dyspnea.
nificantly increased risk of being involved in motor
Physical Examination: Patient was 180 cm (6 ft)
vehicle collisions.57 Severe daytime somnolence may
tall, weighed 99 kg (220 lb), and had a BMI of
prevent them from functioning adequately. Subtle
30 kg/m2. Chest and cardiac examinations were
changes in neuropsychological function include mem-
normal. Chest roentgenogram showed left ven-
ory abnormalities and worsened motor coordination
tricular enlargement and normal lung parenchyma.
and mood that may affect the person’s daily life.
Pulmonary function studies, which met ATS criteria,
A diagnosis of OSA is confirmed by nocturnal showed an FVC 85% of predicted, FEV1/FVC ratio
polysomnography in an accredited sleep laboratory. of 75%, FEV1 80% of predicted, and DLco 75% of
Grading OSA severity depends on the number of predicted.
apnea and hypopnea episodes observed in poly-
A Bruce protocol stress test was performed.
somnography and the severity of hypoxia caused
Maximum exercise could not be achieved due to
by these episodes. There are no standard, well-
fatigue and chest discomfort. Echocardiogram
documented criteria for determining the level of
showed ejection fraction was 40%.
impairment based on the results of polysomnogra-
phy. Ideally, patients with documented sleep apnea Diagnosis: Inadequate cardiac output resulting from
should receive effective therapy, pursue weight loss, myocardial infarction.
and then be reevaluated by polysomnography before
Impairment Rating: Class 0, no impairment.
they are judged to be impaired. The impairment
rating should be based on clinical and physiologic Comment: Although the patient was a smoker, pul-
parameters which are not readily measurable by the monary function studies indicate he is still in class 0
tables included here. The rating physician is encour- and has no pulmonary impairment (see Table 5-4).
Chapter 5
aged to document pathology associated with OSA However, he is limited by cardiac impairment. Further
and affecting other organ systems (ie, corpulmonale; cardiac evaluation is recommended.
polycythemia) and rate these according to the appro-
priate organ system where applicable. Any add-on
for strictly pulmonary impairment must be deter-
mined by an appropriately qualified, accredited, and CLASS 1
experienced sleep specialist physician, and should 2% to 10% Impairment of the Whole Person
not exceed 3% of the whole person impairment.
EXAMPLE 5-2: CHRONIC BRONCHITIS
Subject: A 46-year-old female attorney.

5.11 Examples of Impairment due History: Has had intermittent morning cough
to Pulmonary Disorders productive of sputum for several years. She uses
over-the-counter medications that help the cough
somewhat. She has no dyspnea, chest pain, or
hemoptysis but notes wheezing, especially with
CLASS 0
colds. She is a smoker and has smoked 1 pack per
day since age 18 years. There is no history of asthma
or pneumonia. She knows of no occupational or
EXAMPLE 5-1: INADEQUATE CARDIAC OUTPUT environmental exposures to respiratory hazards.
Subject: A 50-year-old male delivery truck driver. Current Symptoms: Intermittent morning cough
productive of sputum.
History: Truck driver for the past 25 years; was
referred because he had become too short of breath Physical Examination: Patient’s height was 168
to carry 3 boxes up a flight of stairs. Three months cm (5 ft 7 in), and her weight was 58.5 kg (130 lb).
Guides6e_05_077-100.indd 93 2/17/09 2:34:41 PM

There was an expiratory wheeze with forced exhala- Current Symptoms: None, after 2 years of avoid-
tion. Otherwise, results of the physical examination ance of spray painting and faithfully following
were normal. Chest roentgenogram was normal. his medication regimen, except for wheezing and
Pulmonary function studies, which were found to be coughing when exposed to perfumes, tobacco
valid based on ATS criteria, revealed FVC 85% of smoke, or hairspray.
predicted, FEV1 70% of predicted, and DLCO 75%
Physical Examination: Normal.
of predicted.
Clinical Studies: Spirometry reveals reversible
Clinical Studies: Cardiopulmonary stress test was
obstructive ventilatory defect with maximal post-
performed, and her Vo2 at maximal exercise was
bronchodilator FEV1 of 69% predicted. His FEV1
25 mL/kg/min.
improved 15% with bronchodilator compared with
Diagnosis: Chronic bronchitis with mild airflow baseline.
obstruction.
Diagnosis: Occupational asthma due to occupational
Impairment Rating: Class 1, 6% whole person exposure to polyurethane paints.
impairment (Table 5-4).
Impairment Rating: Worker was evaluated for per-
Pulmonary function studies (key factor in Table 5-4) manent impairment approximately 2 years after leav-
indicated she was in class 1 (ie, FEV1 70% of pre- ing the workplace. Now it is reasonable to consider
dicted). Maximal exercise Vo2 of 25 mL/kg/min also his lung function and symptoms under the best con-
places her in class 1. Note that one needs only 1 of trol possible. Objective test for the degree of airway
the key objective findings to be qualified for a class hyperresponsiveness (key factor using Table 5-5)
using Table 5-4. Exercise testing is not needed to shows that this worker’s impairment is in the middle
make this determination of impairment. Her non-key of class 2 (the maximum postbronchodilator FEV1 of
criteria of impairment (history and physical find- 69% predicted places him in class 2). However, the
ings) also place her in class 1. Therefore, in the final clinical parameters document that he requires daily
analysis she remains in the middle of class 1, with a high-dose inhaled corticosteroids and occasional
6% whole person impairment. use of inhaled -agonist bronchodilator for his lung
function to remain stable. These values would place
him in class 3 of Table 5-5. Therefore, in the final
analysis, he remains in the class 2 but 1 grade higher
Chapter 5
CLASS 2 than the default, for class 2D. This is a 20% whole
11% to 23% Impairment of the Whole Person person impairment.
Comment: Further exposure to diisocyanate should
EXAMPLE 5-3: OCCUPATIONAL ASTHMA be discouraged, as the evidence suggests that indi-
viduals with immune-mediated asthma do better
Subject: A 28-year-old male auto body worker.
when they are diagnosed early and removed from
History: Had no history of asthma at the time of exposure.
hiring. He had been spray painting for 10 years with
polyurethane paints containing an asthma-causing
diisocyanate. Over the first several years of employ-
ment, he noticed a gradual onset of chest tightness, CLASS 3
with a nonproductive cough. This occurred mostly 24% to 40% Impairment of the Whole Person
at work and gradually improved when away from
work, on weekends and during vacations. Three
EXAMPLE 5- 4: OCCUPATIONAL
years earlier he had been admitted to the hospital
PNEUMOCONIOSIS (ASBESTOSIS)
with severe dyspnea and wheezing; a diagnosis of
asthma was made and asthma therapy was initiated. Subject: A 52-year-old man.
He requires daily high-dose inhaled corticosteroid
History: Complains of increasing dyspnea of 5
therapy and occasional use of an inhaled -agonist
years’ duration that now affects his ADLs, making
bronchodilator.
it difficult for him to participate in basic ADLs. He
Guides6e_05_077-100.indd 94 2/17/09 2:34:42 PM

has difficulty keeping up with others of his age, and in class 3E, for a final impairment rating of 40%
he usually has to stop and rest before climbing a whole person impairment.
flight of stairs. He says his coworkers have to help
him with lifting and carrying at work; otherwise,
he would lose his job. He denies cough, wheezing,
or chest pain. He has worked as an insulator for 35 CLASS 4
years; had mixed powdered asbestos with water and 45% to 65% Impairment of the Whole Person
applied it to pipes and steel beams for the first 20
years of his working life. He reports to be a lifelong
EXAMPLE 5-5: SEVERE EMPHYSEMA
nonsmoker.
Subject: A 57-year-old female law professor.
Current Symptom: Dyspnea.
History: Shortness of breath gradually developed
Physical Examination: Examination disclosed that
during a 10-year period. Dyspnea became so severe
the patient was 170 cm (5 ft 8 in) tall and weighed
that she is unable to perform routine daily activities,
63 kg (140 lb). There was finger clubbing. He had
such as driving to and from work, walking on level
bilateral end-inspiratory, fine crackles, signs of
ground, taking a shower, or self-dressing. She has
severe interstitial lung disease. The results of the
no wheezing, chest pain, or hemoptysis. She reports
cardiac examination were normal. Chest roentgeno-
smoking regularly 2 1/2 packs a day for the past
gram showed moderately pronounced, small, linear,
40 years and was able to stop smoking 6 months pre-
irregular opacities at the lung bases. Small, bilateral
viously. There is no history of asthma or pneumonia.
pleural plaques were present.
She knows of no respiratory exposure to occupa-
Clinical Studies: Pulmonary function studies, tional or environmental hazards.
which based on ATS criteria were found to be valid,
Current Symptoms: Dyspnea; occasional, nonpro-
showed FVC 55% of predicted, FEV1/FVC ratio
ductive cough.
75%, FEV1 60% of predicted and DLco to be 50% of
predicted. Exercise testing showed the maximal Vo2 Physical Examination: She was found to be 163 cm
to be 16 mL/kg/min. (5 ft 5 in) tall and weigh 116 lb. She is barrel-
chested, and breath sounds were barely audible. No
Diagnosis: Occupational pneumoconiosis
crackles or wheezes were heard. Cardiac examina-
(asbestosis).
Chapter 5
tion was unremarkable.
Impairment Rating: Class 3, 40% whole person
Clinical Studies: Chest roentgenogram showed
impairment (Table 5-4). This man’s interstitial lung
hyperinflated lungs, narrowed mediastinum, wide
disease is moderately impairing his lung capacity.
retrosternal space, emphysematous bullae, and lack
The crackles on chest auscultation, presence of fin-
of truncated vascular markings. Pulmonary function
ger clubbing, decreased vital capacity, and decreased
studies, which based on ATS criteria were found to
gas exchange by diffusion capacity measurement
be valid, showed FVC of 65% of predicted, FEV1/
are consistent with interstitial lung disease and
FVC ratio of 40%, FEV1 of 31% predicted, and DLco
restriction of lung volumes. Pulmonary function
of 37% of predicted.
studies (key factor using Table 5-4) showing FVC to
be 55% of predicted indicate he has class 3 impair- Diagnosis: Severe emphysema.
ment, which by default places him in the middle
Impairment Rating: Class 4, 65% whole person
of the class. Maximal exercise Vo2 value of 16
impairment (Table 5-4). According to Table 5-4, the
mL/kg/min also places him in the middle (median
key factor (objective test results) places her in class 4;
as default) of class 3. (Again, note that only one of
her non-key factors (functional history and physical
the objective findings is needed to be qualified for a
findings) also place her in class 4. The relative dif-
class under Table 5-4, and exercise testing is usually
ference is 2 units greater than the “default” (add 1
unnecessary to determine this extent of impairment.)
to each non-key factor when key factor is in class 4),
The next step is to review the non-key criteria (his-
which places her in final impairment class/grade 4E.
tory and physical findings), both of which place him
This results in a final impairment rating of 65% whole
in impairment class 4. The relative difference is 2
person impairment.
intervals greater than the default, which places him
Guides6e_05_077-100.indd 95 2/17/09 2:34:42 PM

5.12Pulmonary Impairment
Evaluation Summary
Table 5-7 provides a summary of pulmonary impair-
ment evaluation.
TA B L E 5 -7
Pulmonary Impairment Evaluation Summary
Disorder History, Including Selected Examination Record Assessment of Pulmonary
Relevant Symptoms Function
General Respiratory symptoms Comprehensive physical Data derived from relevant
(eg, cough); general symptoms examination; detailed studies (eg, pulmonary function
respiratory system tests)
Impact of symptoms on function
assessment
and ability to do daily activities;
prognosis if change anticipated
Obstructive Disorders Dyspnea; cough; sputum Note breath sounds, Pulmonary function: spirometry,
production; infections; wheeze, loud P2, jugular lung volumes, diffusing capacity,
medication use; exercise vein distention, right heart methacholine challenge,
tolerance prominence radiographs
Restrictive Disorders Dyspnea; cough; fatigue; Chest wall excursion; crack- Pulmonary function: spirometry,
sputum; exercise tolerance les; clubbing lung volumes, diffusing capacity,
imaging studies
Cancer Exercise tolerance; dyspnea; Chest wall excursion; Bronchoscopy; pulmonary
chest pain; fatigue; weight loss; crackles; clubbing; function tests; biopsy
tobacco use; environmental adenopathy
exposures
Chapter 5
Guides6e_05_077-100.indd 96 2/17/09 2:34:43 PM

End-Organ Damage Diagnosis Degree of Impairment
Include assessment of sequelae, Record all pertinent diagnosis(es); Criteria outlined in this chapter, see Tables 5-
including end-organ damage and note if they are at maximal medical 1, 5-2, 5-3 and 5-4
impairment improvement; if not, discuss under
what conditions and when stability is
expected
Assess relevant organs (eg, cardiac Asthma; chronic bronchitis and See Table 5-5 for asthma, see Table 5-4 for
function, cor pulmonale) emphysema; other obstructive other diseases
diseases
Assess cardiac function Idiopathic pulmonary fibrosis;

asbestosis; pneumoconiosis; chest wall
disorders; others
Assess other organ function; signs Squamous, adeno, small cell, etc See Table 5-4 and Table 5-6
of metastases
Chapter 5
Guides6e_05_077-100.indd 97 2/17/09 2:34:43 PM

18. Yuan H, Wong LS, Bhattacharya M, et al. The effects of

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34. Hankinson JL, Bang KM. Acceptability and 47. Gjevre JA, Hurst TS, Taylor-Gjevre RM, Cockcroft DW.
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35. McIntyre N, Crapo RO, Viegi G, et al. Standardization 48. Ranavaya, MI. The challenge of evaluating asthma
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Chapter 5
exercise testing. Am J Respir Crit Care Med.
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Guides6e_05_077-100.indd 99 2/17/09 2:34:44 PM

100
CHAPTER 6
The Digestive System
6.2 Upper Digestive Tract
6.3 Colon, Rectum, and Anus
6.4 Enterocutaneous Fistulas
6.5 Liver and Biliary Tract
6.6 Hernias
6.7 Digestive System Impairment Evaluation

Introduction
Summary
This chapter provides criteria for evaluating perma-
nent impairment of the digestive system, consisting
of the alimentary canal, liver, biliary tract, and pan-
creas. The criteria for assigning permanent impair-
ment ratings of digestive system disease include
clinically established or objectively determined
deviations from normal in the transport and assimi-
Chapter 6
lation of ingested food, nutrition, metabolism, waste
product excretion, and the effect of these problems
on individuals’ performance of Activities of Daily
Living (ADLs).
The chapter has been extensively revised from the
Fifth Edition with regard to the impairment percent-
ages assigned to each class and the overall use of the
system for rating impairment as outlined in Chapter
1. As with other chapters, these changes have been
adopted both to increase interrater reliability with
regard to the assessment of gastrointestinal (GI) tract
impairment and to allow for ratings that are com-
parable to those assigned for dysfunction of other
organ systems. In particular, this applies to the fol-
lowing: (1) Impairments of similar gravity, which
have similar impact on the ability to perform ADLs
for the small and large intestine, have been given
101
Guides6e_06_101-128.indd 101 2/17/09 2:36:05 PM

the same impairment ratings for comparable classes. Stomach and duodenum impairment symptoms
(2) Ratings of impairment from hepatic and other and signs include nausea, vomiting, pain, bleeding,
diseases have been revised downward due to the ten- obstruction, diarrhea, weight loss, and certain types
dency, in prior editions of the Guides, for the rating of malabsorption. Some impairments may produce
to encompass both organ-system specific pathology nutritional deficiencies that lead to hematologic and
and the affect it has on other organ systems; the neurologic manifestations, which would be rated
rater is now encouraged to rate secondary disease separately and combined with digestive system
processes separately and combine them with the impairments.
rating for the primary gastroenterological disease.
Small-intestine impairment symptoms and signs
(3) Home parenteral nutrition programs have reha-
include abdominal pain, diarrhea, steatorrhea, bleed-
bilitated some and improved the daily lives of many
ing, obstruction, and weight loss, which often are
individuals with intestinal failure resulting from a
associated with general debility and other extraintes-
variety of causes, but compliance with the treatment
tinal manifestations.
regimens does have an impact on ADLs; this is now
recognized by allowing for the addition of percent- Pancreatic function impairment symptoms and
age points for “Burden of Treatment Compliance” signs include, but are not limited to, pain, anorexia,
(See Appendix B) to the GI tract impairment rating. nausea, vomiting, diarrhea, steatorrhea, weight loss,
(4) The effect of a given gastroenterological condi- muscle wasting, jaundice, diabetes mellitus, and
tion on the ability to function is incorporated into the debility. Impairment due to endocrine disturbance
ratings and is also reflected by the BOTC; there is no related to the pancreas is considered in the Guides
separate “Functional Evaluation” by questionnaire in chapter on the endocrine system (Chapter 10).
this chapter.
Colon, rectum, and anus impairment symptoms and
signs include abdominal, pelvic, or perineal pain; dis-
ordered bowel action; tenesmus; fecal incontinence;
bleeding; suppuration; and the appearance of hemor-
6.1 Principles of Assessment rhoids, fissures, and fistulas. Systemic manifestations
may include fever, weight loss, debility, and anemia.
Before using the information in this chapter, the
Guides user should become familiar with Chapters Hepatobiliary impairment symptoms and signs
1 and 2 and the Glossary. Chapters 1 and 2 discuss include pain, nausea, vomiting, anorexia, loss of
the Guides’ purpose, applications, and methods for strength and stamina, reduced resistance to infec-
performing and reporting impairment evaluations. tion, altered immune response, jaundice, and pruri-
The Glossary provides definitions of common terms tus. Advanced liver disease complications include
used by many specialties in impairment evaluation. edema and generalized ascites, portal hypertension
This information should be available to determine leading to esophageal varices and hemorrhage, and
impairment. metabolic disturbances leading to hepatic encepha-
lopathy and renal failure.
6.1a Interpretation of Symptoms and Signs
Abdominal wall impairment symptoms and signs
Chapter 6
Some upper digestive tract symptoms limit the abil-

include typically intermittent discomfort or pain at
ity to perform daily activities. As this information is
or near the herniation site, often associated with a
subjective and subject to misinterpretation, it does
visible, palpable protrusion or swelling at the hernia-
not serve as the key factor for assigning impairment
tion site, appearing and disappearing with postural
ratings. Rather, the examiner should obtain objec-
changes or abdominal pressure. More acute and
tive data about the injury or disorder, usually from
intense pain can be seen due to complications, espe-
a review of pertinent medical records, and integrate
cially incarceration and strangulation of contained
those findings with the subjective data to estimate
bowel or omentum.
the degree of permanent impairment.
Incisional hernias may be unsightly and annoying;
Esophageal impairment symptoms and signs include
other symptoms, if any, tend to be related to the
dysphagia, pyrosis or heartburn, retrosternal pain,
incisional hernia size. Inguinal and femoral hernias
regurgitation, bleeding, and weight loss. Note that
typically are painful and entail a greater risk of
occasional minor dyspepsia, gas, and belching are
incarceration or strangulation. Most abdominal wall
within the experience of all individuals.
hernias are amenable to surgical correction.
Guides6e_06_101-128.indd 102 2/17/09 2:36:07 PM

The Digestive System 103
Signs and symptoms can be categorized by fre- plain or scout films of the abdomen, ultrasonogra-
quency, severity, and level of functional loss. Never phy, CT, magnetic resonance imaging (MRI), and
or occasional signs or symptoms, when present up to endoscopic pancreatography; (3) guided, fine-needle
33% of the time, do not generally warrant an impair- aspiration; (4) determination of plasma glucose level
ment rating (unless the ensuing disruption in ADLs is and glucose tolerance; (5) assay of pancreatic enzyme
significant). Frequent signs or symptoms are present activity in blood, urine, and feces; (6) sweat electro-
between 34% and 66% of the time, and continuous lyte test; (7) peroral endoscopy of the pancreatic and
signs and symptoms are present 67% of the time and biliary tract, with biopsy and cytologic study; and
above (with it understood that this level of precision (8) procedures such as the secretin test.
is impossible to achieve clinically). When present
Objective procedures useful in establishing colon,
and in general, minimal level of signs or symptoms
rectum, and anus impairment include, but are not
interfere with ADLs 1 to 10% of the time, mild signs
limited to: (1) digital and endoscopic examination,
or symptoms interfere with ADLs 11 to 25% of the
including anoscopy, proctoscopy, sigmoidoscopy,
time; moderate signs and symptoms affect ADLS 26
and colonoscopy; (2) biopsy and cytology; (3) fecal
to 50% of the time and can have an impact on work
microscopy and culture; (4), rectal and colon
and recreational activities. Severe signs or symptoms
manometry; and (5) fluoroscopy and roentgenogra-
interfere with ADLs up to 51% to 75% of the time to
phy employing contrast media.
the point of requiring modification of many routine
ADLs (personal, work-related, and recreational). Objective procedures useful in establishing hepato-
Extreme functional loss occurs when symptoms and biliary impairment include, but are not limited to:
signs cannot be controlled by medication and inter- (1) ultrasonography; (2) contrast radiography, such
fere with ADLs up to 100% of the time. as percutaneous and endoscopic cholangiography;
(3) CT and MRI or spiral CT; (4) nucleotide scin-
6.1b Description of Clinical Studies tigraphy; (5) angiography; (6) liver biopsy and fine-
Objective procedures useful in establishing esopha- needle aspiration; and (7) laboratory tests to assess
geal impairment include, but are not limited to: (1) the bile ducts and various liver functions.
imaging procedures, such as fluoroscopy and radiog-
Objective procedures useful in establishing impair-
raphy, employing contrast media; ultrasonography;
ment by hernias include, but are not limited to:
and computed tomography (CT); (2) peroral and cap-
(1) abdominal wall physical examination; and
sule endoscopy, including cytologic study or biopsy;
(2) imaging by roentgenography or CT scan with
and (3) functional tests, such as manometry, imped-
or without contrast media.
ance, or intraesophageal pH measurement.
In general, an objective procedure is described as
Objective procedures useful in establishing stomach
minimally abnormal if there is an anatomic abnor-
and duodenum impairment include, but are not lim-
mality that leads to no more than a 10% degree of
ited to: (1) imaging techniques, such as fluoroscopy
functional organ impairment and is generally asymp-
and roentgenography, with contrast media; scin-
tomatic. A mild abnormality does not (or would
tigraphy; ultrasonography; and CT; (2) peroral and
not be expected to) lead to more than a 10% to 25%
capsule endoscopy, with biopsy and cytologic study;
Chapter 6
degree of functional organ impairment. A moderate
(3) gastric secretory tests; (4) malabsorption tests;
abnormality would result in a 26% to 50% loss of
(5) stool examination; and (6) urea breath test for
function (if untreated), a severe abnormality would
Helicobacter pylori.
be one that is accompanied by a 51% to 75% func-
Objective procedures useful in establishing impair- tional loss (if untreated); and an extreme abnormality
ment of the small intestine include, but are not is one that leads to a greater than 75% loss of organ
limited to: (1) fluoroscopy and roentgenography function (if untreated).
employing contrast media; (2) peroral and capsule
endoscopy and mucosal biopsy; and (3) intestinal 6.1c Desirable Weight
malabsorption testing measures such as fecal fat Weight loss is an essential criterion for evaluating
content and urinary D-xylose excretion tests, breath the severity and consequences of GI tract disorders,
tests, and Schilling test. and it is the usual physical examination factor of sig-
nificance. To determine impairment resulting from
Objective procedures useful in establishing impair-
digestive disorders, one can determine desirable
ment of pancreatic function include, but are not lim-
weight from the Tables 6-1 and 6-2.
ited to: (1) ultrasonography; (2) radiography, including
Guides6e_06_101-128.indd 103 2/17/09 2:36:07 PM

TA B L E 6 -1 which special dietary modifications and restrictions

Desirable Weights for Men by Height and Body are required to control symptoms and signs of disease
Build and any functional limitations that are caused by either
Weight, lb (kg) the impairment itself or required treatment. There are
Height,
in (cm) Small Frame Medium Frame Large Frame
some GI tract conditions in which well-recognized
symptoms occur without significant anatomic or physi-
62 (157) 128-134 131-141 138-150
(58.0-60.7) (59.2-63.9) (62.5-67.8) ologic abnormality, but with symptoms (primarily
pain) that can be either partially or completely con-
63 (160) 130-136 133-143 140-153
(59.0-61.7) (60.3-64.9) (63.5-69.4) trolled by simple medication. Examples would include
esophageal reflux, irritable bowel syndrome, “spastic
64 (163) 132-138 135-145 142-156
(60.0-62.7) (61.3-66.0) (64.5-71.1) colon,” chronic constipation, or chronic abdominal
65 (165) 134-140 137-148 144-160
pain without known origin. If the examining physician
(60.8-63.5) (62.1-67.0) (65.3-72.5) believes that conditions like these, that are otherwise
66 (168) 136-142 139-151 146-164
not ratable by the sections and tables in this chapter,
(61.8-64.6) (63.2-68.7) (66.4-74.7) are significantly disruptive of ADLs, the physician
67 (170) 138-145 142-154 149-168 may choose to rate these up to a 3% whole person
(62.5-65.7) (64.3-69.8) (67.5-76.1) impairment.
68 (173) 140-148 145-157 152-172
(63.6-67.3) (65.9-71.4) (69.1-78.2)
TA B L E 6 -2
69 (175) 142-151 148-160 155-176
(64.3-68.3) (66.9-72.4) (70.1-79.6) Desirable Weights for Women by Height and
70 (178) 144-154 151-163 158-180
Body Build
(65.4-70.0) (68.6-74.0) (71.8-81.8) Weight, lb (kg)
Height,
71 (180) 146-157 154-166 161-184 in (cm) Small Frame Medium Frame Large Frame
(66.1-71.0) (69.7-75.1) (72.8-83.3)
58 (147) 102-111 109-121 118-131
72 (183) 149-160 157-170 164-188 (46.2-50.2) (49.3-54.7) (53.3-59.3)
(67.7-72.7) (71.3-77.2) (74.5-85.4)
59 (150) 103-113 111-123 120-134
73 (185) 152-164 160-174 168-192 (46.7-51.3) (50.3-55.9) (54.4-60.9)
(68.7-74.1) (72.4-78.6) (75.9-86.8)
60 (152) 104-115 113-126 122-137
74 (188) 155-168 164-178 172-197 (47.1-52.1) (51.1-57.0) (55.2-61.9)
(70.3-76.2) (74.4-80.7) (78.0-89.4)
61 (155) 106-118 115-129 125-140
75 (190) 158-172 167-182 176-202 (48.1-53.6) (52.2-58.6) (56.8-63.6)
(71.4-77.6) (75.4-82.2) (79.4-91.2)
62 (157) 108-121 118-132 128-143
76 (193) 162-176 171-187 181-207 (48.8-54.6) (53.2-59.6) (57.8-64.6)
(73.5-79.8) (77.6-84.8) (82.1-93.9)
63 (160) 111-124 121-135 131-147
* (indoor clothing weighing 2.3 kg [5 lb] and shoes with 2.5-cm (50.3-56.2) (54.9-61.2) (59.4-66.7)
[1-in] heels)
64 (163) 114-127 124-138 134-151
(51.9-57.8) (56.4-62.8) (61.0-68.8)
Chapter 6
The examiner should refer to the gender (sex)- 65 (165) 117-130 127-141 137-155
appropriate table of desirable weights and calculate (53.0-58.9) (57.5-63.9) (62.0-70.2)
deviations from the lower end of the table’s range 66 (168) 120-133 130-144 140-159
that corresponds to the individual’s gender, height, (54.6-60.5) (59.2-65.5) (63.7-72.4)
and body build. 67 (170) 123-136 133-147 143-163
(55.7-61.6) (60.2-66.6) (64.8-73.8)
Exogenous obesity is not a GI tract disorder. The
68 (173) 126-139 136-150 146-167
anatomic consequences of surgery for morbid obe- (57.3-63.2) (61.8-68.2) (66.4-75.9)
sity are ratable using the Upper Digestive Tract 69 (175) 129-142 139-153 149-170
Section (Section 6.2) of this chapter. (58.3-64.2) (62.8-69.2) (67.4-76.9)
70 (178) 132-145 142-156 152-173
6.1d Impairment Determination (60.0-65.9) (64.5-70.9) (69.0-78.6)
Impairment classes, as listed in Tables 6-3 through 71 (180) 135-148 145-159 155-176
6-10, are organ and system specific. The impairment (61.0-66.9) (65.6-71.9) (70.1-79.6)
classes and percentage ratings reflect anatomic, physi- 72 (183) 138-151 148-162 158-179
ological, and functional abnormalities at the organ (62.6-68.4) (67.0-73.4) (71.6-81.2)
and system level and the impact of GI tract disease on * (indoor clothing weighing 1.4 kg [3 lb] and shoes with 2.5-cm
ability to perform ADLs. This includes the degree to [1-in] heels)
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The definitions provided previously of “infrequent,” grid. The examiner will use this key factor to deter-
“occasional,” “frequent,” “constant,” “minimal,” mine the appropriate class with the middle grade
“mild,” “moderate,” “severe,” and “extreme” as they (integer) in that class as the initial (default) rating
relate to symptoms and signs are often incorporated (refer to Table 6-3).
in tables used for the determination of impairment,
The examiner will then use non-key factors to assign
as are the terms “minimal,” “mild,” “moderate,”
grades for factors other than that considered “key,”
“severe,” and “extreme” as they relate to organ func-
with it being impossible to move upward or down-
tion. The concept of BOTC is applied to this chapter
ward between classes based on these non-key factors.
according to the BOTC found in the Appendix. Due
The number of potential grades for each impairment
to the systemic ramifications of corticosteroid use,
class varies based on the number of relevant factors.
an additional 3% impairment can be assigned when
When there are 2 non-key factors, there are generally
these medications are used on a daily basis to control
5 impairment grades per class; the presence of only
disease; however, the evaluator is required to provide
one relevant factor other than the key factor reduces
the basis for this determination. A GI system impair-
the number of possible grades to 3 per class.
ment evaluation whose results fall in the normal
range reflects an individual who performs all ADLs If the examiner determines that the other factors
with only normal, occasional GI tract symptoms; no affecting the rating are in the same class that had
limitation of activities; no dietary modifications that been used for the key factor rating, the final rating
interfere significantly with ADLs; and no required will generally stay in the middle of that class. On
medication, with adequate reserve capacity that the other hand, if the classes chosen are higher or
allows the body to obtain the required nutrition and lower than that used for the baseline impairment rat-
maintain normal weight. ing, the level will be moved to the right or to the left
(to a higher or lower value) to reflect the numerical
For the purposes of impairment ratings, the upper
discrepancy. For example, if the key factor places the
digestive tract has been defined to include the esoph-
initial rating in class 3, grade C and there are 2 non-
agus, stomach and duodenum, small intestine, and
key factors (leading to a total of 5 possible grades)
pancreas. Impairment criteria and classes have been
that are in class 1 and class 4, respectively, the first
combined for the colon and rectum; anal; liver and
factor would move the grade down 2 levels to grade
biliary impairments; and hernia impairments.
A and the second would move it back up 1 level to
grade B. However, if both non-key factors were class
Methodology for Determining the Grade in an
1, the rating could not go any lower than class 3,
Impairment Class
grade A, the lowest value for the class. An exception
This chapter employs impairment grids to use in
to this rule may occur when the key factor is in the
highest impairment class for the disorder, as non-key
and severity grade (grade) within a class for the
factors falling in the same class can be used to adjust
condition or conditions being rated at Maximum
the impairment rating upward to the highest grade
Medical Improvement (MMI). As was stated in
within the class rather than keep it at the middle
chapter 1, the decision regarding which factor is the
level. Specific tables will indicate if a rating schema
primary determinant of impairment (key factor) will
Chapter 6
other than this is used.
be clearly stated in each organ system impairment
IMPAIRMENT CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

SEVERITY GRADE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
(%) (A B C D E) (A B C D E) (A B C D E) (A B C D E)
c c c c
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The impairment criteria generally used in this chap- and the relative absence of symptoms does not war-
ter on the digestive system include the history, and rant more than a class 0 rating.
physical findings. The assignment of a key factor and
Comment: The original hiatal hernia and motility
relative importance of the criteria will vary accord-
disorder do not require treatment, and neither inter-
ing to each regional disorder.
feres with normal nutrition nor impairs ability to
perform usual daily activities.1
6.2 Upper Digestive Tract EXAMPLE 6-2: STOMACH OR DUODENUM

(Esophagus, Stomach and DISEASE OR INJURY
Duodenum, Small Intestine, Subject: 28-year-old man.
and Pancreas) History: 5 years’ epigastric pain and burning. Use of
nonsteroidal anti-inflammatory drugs (NSAIDs) for
6.2a Criteria for Rating Permanent a work-related back injury caused his GI tract symp-
Impairment due to Upper Digestive Tract toms to increase and was associated with minimal
Disease weight loss, but symptoms are now resolved.
Criteria for evaluating impairments related to upper
Current Symptoms: Denied nausea, vomiting,
digestive tract disease are given in Table 6-4. The
hematemesis, or melena. Painful episodes had lasted
history is the key factor that determines the impair-
up to 2 weeks, woke patient at night, and required
ment class. The medical records will usually permit
antacids, food, and over-the-counter (OTC) H2
the physician to choose the correct impairment class.
blockers for relief. Increased symptoms persisted
despite discontinuation of NSAIDs.
Physical Exam: Height: 1.8 m (5 ft 11 in); weight:
CLASS 0 72.6 kg (160 lb).
Clinical Studies: Barium meal: deformed duode-
nal bulb. No gastric retention or pyloric stenosis.
EXAMPLE 6-1: UPPER DIGESTIVE TRACT Peroral endoscopy: 1-cm duodenum ulcer-crater;
DISEASE considerable surrounding deformity. Antral biopsies
were positive for H pylori; full-course triple-therapy
(omeprazole, clarithromycin, and metronidazole)
History: Warehouse stockman; transient difficulty relieved symptoms. Complete healing was found at
swallowing; first occurrence 9 months ago in asso- follow-up endoscopy 8 weeks later. Repeated antral
ciation with doing a great deal of bending and heavy biopsies: no H pylori.
lifting after eating a lunch that included broiled
Diagnosis: Resolved peptic duodenal ulcer disease
lobster. Formerly drank large amounts of caffeinated
associated with H pylori infection. Exacerbation of
Chapter 6
beverages on a daily basis. Has now ceased doing so.

symptoms by NSAIDs—now resolved.
Current Symptoms: Infrequent symptoms of esoph-
Impairment Rating: Class 0, 0%. He is now in
ageal disease after meals containing large amounts
remission, and test results are normal. History results
of protein.
in a class 0 rating.
Physical Exam: Within normal limits. Weight: 68.1
Comment: H pylori can be found in 95% to 100%
kg (150 lb); height: 1.78 m (5 ft 10 in); within desir-
of patients with duodenal ulcer and 70% to 80%
able limits. Healthy appearance; vital signs normal.
of patients with peptic stomach ulcers. Successful
Clinical Studies: Chest roentgenogram, electrocar- eradication of infection induces a long remission.2
diogram (ECG): normal. Barium swallow: small, Although NSAID use led to definitive endoscopic
sliding hiatal hernia. Endoscopy: no mucosal defect. evaluation of his symptoms, they were not the pri-
mary cause of his pathology. Had his endoscopic
Diagnosis: Hiatal hernia, uncomplicated.
findings been solely consistent with NSAID-related
Impairment Rating: Class 0, 0% impairment of gastritis, resolution of pathology after discontinua-
the whole person. Despite anatomic abnormalities, tion of the medications would have still resulted in
which are not work-related, history is the key factor, no residual impairment.
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TA B L E 6 - 4 Criteria for Rating Permanent Impairment due to Upper Digestive Tract (Esophagus,
Stomach and Duodenum, Small Intestine, and Pancreas) Disease
Upper Digestive Tract

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4C
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-9% 12%-20% 22%-38% 40%-60%
SEVERITY 1 3 5 7 9 12 14 16 18 20 22 26 30 34 38 40 45 50 55 60
HISTORYa Prior history of Frequent minimal Frequent mild or Frequent moder- Frequent severe
upper digestive or occasional occasional mod- ate or occasional or occasional
tract disease; no mild symptoms erate symptoms severe symptoms extreme symp-
active symptoms or signs of upper or signs of upper or signs of upper toms or signs of
digestive tract digestive tract digestive tract upper digestive
disease disease disease tract disease
and and and and
continuous daily medication daily medication daily medication
treatment not and or appro- and/or appro- and/or appro-
required priate dietary priate dietary priate dietary
restrictions restrictions restrictions
required required required
PHYSICAL Maintains weight Maintains weight Weight loss of 10%-20% weight Greater than
FINDINGSb at desirable level at desirable level under 10% of loss below desir- 20% weight loss
desirable weight able weight due below desirable
due to upper to upper diges- weight due to
digestive tract tive tract disorder upper digestive
disorder tract disorder
OBJECTIVE TEST No objective Mild documented Moderate docu- Severe docu- Extreme
RESULTS abnormalities anatomic or func- mented anatomic mented anatomic documented
tional loss or functional loss or functional loss anatomic or func-
tional loss with
expected future
need for surgical
correction
or
complete absence
of organ
Chapter 6
a
Key factor. In class 1, as weight loss does not contribute to the impairment rating, the presence of both symptoms and class
1 objective abnormalities leads to a 5% rating. Symptoms without objective abnormalities warrants only a 1% rating.
b
Note that this is based on ideal body weight (IBW) and not weight loss per se. As both class 0 and class 1 ratings are not
associated with weight loss, it is not used to discriminate between grades in class 1.
c
If evaluee is rated as class 4 based on the history and either weight loss or objective test results the rating should be 50%.
Presence of all three will lead to a 60 % impairment rating.
CLASS 1 of injury he had surgical closure of several holes

1% to 9% Impairment of the Whole Person in the small intestine, but no intestine needed to
be resected. His injury was complicated by a sub-
phrenic abscess that was drained percutaneously.
EXAMPLE 6-3: SMALL INTESTINE DISEASE
Six months after injury he was readmitted to the
Subject: 35-year-old man. hospital because of an obstruction of the small bowel
that resolved without another operation. He has had
History: Police officer stabbed in the abdomen by
occasional recurrent episodes of abdominal pain
a knife during apprehension of a felon. On the day
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that were identical to the bowel obstruction pain, but Clinical Studies: Mild elevation of amylase.
which resolved in a few hours, and these other epi-
Diagnosis: Recurrent acute pancreatitis.
sodes did not require hospitalization or surgery. He
uses opioids only for the most severe of his abdomi- Impairment Rating: Class 1, 5% impairment of
nal pain episodes. On average he uses 5 to 10 doses the whole person assigned based on intermittent
of an oral opioid each year. symptoms and functional (based on elevated amylase
level) abnormality but no weight loss.
Current Symptoms: Has been asymptomatic for 30
days. Performs all ADLs without difficulty.
Physical Exam: Height 178 cm (5 ft 10 in). Weight:
70.3 kg (155 lb) on unrestricted diet; usual pre-illness CLASS 2
weight: 72.6 kg (160 lb). 12% to 20% Impairment of the Whole Person
Clinical Studies: Flat and upright abdominal radio-

graphs and an abdominal CT scan were consistent EXAMPLE 6-5: UPPER DIGESTIVE TRACT
with mechanical small-bowel obstruction during his DISEASE
readmission.
Diagnosis: Partial, small-bowel obstruction sec-
History: 5 years’ almost daily retrosternal pain
ondary to intra-abdominal adhesions from prior
associated with difficulty swallowing.
peritonitis.
Current Symptoms: Symptoms less severe when
Impairment Rating: Class 1. The table for deter-
diet limited to soft foods; symptoms aggravated
mining the appropriate class for intestinal disorders
when upset, particularly when worried. Patient has
indicates that having had 1 documented episode of
used OTC histamine-2 blockers as needed and pre-
bowel obstruction places this police officer in class
scription proton pump inhibitors (PPIs) once daily.
1. He has not had the resection of any small bowel,
he has not had surgery for bowel obstruction, and he Physical Exam: Height: 1.7 m (5 ft 7 in), medium
has had only 1 admission for bowel obstruction, so frame; weight: 53.6 kg (118 lb), within 10% of usual
classes 2 to 4 are not appropriate. Objective findings weight of 58 kg (128 lb). Blood pressure: 145/90 mm
are class 1. Hg. Appears older than stated age.
His weight is normal for his medium frame size, Clinical Studies: Chest roentgenogram, ECG: nor-
which can be a class 1 finding. He does use opioids, mal; uncoordinated contractions in lower esophagus
so his medication use is class 1. Thus, by the table resulting in “corkscrew” configuration, indicative of
used to determine the appropriate grade, he gets the diffuse spasm. Esophageal manometry: prolonged
middle integer or default rating of 5% whole person high amplitude, irregular synchronous contrac-
impairment. tions with water swallowing, consistent with diffuse
spasm. Ambulatory esophageal pH study: percentage
of time that esophageal pH is less than 4 is within
Chapter 6
EXAMPLE 6- 4: PANCREATIC DISEASE normal limits. Endoscopy: no mucosal defect.

Subject: 40-year-old woman. Diagnosis: Diffuse spasm of the esophagus.
History: Bartender; episodic epigastric pain asso- Impairment Rating: 16% impairment of the whole
ciated with elevated serum amylase activity, 2 to person. Symptoms, anatomic/functional abnormali-
3 episodes per year for 3 years. Cholecystectomy ties, and class 2 weight loss warrant the default 16%
for gallstone removal 2 years ago. Reduced-energy rating.
(reduced-calorie) diet corrected exogenous obe-
Comment: Persistent symptoms obligated woman
sity; weight did not fall below desirable level. Mild
to restrict diet. Weight loss did not exceed 10% of
dietary restrictions.
desirable level. Daily activities only slightly limited.
Current Symptoms: Pain attacks, especially after Symptomatic management with agents such as nife-
large meals or immoderate alcoholic beverage dipine and diltiazem hydrochloride may be helpful
consumption. and sufficient; if not, surgical myotomy is reported
to be beneficial in 70% to 80% of cases.3
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EXAMPLE 6-6: GASTROESOPHAGEAL REFLUX Physical Exam: Height: 1.78 m (5 ft 8 in); weight:
DISEASE 59 kg (130 lb), 7% below desirable.
Subject: 43-year-old man. Clinical Studies: Upper GI tract roentgenograms:
marked duodenal bulb cloverleaf deformity with
History: Burning retrosternal chest distress increas-
3-mm ulcer fleck. Esophagogastroduodenoscopy
ing in severity and frequency over the last 18
confirms presence of duodenal ulcer with deformity
months. Occurred after meals; he wakened with
and narrowing of first portion of duodenum. Biopsy
occasional sour regurgitation into mouth and cough-
specimens taken, negative for H pylori.
ing episodes. Antacids helped very briefly; improve-
ment noted with OTC histamine receptor blockers. Diagnosis: Active duodenal ulcer with a history of
Excellent relief with intensive doses of omeprazole recurring complications.
once daily.
Impairment Rating: 18% impairment of the whole
Current Symptoms: Above symptoms recurred person. History leads to impairment rating of class
when medication use stopped after 8 weeks. 2, 16%. Weight loss is consistent with class 2, but
objective test results reveal a severe abnormality
Physical Exam: Unremarkable; minimal weight
consistent with class 3, leading to an adjustment
loss.
upward to 18%.
Clinical Studies: Blood studies: normal. X rays of
Comment: Complicated disease; recurrent symp-
esophagus and stomach: suggest lower esophagus
toms despite medical therapy. H pylori may be fac-
ulceration. Endoscopy: moderately severe esopha-
tor in chronic complicated duodenal ulcer disease;
gitis; longitudinal ridging, denuded mucosa in
should be sought and, if found, treated. Other ulcer
between. Biopsy: inflamed squamous epithelium.
complications (ie, bleeding) respond to injection or
Diagnosis: Moderately severe gastroesophageal thermal/laser therapy; results equal to surgical treat-
reflux disease without stricture. ment. Current surgical treatment reserved for ulcers
intractable to intensive acid suppression therapy,
extremely large duodenal or stomach ulcers, and
person. 16% impairment initially assigned (class 2)
ulcers associated with malignancy.6
based on history, as patient needs continuous medi-
cations to remain symptom-free. Adjusted downward
to 14% impairment based on absence of weight loss
EXAMPLE 6-8: SMALL-INTESTINE DISEASE
(class 1). No change in grade based on clinical stud-
ies (consistent with class 2). Subject: 64-year-old woman.
Comment: Persistent untreated gastroesophageal History: Commercial artist; 5 years’ diarrhea, weight
reflux may result in stricture formation, necessitating loss, and vague abdominal distress. All symptoms
repeated dilatations and medical therapy resumption. cleared with oral tetracycline and parenteral cyanoco-
Possible endoscopic luminal procedure or antireflux balamin (vitamin B12). Mild diarrhea for several weeks
surgery. Reflux may induce premalignant changes in 2 years ago; subsided with tetracycline.
Chapter 6
lower esophagus; regular surveillance and possible
Current Symptoms: Mild weight loss. No untoward
surgical treatment increase impairment rating.4,5
symptoms; mild dietary restrictions, patient tried
1 course of probiotics without relief of symptoms.
Patient received monthly intramuscular cyanoco-
EXAMPLE 6-7: DUODENUM DISEASE
balamin injections.
Physical Exam: Weight: 49.9 kg (110 lb); pre-illness
History: 10 years’ intermittent ulcer symptoms. weight: 54.4 kg (120 lb). Height: 1.55 m (5 ft 1 in).
Three bleeding episodes; twice required blood
Clinical Studies: Macrocytic anemia; barium meal
replacement. One transient pyloric obstruction
examination: extensive small intestine diverticulo-
episode.
sis. Roentgenographic examination: persistence of
Current Symptoms: Performance of daily activities numerous diverticula in small intestine, even more
repeatedly interrupted. Refuses to consider surgi-
cal remedy; requires continuing medical therapy
with daily high-dose PPIs to maintain any degree of
symptomatic remission. Mild dietary restrictions.
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prominent in jejunum. Breath test consistent with Comment: Impaired pancreatic exocrine function;
small bowel overgrowth. weight maintained within 10% of desirable level.
Reduced capacity to perform ADLs.7
Diagnosis: Diverticulosis of the small intestine;
overgrowth of enteric bacterial flora.
Impairment Rating: 16% impairment due to diver-
ticulosis of the small intestine based on history, CLASS 3
physical examination findings, and test results; com- 22% to 38% Impairment of the Whole Person
bine with appropriate impairment estimate for ane-
mia (see Chapter 9, The Hematopoietic System).
EXAMPLE 6-10: UPPER DIGESTIVE TRACT
Comment: Performs ADLs; unimpaired weight, but DISEASE
patient is dependent on continuing therapy. Diffuse
intestinal motility disorder possibly associated with
small-intestine diverticulosis may produce a pro- History: 5 years’ intermittent retrosternal pain, dys-
gressively disabling condition, “intestinal pseudo- phagia, and nocturnal regurgitation with occasional
obstruction,” with abdominal distention, diarrhea, and partial remission.
and malnutrition and with little or no response to
Current Symptoms: Pain less prominent; dyspha-
usual therapy. Possible long-term parenteral feeding;
gia more troublesome. Swallows solid foods only
if required, her impairment would advance to class
with large volumes of liquids. Moderate dietary
3 or 4.
restrictions.
Physical Exam: Weight: 70.4 kg (155 lb); pre-illness
EXAMPLE 6-9: PANCREATIC DISEASE OR weight: 81.7 kg (180 lb). Height: 1.88 m (6 ft 2 in);
INJURY lanky and gaunt. Normal vital signs.
Subject: 35-year-old man. Clinical Studies: Chest roentgenogram: mediastinal
widening; no lung field densities that might indi-
History: Thrown against steering wheel of truck
cate aspiration. Barium swallow: markedly dilated
when it slid off a road. Increasing abdominal pain
and tortuous esophagus terminating in filiform
and distention a few weeks later. Serial ultrasonog-
constriction. Esophageal manometry: markedly
raphy followed by CT scans: expanding pancreatic
elevated lower esophageal sphincter pressure without
cyst. No response to bowel rest and parenteral
decrease of pressure on swallowing. Endoscopy: no
nutrition. Subtotal pancreatectomy; cyst removed,
mucosal defect. Successful pneumatic dilation of
and associated inflammatory reaction allayed.
lower esophageal sphincter after repeated attempts.
Medications: pancreatic enzymes 4 times a day, PPIs
and narcotic analgesics as needed. Diagnosis: Achalasia of the esophagus.
Current Symptoms: Intermittent diarrhea, steat- Impairment Rating: 30% impairment of the whole
orrhea, and diminished stamina 15 months later person based on class 3 history, weight loss, and
Chapter 6
that moderately impacts ADLs, despite pancreatic objective test results.

enzyme supplements. Moderate dietary restrictions.
Comment: Symptoms persistent and progressive
Occasional epigastric and back pain.
despite dietary limitation and esophageal dila-
Physical Exam: Height: 1.9 m (6 ft 3 in); weight: tion; weight loss exceeded 10% of desirable level.
74.5 kg (164 lb); pre-illness weight: 81.7 kg (180 Esophagomyotomy highly recommended due to
lb). No evidence of impaired glucose tolerance or individual’s age, and possible combination of antire-
diabetes. flux procedure. Basic defect in achalasia, and loss of
ganglion cells and nerve fibers, cannot be corrected;
Clinical Studies: Blood studies: normal; modest
therapy goal to prevent progressive proximal esopha-
steatorrhea.
geal dilation. Successful treatment could reduce
Diagnosis: Status after subtotal pancreatectomy con- impairment to class 2. Progressive proximal esopha-
sequent to trauma, residual chronic pancreatitis and geal dilation with failure or omission of treatment
exocrine pancreatic insufficiency. may result in class 4 rating.4
person (class 2) based on history, weight loss, and
objective test results.
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EXAMPLE 6-11: STOMACH OR DUODENUM Clinical Studies: Small intestine roentgenogram:

DISEASE OR INJURY segmental distortion consistent with recurrent
inflammation and edema.
Diagnosis: Recurrent regional enteritis, with intes-
History: Librarian; partial gastrectomy 2 years ago
tinal malabsorption and recurring obstruction after
to remove focus of multiple, dysplastic, adenomatous
ileal resection.
polyps.
BOTC: An additional 5% impairment is assigned
Current Symptoms: Lightheadedness, sweating,
due to daily use of TPN along with 3% due to
and palpitation 15 minutes after meals. Symptoms
requirements for daily corticosteroids.
modified by moderate dietary restriction and lying
down. Weight dropped since operation to approxi- Impairment Rating: 38% impairment of the whole
mately 15% below desirable. person. History is consistent with class 3, 30%.
Physical examination and objective test results are
Physical Exam: Weight: 45.4 kg (100 lb); height: 1.6
also consistent with class 3, so this impairment per-
m (5 ft 3 in) with a medium frame. Well-healed scar
centage is retained. The BOTC results in the assig-
on upper abdomen; physical examination findings
nation of an additional 8% for a total of 38%.
otherwise unremarkable.
Comment: Only marginal function; impaired nutri-
Clinical Studies: Upper GI tract roentgeno-
tional state, and weight deficit exceeds 10% of desir-
grams: 70% gastric resection; patent, undistorted
able level despite dietary adjustment and medication.
gastrojejunostomy.
Parenteral nutrition therapy (home treatment pro-
Diagnosis: Postgastrectomy dumping syndrome. gram), administered characteristically at night while
person is asleep, greatly reduces degree of impair-
ment of many individuals and has maintained nutri-
person based on class 3 history, weight loss, and
tional status consistent with a class 3 rating, which
objective test results.
may improve further to class 2 and permit adjust-
Comment: Symptoms interfered with performance ment of the baseline class 3 impairment to 26%. If
of normal daily activities despite dietary restriction. this is deemed possible, patient may not yet be at
Unable to maintain weight within 10% of desirable MMI. Length and function of remaining normal
level. bowel is an important consideration when assessing
severity of impairment.8
EXAMPLE 6-12: REGIONAL ENTERITIS

EXAMPLE 6-13: PANCREATIC DISEASE
History: Diarrhea and stamina loss. Partial resec-
tion of the distal ileum 3 years ago; evidence of History: Chronic abdominal pain secondary to
regional enteritis. Several bouts of partial intestinal chronic pancreatitis. Reported a 10-year excessive
Chapter 6
obstruction, each subsiding with supportive therapy. alcohol intake and repeated acute pancreatitis. Daily
Required no repeated surgical intervention. Dietary opioid drugs every 4 to 6 hours required for some
restriction. Oral corticosteroid once a day, oral 5 relief. Diabetes mellitus; requires small but multiple
aminosalicylic acid (5-ASA) therapy daily, vitamin daily insulin doses. Daily pancreatic enzymes at
B12: monthly injection and folic acid, oral daily anti- least 3 times a day. Diarrhea with steatorrhea over
diarrheal agents 4 to 6 times a day. Corticosteroid last year helped by pancreatic enzymes. Moderate
therapy needed to help sustain adequate health state. dietary restrictions
Currently receiving anti-tumor necrosis factor (TNF)
Current Symptoms: Unable to maintain weight;
injections every 6 weeks. Receiving nightly TPN.
15% below ideal. Currently abstaining from alcohol.
Current Symptoms: Episode diarrhea and abdomi-
Physical Exam: Substantial weight loss; abdominal
nal cramps.
burn marks from heating pads.
Clinical Studies: Abdomen CT scan: calcification
49.9 kg (110 lb); pre-illness weight: 59 kg (130 lb).
throughout pancreas. Endoscopic retrograde cholan-
Guides6e_06_101-128.indd 111 2/17/09 2:36:12 PM

giopancreatography: normal biliary ductal system. Diagnosis: Postoperative absence of the stomach
Main pancreatic duct very distorted with abnormal with esophagojejunal anastomosis; secondary nutri-
side branches and small 2-mm pseudocyst. No evi- tional deficiency.
dence of malignancy.
Impairment Rating: 60%. 50% impairment based
Diagnosis: Chronic pancreatitis with intractable on history. Weight loss also consistent with class 4
pain; exocrine and endocrine insufficiency. impairment, as is total gastrectomy, warranting use
of highest rating for class (60%). This is combined
Impairment Rating: 34% impairment. History and
with appropriate anemia impairment estimate (see
weight loss consistent with class 3, 30%. However,
Chapter 9, The Hematopoietic System) to determine
objective test results showed severe abnormalities,
with potential need for subtotal pancreatectomy con-
sistent with a class 4 rating, which leads to upward Comment: Weight loss exceeds 20% of desirable
adjustment of initial 30% rating to 34%. Combine level; evidence of marked nutritional deficiency.
(see the Combined Values Chart in the Appendix) Individual unable to perform many ADLs. If he con-
with appropriate impairment estimate for diabetes tinues to be free of recurrent cancer, consider supple-
to determine whole person impairment. See Chapter mental parenteral nutrition therapy (home treatment
10, The Endocrine System, for impairment related to program).
diabetes mellitus.
Comment: Impaired exocrine and endocrine pan-
EXAMPLE 6-15: UPPER DIGESTIVE TRACT
creatic functions; continuing treatment necessary.
DISEASE
Despite treatment, individual unable to bring weight
to within 10% of desirable level. Subtotal pancre- Subject: 58-year-old man.
atectomy may be indicated for pain relief attempt.
History: Almost complete esophageal obstruction.
Continuing alcohol use greatly increases mortality.7
Extensive lower esophagus and proximal stomach
Offered surgery for duct and pseudocyst drainage
resection due to cancer 5 years ago. No evidence of
and possible pain management. No surgical benefit
tumor recurrence by CT imaging and endoscopic
for diabetes and malabsorption.
studies. Early satiety severely restricts eating ability;
primarily able to take only liquids.
Current Symptoms: Gastrostomy tube for feeding.
CLASS 4 Dilation of strictured esophagus required once a
40% to 60% Impairment of the Whole Person month to accommodate saliva secretion.
EXAMPLE 6-14: UPPER DIGESTIVE TRACT 49.9 kg (110 lb); pre-illness weight: 68.1 kg (150 lb).
DISEASE
Clinical Studies: Endoscopy: no evidence of tumor
Subject: 62-year-old man. recurrence, foreshortened esophagus with tight nar-
rowed stricture, esophagogastric anastomosis at
Chapter 6
History: Total gastrectomy 3 years ago for treatment

28 cm from incisors only able to accommodate pedi-
of stomach cancer. Esophagoenterostomy (Hunt-
atric endoscope.
Lawrence pouch) constructed. Oral vitamins.
Diagnosis: Status after resection of esophageal neo-
Current Symptoms: Postoperative anorexia and
plasm with esophageal stricture.
early satiety; unrelenting weight loss and signs of
nutritional deficiency. Marked fatigue, weakness, Impairment Rating: 64%. History consistent with
and inability to read or write except for brief periods. class 4 impairment, as is his weight loss of greater
Severe dietary restrictions. than 20% and the objective evidence of esophageal
disease, leading to a 60% impairment rating. This is
combined with 10% impairment due to gastrostomy
52.7 kg (116 lb). Malnourished; appears older than
to arrive at a rating of 64% impairment of the whole
stated age. Tongue smooth and glistening. No pal-
person (See Table 6-7) (see the Combined Values
pated masses in vicinity of healed upper abdominal
Chart in the Appendix). Combine impairments due
scar. Slight pedal edema.
to cancer and other medical conditions with this
Clinical Studies: Laboratory tests: anemia and impairment percentage.
hypoproteinemia. Roentgenography: intact esoph-
agojejunostomy; no mucosal defect.
Guides6e_06_101-128.indd 112 2/17/09 2:36:12 PM

Comment: Disease symptoms and signs progressed Current Symptoms: Dependent on continuous
despite exhaustive treatment; further therapy only home TPN. Takes daily narcotics 2 to 3 times a day
palliative. Poor prognosis. Esophageal stent may pro- for diarrhea. Diminished stamina; needs assistance
vide palliation and avoidance of dilations. with essential ADLs.
39.5 kg (87 lb), relatively stable; should be at least
EXAMPLE 6-16: PANCREATIC DISEASE
57.6 kg (127 lb) for medium frame. Sharply reduced
Subject: 47-year-old man. intestinal absorptive capacity. Otherwise normal.
History: Manufacturer’s representative; 13 months Clinical Studies: Hematologic studies: consis-
prior onset of vague abdominal pain, weight loss, tent with malabsorption. Low albumin, calcium,
and uncharacteristic depression, followed by gradu- magnesium.
ally deepening jaundice. Cystic adenocarcinoma
Diagnosis: Intestinal malabsorption due to extensive
occupying most of the pancreas. Surgical eradication
small-bowel resection.
of lesion required total pancreatectomy and duode-
nectomy (Whipple operation). Severe dietary restric- BOTC: Use of daily TPN warrants assignation of an
tions. Malabsorption syndrome with steatorrhea only additional impairment percentage of 5%.
partially relieved by pancreatic enzyme supplements
Impairment Rating: 55%. History is consistent with
after meals, PPI once day, narcotics, PRN analgesics.
class 4 impairment rating of 50%. The combination
Brittle diabetes mellitus after operation despite close
of class 4 weight loss and class 3 objective testing (as
monitoring and repeated daily insulin injections.
no surgical intervention is anticipated and intestinal
Current Symptoms: Barely able to perform essen- resection was not complete) leads to adjustment of
tial ADLs. rating back to 50%. The BOTC leads to assignment
of an additional 5% for a total rating of 55%.
Physical Exam: Cachectic. Weight declined since
operation to 25% below desirable level. Comment: Nutritional status severely impaired
by irreversible small-intestine defect. Weight loss
Clinical Studies: Glucose levels: highly variable.
exceeds 20% of desirable level; needs assistance
Diagnosis: Pancreatic insufficiency consequent to with performance of daily living activities.
total pancreatectomy.
Impairment Rating: 60%. Class 4 impairment due
to history. Weight loss and objective testing (absence
of organ) also consistent with class 4 so final rating
6.3 Colon, Rectum, and Anus
adjusted to the top of the class (60%). This will be
combined with appropriate impairment estimate for 6.3a Criteria for Rating Permanent
diabetes mellitus (refer to Chapter 10, The Endocrine Impairment due to Colonic or Rectal
System and see Combined Values Chart in the Disease
Appendix to determine whole person impairment). Criteria for evaluating impairments in function of
Chapter 6
the colon and rectum are listed in Table 6-5. The
Comment: Capacity to perform normal ADLs seri-
history is the key factor that determines the impair-
ously impaired by total pancreatic loss; intensive
ment class. The medical records will usually permit
treatment only partially alleviated debility.7
the physician to choose the correct impairment class.
EXAMPLE 6-17: SMALL INTESTINE DISEASE

History: Department store salesperson; life-
threatening volvulus 1 year ago. Major small-bowel
portion entrapped in adhesions from previous opera- EXAMPLE 6-18: COLONIC OR RECTAL DISEASE
tion required extensive resection of incarcerated
and strangulated intestine, with some intestine still
remaining. Dehydration and electrolyte depletion History: Part-time social worker; general good
necessitated repeated hospitalization. health. Several years’ tendency of mildly erratic
Guides6e_06_101-128.indd 113 2/17/09 2:36:13 PM

TA B L E 6 - 5 Criteria for Rating Permanent Impairment due to Colonic and Rectal Disorders
Colonic and Rectal Disorders

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4c
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-9% 12%-20% 22%-38% 40%-60%
SEVERITY 1 3 5 7 9 12 14 16 18 20 22 26 30 34 38 40 45 50 55 60
HISTORYa Prior history Occasional mild Frequent mild Frequent moder- Frequent severe
of colonic or or continuous or occasional ate or occasional or occasional
rectal tract dis- minimal symp- moderate symp- severe symp- extreme symp-
ease, return not toms or signs of toms and signs of toms or signs of toms or signs of
expected; colonic or rectal colonic or rectal colonic or rectal colonic or rectal
no active disease disease despite disease despite disease despite
symptoms daily medication daily medication daily medication
and
and/or appro- and/or appro- and/or appro-
continuous priate dietary priate dietary priate dietary
treatment not restrictions restrictions restrictions
required
PHYSICAL No signs of Occasional signs Constitutional Weight loss Greater than

FINDINGS b colonic or rectal of colonic or rec- manifestations below desirable 20% weight loss
disease tal disease; nutri- such as fever weight from 10% below desirable
tion normal or weight loss to 20% due to weight due to
below desirable colonic or rectal colonic or rectal
weight that does disorder disorder
not exceed 10%
OBJECTIVE TEST No objective Mild documented Moderate docu- Severe docu- Extreme
RESULTS abnormalities anatomic or func- mented anatomic mented anatomic documented
tional loss or functional loss or functional loss anatomic or func-
tional loss with
expected future
need for surgical
correction
or
complete absence
of organ
a
Key factor.
Chapter 6
b
Note that this is based on IBW and not weight loss per se. Constitutional findings must be present at time of examination to
be rated.
c
If an individual is rated at class 4 for factors other than the key factor this will move the rating one grade higher within the class.
bowel action with alternating constipation and diar- Diagnosis: Irritable bowel syndrome and
rhea. Stools of varied consistency never contained diverticulosis.
abnormal materials.
Current Symptoms: Episodes of cramping bowel person.
movements; alternating diarrhea and constipation.
Comment: Symptoms, while occasionally annoying,
Physical Exam: Normal. do not interfere with performance of daily activities.
Needs only minor dietary adjustment.
Clinical Studies: Proctosigmoidoscopy: clear
mucosa; barium enema: normal colon with sev-
eral scattered sigmoid diverticula; no evidence of
diverticulitis.
Guides6e_06_101-128.indd 114 2/17/09 2:36:13 PM

CLASS 2 nocturnal rectal nonabsorbable steroids, and inflix-

12% to 20% Impairment of the Whole Person imab (Remicade) intravenously every 6 weeks. Mild
dietary restrictions.
EXAMPLE 6-19: COLONIC OR RECTAL DISEASE Physical Exam: Weight remains 20% or more below
desirable level. Guaiac-positive stools.
Clinical Studies: Crohn’s disease lesions affecting
History: Graduate student; part-time teach-
the perineum, rectum, several colon segments, and
ing assistant; 10 year recurring ulcerative colitis.
the terminal ileum.
Exacerbations produced moderate abdominal dis-
tress, diarrhea, and passage of blood-tinged stools. Diagnosis: Chronic, recurrent enterocolitis (Crohn’s
No fever, anemia, or hospitalization. Symptoms disease).
responded to moderately restricted diet and antidiar-
Impairment Rating: 34% due to colonic or rectal
rheal medication.
disease. History places him in class 3 with 30%
Current Symptoms: Episodic diarrhea. impairment, as do objective test findings. This is
adjusted upward to 34% impairment due to his
Physical Exam: Guaiac-positive stools.
weight loss of more than 20% of IBW. This will be
Clinical Studies: Colonoscopy: varying degrees of combined with a class 2 grade C rating of 15% for
granularity and punctate friability in rectosigmoid his upper GI tract disease (class 2 history, class 3
mucosa; remainder of colon and terminal ileum weight loss, class 1 objective testing) for a total GI
appeared normal. rating of 44%, and then combined with the impair-
ment from anemia, if still present, to determine
Diagnosis: Idiopathic ulcerative proctocolitis; mild;
whole person impairment (see Combined Values
limited to the rectosigmoid segment.
Chart in the Appendix).
Impairment Rating: 16%. Based on symptoms she
Comment: Chronic inflammatory bowel disease,
is class 2—default value of 16%. Her physical find-
while remitting occasionally, interferes with perfor-
ings are class 1, but her objective test results are
mance of daily activities. Requires continuing close
class 3. This would leave her at the default value.
observation and treatment. Impaired nutritional
Comment: Remittent disease; symptoms only status. Continuing Crohn’s disease activity, mostly
occasionally interfere with performance of neces- in colon with only distal ileum involvement; procto-
sary daily activities. Patient may be a candidate for colectomy and Brooke ileostomy may significantly
rectal medications such as budesonide (Entocort) improve the general condition, perhaps with less
nonabsorbable steroid or mesalamine (Rowasa) sup- impairment.
positories; however, symptomatic, supportive therapy
adequately controls disease.6
CLASS 4
Chapter 6
CLASS 3
EXAMPLE 6-21: COLONIC OR RECTAL DISEASE

EXAMPLE 6-20: COLONIC OR RECTAL DISEASE
History: 15 years’ chronic ulcerative colitis. Activity
limited; required intensive treatment, including
History: Computer programmer; Crohn’s disease occasional blood transfusion during hospitalizations.
since age 19 years. Several hospitalizations that Persistent fever, anemia, and jaundice.
required intensive therapy and transfusion of packed
Current Symptoms: Increasing debility; nutritional
red blood cells to correct anemia.
deficiency. Further complications of inflammatory
Current Symptoms: Recurring diarrhea associ- bowel disease.
ated with cramping abdominal pain and occasional
Physical Exam: Cachectic with weight loss of more
perianal suppuration with draining fistulas. Elective
than 25% of IBW; jaundice and hepatomegaly.
proctocolectomy declined. Receiving mesalamine
(Asacol) orally twice a day, oral corticosteroids,
Guides6e_06_101-128.indd 115 2/17/09 2:36:14 PM

Clinical Studies: Colonoscopy: extensive and severe Comment: Patient referred for liver transplanta-
colon involvement. Liver function tests: severely tion evaluation. May need to consider colectomy
abnormal; liver biopsy: nonsuppurative sclerosing as a therapeutic option due to general debility and
cholangitic cirrhosis. advanced, complicated disease. Proctocolectomy
has no beneficial effect on sclerosing cholangitis.9
Diagnosis: Chronic ulcerative colitis, severe; scle-
Increased acceptability of new anastomosis such as
rosing cholangitis with cirrhosis.
ileal-pouch anal anastomosis provides greater secu-
Impairment Rating: 60%. Assigned an initial rat- rity and privacy and may lead to earlier surgery in
ing of 50% based on her class 4 symptoms. This is severe ulcerative colitis.
modified upward to 60%, as both her weight loss
and objective test results are consistent with class 4 6.3b Criteria for Rating Permanent
disease This should be combined with appropriate Impairment due to Anal Disease
impairment estimates for the liver disorder and ane- Anal disease is an uncommon cause of impairment,
mia (see Combined Values Chart in the Appendix). yet the combination of incontinence and severe anal
symptoms unresponsive to therapy can be quite
debilitating. History is the key factor.
TA B L E 6 - 6 Criteria for Rating Permanent Impairment due to Anal Disease
Anal Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-5% 6%-10% 12%-20% 22%-30%
SEVERITY 1 2 3 4 5 6 7 8 9 10 12 14 16 18 20 22 24 26 28 30
HISTORYa Prior history of Frequent mini- Frequent mild or Frequent moder- Frequent severe
anal disease; mal or ocasional occasional mod- ate or occasional or occasional
no active mild symptoms erate symptoms severe symptoms extreme symp-
symptoms or signs of anal or signs of anal or signs of anal toms or signs
disease disease despite disease despite of anal disease
treatment daily medication despite daily
and
and/or other medication
continuous treatment and/or other
treatment not treatment
Chapter 6
required
PHYSICAL No signs of anal Frequent to Frequent to con- Frequent to con- Frequent to con-
FINDINGSb disease continuous mild tinuous moderate tinuous severe tinuous extreme
signs of organic signs of organic signs of organic signs of organic
anal disease anal disease anal disease anal disease
or or or
mild loss of moderate loss of complete func-
anal sphincter anal sphincter tional loss of
mechanism mechanism anal sphincter
mechanism
OBJECTIVE TEST Testing normal Objective evi- Objective evi- Objective evi- Objective evi-
RESULTS dence of minimal dence of mild dence of moder- dence of severe
anal or rectal chronic anal or ate chronic anal anal disease with
disease rectal disease or rectal disease anatomic loss or
with anatomic with anatomic alteration
loss or alteration loss or alteration
a
Key factor.
b
If there is no physical examination performed, one will just omit consideration of this factor from the rating.
Guides6e_06_101-128.indd 116 2/17/09 2:36:15 PM

CLASS 0 Impairment Rating: 10% impairment. Her symp-

0% Impairment of the Whole Person toms are consistent with class 2 disease, with a
baseline impairment of 8%. However, her moderate
impairment of anal function and the extent of objec-
EXAMPLE 6-22: ANAL DISEASE
tively documented disease are both consistent with
Subject: 45-year-old man. class 3, which leads one to move up 2 grades to an
impairment rating of 10%. This will be combined
History: Acute pararectal abscess surgically drained
with ratings for her colonic disease and gynecologic
5 years ago. Anal fistula; recurrent acute infection
impairment (see the Combined Values Chart in the
and intermittent drainage. Fistulectomy 1 year ago.
Appendix).
Current Symptoms: No further infection or drain-
Comment: Impaired anal function, but symptoms
age; regular bowel activity.
generally responsive to treatment when required.
Physical Exam: Well-healed anal scar with no anal Slightly impaired ability to perform ADLs.
orifice distortion; no anal sphincter weakness.
Clinical Studies: Proctosigmoidoscopy: normal
except for anal scarring.
CLASS 4
Diagnosis: Healed anal fistula. 22% to 30% Impairment of the Whole Person

person. EXAMPLE 6-24: ANAL DISEASE
Comment: Documented anal disease appropriately Subject: 56-year-old man.

and successfully treated. Performance of daily activ-
History: Pararectal abscess that drained spontane-
ities unimpaired.
ously; 3 years’ recurrent infection; fistulous tracts
opened 4 other areas surrounding anus. Two-stage
surgical repair; incision and excision of substantial
portions of the anal sphincter muscle. Recovery
CLASS 2
delayed by wound infections.
Current Symptoms: Perineum eventually healed;
no fecal control. Despite daily rectal irrigation, soils
EXAMPLE 6-23: ANAL DISEASE
himself occasionally.
Physical Exam: Complete functional loss of anal
History: 14 years’ Crohn’s colitis, usually well con- sphincter mechanism.
trolled by medical therapy. During one exacerbation,
Clinical Studies: Barium study reveals fistulas.
developed pararectal abscess that ruptured spontane-
Rectal manometry confirms loss of sphincter
ously and led to development of chronically drain-
mechanism.
Chapter 6
ing anal fistula. Later developed small rectovaginal
fistula. Anal dysfunction symptoms occasionally Diagnosis: Anal incontinence due to complete loss
recurred; usually tolerably controlled by treatment. of sphincter function.
Anal fistula surgery attempt inadvisable because of
Impairment Rating: 30%. His symptoms, physical
disease extent elsewhere in the rectum and colon.
findings, and test results are all consistent with class
Infliximab (Remicade) intravenously (IV) every 6
4 disease, leading one to choose the highest rating in
weeks and intermittent courses of oral antibiotics.
that class.
Once daily corticosteroids.
Comment: Uncontrollable fecal incontinence not
Current Symptoms: Episodic fecal incontinence.
amenable to further therapy. Sigmoid colostomy
Physical Exam: Inactive perianal disease. might provide greater comfort and security with less
impairment (see Table 6-7).
Clinical Studies: Colonoscopy: Crohn’s disease
throughout colon and rectum.
Diagnosis: Chronic anal fistula with moderate
impairment of anal function, associated with Crohn’s
disease of the colon.
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6.4 Enterocutaneous Fistulas Table 6-8 on liver disease is a listing for the uncom-
mon gallbladder and biliary tract problems. Those
Evaluate permanent enterocutaneous fistulas of the impairments may be combined with a liver impair-
GI tract, biliary tract, or pancreas that are associ- ment from Table 6-8 if one is present at MMI.
ated with diseases of these structures or their treat-
Criteria for evaluating permanent impairment of the
ment as part of the primarily involved organ system.
liver and biliary tract are listed in Tables 6-8 and 6-9.
Permanent, surgically created stomas usually are
History is the key factor.
provided to compensate for anatomic losses and to
allow either ingress to or egress from the alimentary
tract. There is no additional impairment given to
individuals who use these for nutrition, as the BOTC CLASS 0
is included in the rating for the ostomy. However, the 0% Impairment of the Whole Person
higher rating should be used for these individuals.
Likewise, the highest rating for each category should
EXAMPLE 6-25: LIVER DISEASE
be used if the history or examination indicates that
the stoma is not functioning optimally or interferes Subject: 30-year-old man.
significantly with ADLs. These ratings are carried
History: Occupational exposure to methylene
forward from the Fifth Edition.
chloride. Presented to his primary care physician
If an individual has a permanent, surgically cre- with complaints of malaise. Liver enzyme elevation
ated stoma, combine a percentage based on Table present, but resolved completely after removal from
6-7 with an estimate based on criteria related to the occupational exposure.
involved organ (see the Combined Values Chart in the
Current Symptoms: None.
Appendix). Many people with well-functioning, long-
standing stomas such as Brooke ileostomy or descend- Physical Exam: Normal.
ing colostomy lead full and active lives with few
Clinical Studies: Liver enzymye levels (aspartate
limitations in overall performance of daily activities.
aminotransferase [AST], alanine aminotransferase
[ALT]) bilirubin levels, and prothrombin time are all
normal.
TA B L E 6 -7
Impairments From Surgically Created Stomas Diagnosis: Transient hepatitis from methylene chlo-
% Impairment of the
ride exposure.
Created Stoma Whole Person
Esophagostomy 10%–15% person.
Gastrostomy 10%–15%
Comment: Full symptomatic and biochemical
Jejunostomy 15%–20%
recovery after removal from exposure.
Ileostomy 15%–20%
Ileal pouch-anal anastomosis 15%–20%
Chapter 6
Colostomy 5%–10%
CLASS 2
6.5 Liver and Biliary Tract EXAMPLE 6-26: LIVER DISEASE

History: Plumber; acute viral hepatitis B acquired at
Impairment due to Liver or Biliary Tract
work when exposed to large amounts of sewage with
Disease
a protracted convalescence 10 years ago.
Impairment due to liver disease or injury may be
due to traumatic injury, exposure to viral or parasitic Current Symptoms: Disease quiescent; no visible
agents, or toxic exposure. Such impairments are icterus, ascites, or GI tract bleeding. Satisfactory
rated from this section and Table 6-8. strength and nutritional state; limited stamina.
Receiving daily oral adefovir dipivoxil (Hepsera).
Significant gallbladder disease usually results in cho-
lecystectomy, which usually results in no significant Physical Exam: Well nourished and well muscled.
symptoms or problems (0% impairment). Following Several small telangiectasias on left shoulder.
Guides6e_06_101-128.indd 118 2/17/09 2:36:16 PM

TA B L E 6 - 8 Criteria for Rating Permanent Impairment due to Liver Disease
Liver Disease
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4d
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-13% 15%-27% 30%-42% 45%-65%
SEVERITY 1 4 7 10 13 15 18 21 24 27 30 33 36 39 42 45 50 55 60 65
HISTORYa Prior history Persistent liver History of chronic Progressive Progressive

of liver disease— disease with no liver disease with chronic liver dis- chronic liver
resolved symptoms and no symptoms and ease with either disease or persis-
no history of no history of asci- history of asci- tent jaundice or
ascites, jaundice, tes, jaundice, or tes, jaundice, or bleeding esopha-
or bleeding bleeding esopha- bleeding esophageal or gastric
esophageal vari- geal varices geal varices varices, with
ces within past 3 within past year CNS manifesta-
or
years; disease not tions of hepatic
likely to progress hepatic encepha- insufficiency
lopathy within
past year
PHYSICAL No signs of liver Good nutrition Good nutrition Cutaneous and Poor nutritional
FINDINGSb or biliary tract and strength and strength ocular signs of state
disease with minor or no with mild to chronic liver dis-
signs of chronic moderate signs ease with mildly
liver disease of liver disease affected nutri-
tion and strength
OBJECTIVE TEST Testing normal Biochemical, Biochemical, Biochemical, Biochemical,

RESULTS c imaging, and/or imaging, and/or imaging, and/or imaging, and/or
functional studies functional studies functional studies functional studies
indicate mild dis- indicate moder- indicate severe indicate extreme
turbance in func- ate liver damage liver damage and irreversible
tion or primary or disturbance in with ancillary liver damage with
disorders of bili- function systemic ramifi- significant ancil-
rubin metabolism cations of liver lary systemic rami-
disease such as fications of liver
abnormal pro- disease such as
tein, albumin, abnormal protein,
or coagulation albumin, or coag-
Chapter 6
factors ulation factors
a
Key factor.
b
If there is no physical examination performed, one will just omit consideration of this factor from the rating.
c
Hematologic and neurologic findings are to be also rated in those systems and combined with the rating for the
hepatologic impairment.
d
If an individual is at rated at class 4 for factors other than the key factor this will move the IR one grade higher within the
class – so if all factors are class 4 the top rating of 65% will be used. Most with class 4 disease will also be rated for disease in
other systems.
Nontender, firm, rounded liver edge palpated 4 cm 10–30 U/L) 70 U/L. Positive serum hepatitis B surface
below right costal margin; inferior spleen margin antigen and hepatitis B core antibodies. Liver biopsy
palpated 1cm below left costal margin. specimen: periportal hepatitis and piecemeal necrosis
(now called “interface hepatitis”); early indications of
Clinical Studies: Liver function tests: serum bilirubin,
extension between portal tracts and central veins.
36 mmol/L (2.1 mg/dL); serum albumin, 40 g/L;
serum globulin, 40 g/L; serum ALT, (normal range Diagnosis: Chronic hepatitis B with piecemeal
10–40 U/L) 65 U/L and serum AST, (normal range necrosis.
Guides6e_06_101-128.indd 119 2/17/09 2:36:16 PM

TA B L E 6 -9 Criteria for Rating Permanent Impairment due to Biliary Tract Disease
Biliary Tract Disease

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-9% 11%-19% 21%-29%
SEVERITY 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
GRADE (%) (A B C D E) (A B C D E) (A B C D E)
HISTORYa Prior history of biliary Occasional biliary Recurrent biliary tract Irreparable biliary
tract disease tract impairment impairment with tract impairment
or history of reparable disease with recurrent
cholecystectomy cholangitis
PHYSICAL FINDINGS b No signs of biliary Intermittent signs of Recurrent signs of Recurrent episodes of
tract disease biliary tract disease— biliary tract disease— demonstrable right
no jaundice intermittent episodes upper quadrant pain
of jaundice and jaundice
OBJECTIVE TEST Testing normal Laboratory tests and Laboratory tests Laboratory tests and
RESULTS imaging studies con- and imaging studies imaging studies con-
sistent with mild bili- consistent with mod- sistent with severe
ary tract disease erate biliary tract chronic biliary tract
impairment impairment
a
Key factor.
b
If there are no findings on physical examination at the time of the rating, one can opt to omit consideration of this factor
from the rating or default to assigning the class 1 rating.
Impairment Rating: 21% impairment of the whole Subject: 46-year-old woman.

person. Baseline rating is in class 2, 21% based on
History: Teacher; concerned about increasing pru-
chronic liver disease. This remains at 21%, as both
ritus, loss of strength, and decreased stamina. Itch
the physical examination findings and test results are
onset 2 years ago; routine blood chemistry: elevated
also class 2.
serum alkaline phosphatase levels. Ingested no drugs
Comment: Documented evidence of chronic active known to cause cholestasis; antimitochondrial anti-
hepatitis; can perform normal ADLs, although has body test positive. Using cyproheptadine hydrochlo-
reduced stamina. Slight to moderate impaired liver ride (Periactin) and diphenhydramine hydrochloride
function. Chronic hepatitis implies 6 months or (Benadryl) 4 or more times a day for pruritus.
Chapter 6
more of inflammation; nomenclature for specific

Current Symptoms: Recent significantly increased
forms reflects etiologic or pathologic mechanisms.
impairment: unable to complete all daily activities
Cirrhosis likely; progression to class 3 or 4 impair-
due to increasing debility.
ment. Timing this evolution less predictable; may be
influenced by treatment programs. Prolonged pres- Physical Exam: Generalized hyperpigmentation,
ence of hepatitis B is associated with elevated risk scratch marks, mild jaundice, a few xanthomata, and
of hepatocellular carcinoma.10 probable splenomegaly. No ascites or hepatomegaly.
Spider telangiectasias on extremities.
Clinical Studies: Laboratory studies: alkaline
phosphatase 4 times normal levels; serum bilirubin:
CLASS 3
5.5 mg/dL, positive antimitochondrial antibody.
Retrograde cholangiogram: normal extrahepatic
ducts. Liver biopsy: small bile ducts damaged,
EXAMPLE 6-27 interlobular bile ducts damaged; scarring consis-
tent with primary biliary cirrhosis. Discussed liver
Class 3: 30% to 42% impairment due to liver disease
and 21% to 29% from biliary tract disease.
Guides6e_06_101-128.indd 120 2/17/09 2:36:17 PM

transplantation as future consideration. Responded Physical Exam: Jaundiced and cachectic, with right
only minimally to various treatment protocols. upper quadrant pain to palpitation. Oriented inter-
Cholestasis subsequently increased to 12 mg of mittently to place and location.
serum bilirubin. Individual awaiting liver transplant
Clinical Studies: Laboratory tests: biliary obstruc-
based on donor availability.
tion and advanced liver damage. Ultrasound reveals
Diagnosis: Primary biliary cirrhosis. calculi in gallbladder and common bile duct.
Liver biopsy specimen: advanced biliary cirrhosis.
Impairment Rating: 55% impairment due to
Declined any consideration of an invasive procedure
combined biliary tract and liver disease. Her liver
that might alleviate disease.
disease is class 3 with an initial rating of 36% that
is unchanged by her physical examination findings Diagnosis: Biliary cirrhosis, secondary to recurrent
but modified upward to 39% based on objective test and progressive obstruction of bile ducts.
results. This will be combined with a rating of 29%
for her biliary tract disease (class 3 irreparable dis-
person based on liver and biliary tract disease. Her
ease with abnormal test results and jaundice) for a
biliary tract disease meets all 3 criteria for class
total rating (using the Combined Values Chart in the
3 disease. Her liver disease is class 4 throughout.
Appendix) of 55%.
Combining the maximum impairment grades for
Comment: Primary biliary cirrhosis is a relent- each (29% combined with 65%) leads to an impair-
lessly progressive liver disease that leads to class ment rating of 75%.
4 impairment. Orthotopic liver transplantation
Comment: Severe and irreparable impairment
offers significant benefit and should be considered
of liver and biliary tract function. Needs live-in
early. Currently, most recipients report a remark-
assistance to perform normal ADLs. Laparoscopic
able improvement in quality of life and many enjoy
removal of calculus-containing gallbladder, endo-
normal lifestyles, although compliance with drug
scopic extraction of common bile duct stones, and
therapies and follow-up visits are required. She
variety of radiologic, endoscopic, and surgical bili-
will be at class 4 impairment when put on the liver
ary drainage procedures may greatly reduce the total
transplant waiting list, but a successful transplant
impairment rating.13
may ultimately reduce the impairment of the whole
person.11,12
6.6 Hernias
CLASS 3 AND 4
75% Impairment of the Whole Person 6.6a Criteria for Rating Permanent
Impairment due to Herniation
Criteria for evaluating impairment due to abdomi-
EXAMPLE 6-28
nal herniation are listed in Table 6-10. A typical
Class 4: 45% to 65% impairment due to liver successful hernia repair will usually result in a
Chapter 6
disease and 0% impairment rating. If there are pain com-
plaints due to residual nerve entrapment, please
Class 3: 20% to 29% impairment due to biliary tract
see the CNS chapter (Chapter 13). Diaphragmatic
disease
hernias are rated at 2% whole person impairment
Subject: 55-year-old woman. if successfully repaired or at 5% whole person
impairment if unrepaired and asymptomatic. If
History: Repeated acute cholecystitis attacks for 5
they affect digestive function, Section 6.2, Upper
years. Refused to seek medical care because of reli-
Digestive Tract, is used to rate the impairment.
gious beliefs.
If the diaphragmatic hernias affect respiration,
Current Symptoms: Increasingly frequent and the criteria for restrictive lung disease are used to
severe bouts of right upper quadrant pain, nausea, rate the impairment. Physical findings are the key
vomiting, fever, jaundice, dark urine, and pruritus. factor.
Unable to perform many basic ADLs for more than a
year and is intermittently confused.
Guides6e_06_101-128.indd 121 2/17/09 2:36:18 PM

TA B L E 6 -1 0 Criteria for Rating Permanent Impairment due to Herniation
Herniation
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4a
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%-5% 7%-13% 16%-22% 25%-30%
SEVERITY 1 3 5 7 10 13 16 19 22 25 27 30
GRADE (%) (A B C) (A B C) (A B C) (A B C)
HISTORY History of prior Occasional mild Frequent dis- Frequent dis- History of prior
hernia repair— discomfort at comfort at site comfort at site hernia repair
now without site of defect of defect that of defect that with significant
symptoms that does not precludes heavyb hampers most limitation in most
preclude most lifting but does Activities of Daily Activities of Daily
Activities of Daily not hamper most Living Diving due to dis-
Living other Activities comfort or ana-
of Daily Living tomic factors
PHYSICAL No physical Palpable defect Palpable defect Palpable defect Palpable defect
FINDINGS c findings in supporting in supporting in supporting in supporting
structures of structures of structures of structures of
abdominal wall abdominal wall abdominal wall abdominal wall
and/or and and and
slight protrusion protrusion at persistent, irre- irreparable pro-
at site of defect site of defect ducible protru- trusion or signifi-
with increased with increased sion at site of cant defect
abdominal pres- abdominal pres- defect
sure—easily sure—easily
reducible reducible
a
If an individual is at rated at class 4 for both the history and the physical, one will use the 30% rating. If not, one will choose
the lower grade.
b
Greater than 23 kilograms (50 pounds) for men; 16 kilograms (35 pounds) for women.
c
Key factor.
CLASS 1 Clinical Studies: None.

Diagnosis: Uncomplicated incisional hernia.
Chapter 6

EXAMPLE 6-29: HERNIA
person. Her physical findings place her in class 1 at
Subject: 60-year-old woman. 3%; however, the absence of symptoms moves her
down 1 grade to a 1% impairment rating.
History: Cholecystectomy for calculous biliary tract
disease relief 3 years ago. Uneventful postoperative Comment: Asymptomatic incisional hernia only
course. mildly annoying. No significant risk of complication.
No limit in ability to perform ADLs. If she were
Current Symptoms: No complaints; eating well; no
very uncomfortable or limited due to a larger hernia,
abdominal discomfort.
her history would be class 3 and her rating 5%.
Physical Exam: Healed oblique, right upper quad-
rant incision; palpable defect in middle part. Slight,
visible protrusion at this site when individual rose
from supine position. No pain or discomfort in scar
region, which she perceived as unsightly.
Guides6e_06_101-128.indd 122 2/17/09 2:36:18 PM

CLASS 2 CLASS 3
7% to 13% Impairment of the Whole Person 16% to 22% Impairment of the Whole Person
EXAMPLE 6-30: HERNIA EXAMPLE 6-31: HERNIA
Subject: 50-year-old man. Works for parcel delivery Subject: 64-year-old man.
service.
History: Nearing retirement; recurrent, bilat-
History: Several years’ recurring protrusion in right eral, inguinal hernias despite 3 previous attempts
inguinal area upon straining or exerting increased at repair: 2 on the right side and one on the left.
intra-abdominal pressure. First noticed this at work. Reluctant to submit to further repair attempts.
Current Symptoms: Protrusion visible with bowel Current Symptoms: Frequent discomfort. No
movements; reduces hernia himself; no discomfort. supervening complications.
Physical Exam: Enlarged protrusion entered Physical Exam: Protrusions only partially reducible.
scrotum base; easily and painlessly reduced.
Clinical Studies: None.
Declined recommended surgical repair; willing to
accept heavy lifting preclusion and risk possible Diagnosis: Recurrent bilateral inguinal hernias after
complications. unsuccessful herniorrhaphies.
Clinical Studies: None. Impairment Rating: 22% impairment of the whole
person. Physical findings place him in class 3 at
Diagnosis: Reducible right indirect inguinal hernia.
19%. This is adjusted upward to 22%, the top rating
Impairment Rating: 10% impairment of the whole for the class, based on his class 4 history.
person. Physical findings place him in class 2. He
Comment: Recurrent inguinal hernias only partially
remains at the default rating of 10% based on his
reducible despite repeated surgical repair. Individual
symptoms, which also fit into class 2.
obliged to wear supporting device. Frequent inguinal
Comment: Restricted exertion; chose to live with discomfort. Restricted in performance of normal
limitation. Hernia was accepted as work-related. ADLs, including sports. Possible hazard if support-
Aware of possible consequences of unrepaired ingui- ing device exerts local pressure on partially reduced
nal hernia; declined operation. No impairment of hernia. Encourage further repair attempts with pos-
normally sedentary ADLs. sible use of reinforcing mesh.
Chapter 6
Guides6e_06_101-128.indd 123 2/17/09 2:36:19 PM

6.7 Digestive System Impairment

Evaluation Summary
See Table 6-11 for an evaluation summary for the
assessment of permanent impairment due to diges-
tive system disorders.
TA B L E 6 -11 Digestive System Impairment Evaluation Summary

Disorder History, Including Selected Examination Record Assessment of Dysfunction
Relevant Symptoms
General Gastrointestinal symptoms (eg, Comprehensive physical Data derived from relevant studies
change in appetite, pain, diarrhea) examination; detailed GI (eg, barium swallow, upper and lower
and general symptoms; impact of system assessment endoscopy)
symptoms on function and ability to
do daily activities
Esophageal Dysphagia for solids and/or liquids Evidence of weight loss Location and degree of stricture
Disease G-E reflux Duration of symptoms Is proximal esophagus dilated?
Previous proximal gastrectomy or Evidence of scleroderma or Endoscopic appearance and biopsy
interposition surgery other mesenchymal disease results
Need for dilations and/or medications Previous motility studies
History of aspiration for achalasia or diffuse
Limitation of physical activity spasm
Stomach Vomiting, weight loss, past gastrec- Weight loss; diabetes with Size of gastric pouch
Diseases tomy dumping symptoms; family neuropathy Location and function of gastrojejunal
history of ulcer or endocrinopathy amastomosis
Persistent ulcer diathesis despite Endoscopic evaluation of structures
treatment
Motility studies
Any history of use of ulcerogenic
drugs (NSAIDS, ASA)
Limited physical activity
Small Diarrhea (frequency, nocturnal); Note weight loss Barium studies
Intestine abdominal colic and distention Abdominal distention, Possibly enteroclysis study, jejunal
Disease History of volvulus masses cultures, and mucosal biopsy
Hemorrhage Perianal disease Antigliadin antibody
Family history of celiac sprue, motility Arthropathy Motility studies
disorder Presence of dermatitis Amount of intact small intestine
Weight loss herpetiformis (estimate whether more or less than
Chapter 6
Previous surgery 200 cm)

Limited activity
Pancreatic History of acute pancreatitis Abdominal masses; fistu- Ultrasound pancreas and biliary tract
Disease (documented) lae; previous gallstones; Consider transduodenal ultrasonog-
Frequency; duration; associated evidence of weight loss; raphy, CT scan, ERCP, measure of
jaundice, nausea, anorexia; alcohol jaundice steatorrhea, plain film of abdomen
intake; adequacy of pain control for calcification
GI bleeding (consider splenic vein Sweat Na+ to exclude cystic fibrosis
thrombosis)
Associated chronic lung disease (think
of cystic fibrosis)
Large History of previous colon surgery Abdominal masses Sigmoidoscopy; colonoscopy
Intestine (length remaining, nature of Perianal disease Possible barium studies; mucosal
Disease anastomoses) biopsies
Fistulae arthropathy
Bleeding; need for transfusions Defecation studies; motility; possible
Stool frequency, pattern (nocturnal EMG of sphincter activity
incontinence)
Abdominal pain
Weight loss
Limited activity
Guides6e_06_101-128.indd 124 2/17/09 2:36:20 PM

Assessment of End-Organ Damage Diagnosis(es) Degree of Impairment
Include assessment of sequelae, including Record all pertinent diagnosis(es); Criteria outlined in this chapter
end-organ damage and impairment note if they are at maximal medical
improvement; if not, discuss under
what conditions and when stability is
expected
Motility studies if indicated GERD with inflammatory stricture See Table 6-4
Response to therapy Barrett’s esophagus with or without
Need for esophageal stent or malignant change
interposition surgery Stricture secondary to scleroderma
Frequency of dilations Achalasia, diffuse spasm, Zenker’s
diverticulum
Response to dietary management Postgastrectomy state See Table 6-4

Trial of antisecretory drugs, prokinetic Diabetic gastroparesis
agents Possible Zollinger-Ellison syndrome
Paraesophageal hernia with gastric
volvulus
Effects of malabsorption of iron, B12 , Celiac sprue See Table 6-4

folate tetany possible lymphoma complication
Failure to grow Regional enteritis; Crohn’s; ischemic
Response to gluten restriction, steroids bowel disease
Parenteral nutrition Radiation enteritis

Chronic pseudo-obstruction;
mechanical obstruction (adhesions)
Chapter 6
Degree of fat maldigestion and Alcoholic pancreatitis See Table 6-4
malabsorption Chronic relapsing pancreatitis
Presence of diabetes mellitus Pancreatitis secondary to biliary tract
Need for pain control, including celiac disease
plexus and/or splanchnic block Cystic fibrosis
Uncontrollable diarrhea; intractable Inflammatory bowel disease; ulcerative See Table 6-5 and Table 6-6
constipation colitis; Crohn’s disease; colectomy
Megacolon with ileostomy or ileoanal pouch
anastomosis
Guides6e_06_101-128.indd 125 2/17/09 2:36:20 PM

TA B L E 6 -11 Digestive System Impairment Evaluation Summary (continued)

Disorder History, Including Selected Examination Record Assessment of Dysfunction
Relevant Symptoms
Liver Alcohol intake (past, present) Cutaneous and ocular signs Nutritional status, including
Disease of chronic liver disease hemoglobin, protein, prothrombin time
Previous use of hepatotoxic drugs
Ascites; edema; Platelets
Presence of ascites, edema, jaundice,
skin pigmentation
iron overload (multiple transfusions) Etiologic studies, including complete
(hemochromatosis)
hepatitis serology markers
History of GI hemorrhage
Evidence of previous
Renal function
Pruritus; primary biliary cirrhosis surgery in region of liver
HIV studies
Limited physical activity Keyser-Fleischer rings in
eyes Diabetes if hemochromatosis (serum
iron and ferritin saturation antitrypsin)
Evidence of ulcerative
colitis Antimitochondrial antibody; exclude
genetic and infiltrative diseases (eg, amy-
Xanthomata
loidosis, sarcoidosis, polycystic disease)
Copper studies
Biliary Tract Previous biliary tract surgery Previous attempts at Ultrasound studies
Disease dissolution therapy and
Episodes of cholecystitis, biliary colic, ERCP
or lithotripsy
jaundice
Transhepatic cholangiography if
Jaundice
Family history of bilirubin metabolism needed
disorder Presence of scratch marks
Prothrombin time
Bleeding; pruritus Splenomegaly
Abdominal fistula
Hernia Discomfort, pain associated with Abdominal protrusion or Roentgenography; CT scan
postural changes swelling
Limited physical activity
References A prospective, randomized study of patients with bleeding

peptic ulcers comparing endoscopic retreatment with surgery
after initial endoscopy. Result: Endoscopic re-treatment
1. McCord GS, Staiano A, Clouse RE. Achalasia, diffuse reduces the need for surgery with fewer complications.
spasm and non-specific disorders. Baillieres Clin
Gastroenterol. 1991;5:307-335. 7. Banks PA, et al. The spectrum of chronic pancreatitis.
Parenter Care. 1989;23(9):163-196.
A categorization method of the manometric abnormalities of
diffuse spasm and nonspecific disorders. 8. Scolapio JS, Fleming CR, Kelly DG, Wick DM,
Zinsmeister AR. Survival of home parenteral nutrition
2. Trytgat GNJ, et al. The role of infectious agents in (HPN)-treatment patients: 20 years of experience at the
peptic ulcer disease. Gastroenterol Int. 1993;6:76-89. Mayo Clinic. Mayo Clin Proc. 1999;74:217-222.
3. Henderson RD, Ryder D, Marryatt G. Extended A retrospective review of medical records of all Mayo Clinic
esophagal myotomy and short fundoplication hernia patients treated with HPN between 1975 and 1995. Results:
Chapter 6
repair in diffuse esophageal spasm. Ann Thorac Surg. Most deaths during treatment with HPN are a result of the
1987;43:25-31. primary disease; HPN-related deaths are uncommon.
A follow-up study of the surgical management of diffuse 9. Cangemi JR, Wiesner RH, Beaver SJ, et al. Effect
esophageal spasm. Result: Good results from surgery achieved of proctocolectomy for chronic ulcerative colitis on
in 94% of patients followed 5 to 10.7 years. the natural history of primary sclerosing cholangitis.
4. Pope CE II. Acid reflux disorders. N Engl J Med. Gastroenterology. 1989;96:790-794.
1994;331:656-660. A study of the progression of clinical, biochemical,
General review. cholangiographic, and hepatic histologic features in 45
patients with both primary sclerosing cholangitis and chronic
5. Lagergren J, Bergstrom R, Lindgren A, Nyren O. ulcerative colitis and the benefits of proctocolectomy. Result:
Symptomatic gastroesophageal reflux as a risk factor Proctocolectomy for chronic ulcerative colitis has no beneficial
for gastroesophageal adenocarcinoma. N Engl J Med. effect on the primary sclerosing cholangitis in patients with
1999;340:825-831. both diseases.
An epidemiologic investigation of the possible association 10. Pemberton JH, Phillips SF. In: Sleisinger, Fordtran,
between gastroesophageal reflux and adenocarcinoma, eds. Gastrointestinal and Liver Disease. Vol 2. 6th ed.
indicating a positive but weak association. 1998:1762-1768.
6. Lau JYW, et al. Endoscopic retreatment or surgery after 11. Kiyosawa K, Sodeyama T, Tanaka E, et al.
initial endoscopic control of bleeding ulcers. N Engl J Interrelationships of blood transfusion, non-A, non-B
Med. 1999;340:751-756. hepatitis and hepatocellular carcinoma: analysis by
Guides6e_06_101-128.indd 126 2/17/09 2:36:20 PM

Assessment of End-Organ Damage Diagnosis(es) Degree of Impairment
CNS tolerance to hemorrhage Alcoholic liver disease; cirrhosis; See Table 6-8
hepatoma; posthepatitic cirrhosis
Fluid and salt overload
(previous HBV, HCV); hemochromatosis;
Possible pancreatic insufficiency Wilson’s disease
Secondary development of hepatoma Primary biliary cirrhosis
Intractable prothrombin time Sclerosing cholangitis
prolongation; platelet deficiency;
leukopenia
Persistent hyperbilirubinemia after Biliary tract stricture; impacted stones; See Table 6-9
obstruction relieved sclerosing cholangitis
Findings at surgery Primary biliary cirrhosis
Possible incarceration or strangulation of Abdominal wall hernia; umbilical See Table 6-10
bowel or omentum hernia; incisional hernia; inguinal
hernia; femoral hernia
detection of antibody to hepatitis C virus. Hepatology. Fine KD, Schiller LR. AGA technical review on the
1990;12:671-675. evaluation and management of chronic diarrhea.
Gastroenterology. 1999;116(6):1464-1486.
A study to clarify the relationship between hepatitis C virus
infection and the development of hepatocellular carcinomas as Haubrich WS, Schaffner F, Berk JE, eds. Bockus
a sequela of non-A, non-B post-transfusion hepatitis. Result: A Gastroenterology. 5th ed. Philadelphia, Pa: WB
causal association between hepatitis C virus and hepatocellular Saunders Co; 1994.
carcinoma was indicated.
Lichtenstein GR, Abreu MT, Cohen R, Tremaine
12. Munoz SJ. Long term management of the W. American Gastroenterological Association
liver transplant recipient. Med Clin North Am. Institute technical review on corticosteroids,
1996;80:1103-1120. immunomodulators, and infliximab in inflammatory
bowel disease. Gastroenterology. 2006;130(3):940-987.
A team approach to the long-term management of liver
transplant recipients enables survival in terms of decades, Madoff RD, Fleschman JW. American Gastroenterological
Chapter 6
rather than years. Association technical review on the diagnosis
and treatment of hemorrhoids. Gastroenterology.
13. Desmet VJ. Current problems in diagnosis of
2006;126(5):1463-1473.
biliary disease and cholestasis. Semin Liver Dis.
1986;6:233-245. Miura S, Shikata J, Hasebe M, Kobayashi K. Long-term
outcome of massive small bowel resection. Am J
Gastroenterol. 1991;86:454-459.
Pandolphino JE, Kahrilas PJ. AGA technical review
Bibliography on the clinical use of esophageal manometry.
Gastroenterology. 2005;128(1):209-224.
Bennett JC, Plum F, eds. Cecil’s Textbook of Medicine. 20th Talley NJ, Vakil NB, Moayyed P. American
ed. Philadelphia, Pa: WB Saunders Co; 1996. Gastroenterological Association technical review
Falk GW, Fennerty MB, Rothstein RI. AGA Institute on the evaluation of dyspepsia. Gastroenterology.
technical review on the use of endoscopic therapy for 2005;129(5)1756-1780.
gastroesophageal reflux disease. Gastroenterology.
2006;131(4):1315-1336.
Guides6e_06_101-128.indd 127 2/17/09 2:36:21 PM

128
CHAPTER 7
The Urinary and

Reproductive Systems
7.2 The Urinary System
7.3 Upper Urinary Tract
7.4 Urinary Diversion
7.5 Bladder
7.6 Urethra
7.7 Male Reproductive Organs

Introduction
7.8 Female Reproductive Organs
This chapter provides criteria for evaluating per-
manent impairments of the genitorurinary system
7.9 Urinary and Reproductive Systems
as they affect the body’s overall function and an
Impairment Evaluation Summary
individual’s ability to perform activities of daily
living (ADLs). The entire chapter has been revised
for the Sixth Edition of the AMA Guides using the
rating system described in Chapter 1 to foster greater
interrater reliability in the rating process. This
includes a revision downward of the ratings for the
highest classes of impairment, as many of these rat-
ings reflected secondary impairment of other organ
systems. In this edition of the Guides, readers are
directed (unless specifically instructed otherwise)
to rate secondary impairment separately and com-
Chapter 7
bine any ensuing rating with that for genitourinary

impairment.
This edition of the Guides acknowledges that certain
medications and treatments improve the overall physi-
cal status of patients who receive them but result in
some degree of impairment due to side effects or altera-
tions in ADLs that result solely from their use. This has
been described as the Burden of Treatment Compliance
(BOTC) in other chapters. This is included in the rating
129
Guides6e_07_129-158.indd 129 2/17/09 2:41:38 PM

for disorders in this section, especially with regard to with significant rise in blood pressure. This can be
the use of dialysis. In addition, long-term use of high- demonstrated during cystrometric examination and
dose steroids (in excess of 2 years on a daily basis) is may need attention to prevent cardiovascular compli-
generally associated with some adverse systemic effects cations.3 Urinary tract dysfunction is also seen with
and can be seen in some patients with renal failure. lumbosacral injury below the T10 vertebra level and
Refer to Chapter 10, Endocrine for additional details. would be combined with musculoskeletal impair-
ment to determine whole person impairment.
To determine the individual’s placement in a particu-
lar impairment class range, assess the history (symp-
7.1 Principles of Assessment toms), physical findings, and results of objective
tests. Assessment of functional level is not performed
separately but is implicitly (and sometimes explic-
Guides user should become familiar with Chapters 1
itly) included as part of the rating. Considerations in
and 2 and the Glossary. Chapters 1 and 2 discuss the
the impairment rating include the degree to which
Guides’ purpose, applications, and methods for per-
disease affects functions specific to the urinary or
forming and reporting impairment evaluations. The
reproductive system and overall function, as well as
Glossary provides definitions of common terms used
the impact of medication, regularly required proce-
by many specialties in impairment evaluations.
dures, and lifestyle modifications or interventions on
The purpose of assessment of genitourinary system the ability to perform general ADLs.
impairment is to determine whether a permanent
impairment in these systems exists, to assess the 7.1a Methodology for Determining the
severity, and document the impact of the impairment Grade in an Impairment Class
on the ability to perform ADLs. This chapter employs impairment grids to use in
Pathologic abnormalities in other systems (eg, the
and severity grade (grade) within a class for the con-
hematologic, endocrine, or neurologic systems) may
dition or conditions being rated at Maximum Medical
produce urinary or reproductive system impairment.
Improvement (MMI). As was stated in chapter 1, the
These abnormalities are combined with urinary or
decision regarding which factor is the primary deter-
reproductive system impairments to produce a whole
minant of impairment (key factor) will be clearly
person impairment rating. For example, renal dis-
stated in each organ system impairment grid. The
ease may lead to anemia that would be rated as part
examiner will use this key factor to determine the
of hematopoietic impairment; an intracranial brain
appropriate class with the middle grade (integer) in
lesion above the pons will produce some degree of
that class as the initial (default) rating.
bladder hyperreflexia; an intracranial brain lesion
below the pons will result not only in a hyperreflexic The examiner will then use non-key factors to assign
bladder but also in detrusor-sphincter dyssynergia grades for factors other than that considered “key,”
(DSD). Some cases of dyssynergia may result in dif- with it being impossible to move upward or down-
ficulty urinating, high intravesical pressures, vesi- ward between classes based on these non-key factors.
coureteral reflux, and subsequent hydronephrosis.1,2 The number of potential grades for each impairment
Spinal cord injury patients with DSD will also have class varies based on the number of relevant factors.
some degree of autonomic dysreflexia manifesting
TA B L E 7-1 Methodology for Determining the Grade in an Impairment Class

Chapter 7

SEVERITY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
GRADE (%) A B C D E A B C D E A B C D E A B C D E
c c c c
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The Urinary and Reproductive Systems 131
When there are 2 non-key factors, there are generally pathologic conditions within or outside the urinary
5 impairment grades per class; the presence of only system. Within the urinary system, bladder tumors,
one relevant factor other than the key factor reduces stones, and inflammatory lesions may produce uri-
the number of possible grades to 3 per class. nary system impairment.
If the examiner determines that the other factors In women, the urethra is a urinary conduit contain-
affecting the rating are in the same class that had ing a voluntary sphincter. In men, the urethra pos-
been used for the key factor rating, the final rating sesses a voluntary sphincter and propulsive muscles
will generally stay in the middle of that class. On and is a conduit for urine and seminal ejaculations.
the other hand, if the classes chosen are higher or
Permanent, surgically created urinary diversions
lower than that used for the baseline impairment rat-
are usually performed to compensate for anatomic
ing, the level will be moved to the right or to the left
losses, following cystectomy to allow for urine out-
flow. Diversions are evaluated as a part of, and in
conjunction with, the assessment of the involved
portion of the urinary tract. When permanent
impairment of any segment of the urinary system
is evaluated, impairments of all components of the
factor would move the grade down 2 levels to grade
upper and lower tract must be evaluated and com-
A and the second would move it back up 1 level to
bined to determine renal system impairment. (See
grade B. However, if both non-key factors were class
the Combined Values Chart in the Appendix.)
1, the rating could not go any lower than class 3,
grade A, the lowest value for the class. An exception
7.2a Interpretation of Urinary
to this rule may occur when the key factor is in the
Symptoms and Signs
highest impairment class for the disorder, as non-key
Symptoms and signs of upper urinary tract function
factors falling in the same class can be used to adjust
impairment may include changes in urination; edema;
the impairment rating upward to the highest grade
decreased physical stamina; appetite and weight loss;
within the class rather than keep it at the middle
anemia; uremia; loin, abdominal, or costovertebral
level. Specific tables will indicate if a rating schema
angle pain; hematuria; chills and fever; hypertension
other than this is used.
and its complications; abnormalities in the appearance
The impairment criteria generally used in this chap- of the urine or its sediment; and biochemical blood
ter on the urinary and reproductive system include changes. Renal disease, especially in early stages, may
the history, physical findings, and objective test be made evident only by laboratory findings.
results. The assignment of a key factor and relative
Symptoms and signs of bladder function impair-
importance of the criteria will vary according to
ment may include urinary frequency, dysuria, incon-
each regional disorder.
tinence, retention, hematuria, pyuria, passage of
urinary calculi, and a suprapubic mass.
Symptoms and signs of urethral function impairment
7.2 The Urinary System include dysuria, diminished stream, retention, incon-
tinence, extraneous or ectopic urinary openings,
The urinary system consists of the upper urinary periurethral masses, and diminished urethral caliber.
tract (the kidneys and ureters), the bladder, and the
As is the case for other chapters, signs and symp-
urethra. The parenchyma of the kidneys produces
toms can be categorized by frequency, severity,
urine, which is conducted through the renal calices,
and level of functional loss. Never or occasional
pelvis, ureters, bladder, and then the urethra.
signs or symptoms, when present up to 33% of the
The kidneys are an important homeostatic regula- time, do not generally warrant an impairment rat-
Chapter 7
tory organ. The degree to which kidney and conduit ing (unless the ensuing disruption in ADLs is sig-
abnormalities may affect the whole person ranges nificant). Frequent signs or symptoms are present
from a clinically undetectable change to marked between 34% and 66% of the time, and continuous
deterioration of the nephron reserves, loss of kidney signs and symptoms are present 67% of the time and
function, and urine transport abnormalities. above (with it understood that this level of precision
is impossible to achieve clinically). When present,
The bladder is a voluntarily controllable urine
and in general minimal level of signs or symptoms
reservoir that normally permits several hours of
interfere with ADLs 1% to 10% of the time, mild
urine retention. Bladder dysfunction may be due to
signs or symptoms interfere with ADLs 11% to 25%
Guides6e_07_129-158.indd 131 2/17/09 2:41:39 PM

of the time; moderate signs and symptoms affect asymptomatic. A mild abnormality does not (or
ADLs 26% to 50% of the time and can have an would not be expected to) lead to more than a 11% to
impact on work and recreational activities. Severe 25% degree of functional organ impairment, a mod-
signs or symptoms interfere with ADLs up to 75% erate abnormality would result in a 26% to 50% loss
of the time, to the point of requiring modification of function (if untreated), a severe abnormality would
of many routine ADLs (personal, work-related, and be accompanied by a 51% to 75% functional loss (if
recreational). Extreme functional loss occurs when untreated), and an extreme abnormality leads to a
symptoms and signs cannot be controlled by medica- greater than 75% loss of organ function (if untreated).
tion and therefore interfere with ADLs up to 100%
of the time.
7.2b Description of Clinical Studies 7.3 Upper Urinary Tract

Two clinically useful renal function determinations,
serum creatinine and the renal clearance of endog-
enous creatinine, may serve as criteria for evaluating
Impairment due to Upper Urinary
upper urinary tract function. The serum creatinine
Tract Disease
level reflects overall renal function. Under normal
The impairment criteria for evaluating upper urinary
hydration conditions, the serum creatinine level
tract disease are given in Table 7-2. History is key
should be less than 133 ␮mol/L (1.5 mg/dL).
factor. The creatinine clearance, the most accurate
The glomerular filtration rate, which measures renal reflection of renal function, is an important crite-
clearance of endogenous creatinine, gives a quantita- rion in each class because it quantifies the degree
tive estimate of the total functioning nephron popu- of upper urinary tract functional impairment. Also
lation. Because longer periods of urine collection of relevance are whether there are intermittent or
improve the reliability of renal function clearance persistent abnormalities in other diagnostic tests,
tests, using 24-hour endogenous creatinine clearance as well as the magnitude and implications of these
measurements may be desirable. The normal creati- abnormalities.
nine clearance ranges are 130 to 200 L/24 h (90 to
Management of patients with upper urinary tract
139 mL/min) for men and 115 to 180 L/24 h (80 to
dysfunction may require treatment with medication
125 mL/min) for women.
or dialysis. This burden of treatment compliance
If there are discrepancies or additional information (BOTC) has an impact on the ability to perform
is needed, additional testing may include metabolic ADLs that is additive to that caused by the disease
studies, tests of electrolytes or chemicals, urine process itself. Indeed, BOTC may be the primary
osmolality, urinalyses, cultures, radiologic investiga- source of functional impairment. The degree of
tions, and/or isotope studies. functional impairment due to medications, treat-
ment, or procedures is based on the tables in Chapter
Parenchymal disfiguration and conduit abnormality
10, Endocrine and includes an estimate of the like-
assessment may require diagnostic procedures such
lihood and impact of side effects, complications
as biochemical lab tests, cystoscopy, biopsy, arteri-
(eg, infection), or recurrent procedures from their
ography, radiography of the urinary tract, computed
use. Refer to BOTC in Appendix B. Renal function
tomography (CT), or magnetic resonance imaging
deterioration that requires either peritoneal dialysis
(MRI).
or hemodialysis will generate severe impairment in
Objective techniques useful in evaluating bladder the 55% to 75% range, a class 4 impairment (Table
function include (but are not limited to) cystoscopy, 7-2). Successful renal transplantation may result in
cystography, voiding cystourethrography, cystom- marked renal function improvement; the impairment
etry, uroflometry, urinalysis, and urine cultures. based on the clinical implications of having a trans-
Chapter 7
plant alone is now in the 16% to 32% range, a class 2

Objective techniques useful in evaluating urethral
impairment. However, transplant recipients require
function include (but are not limited to) urethros-
continuous observation and medication, which may
copy, urethrography, cystourethrography, endoscopy,
add to their impairment. For this reason, depending
and cystometrography.
on the type, dosing frequency, and dosing route of
In general, an objective procedure is described as medication, as well as the frequency of anticipated
minimally abnormal if there is an anatomic abnor- diagnostic testing and procedures, especially if inva-
mality that leads to no more than a 10% degree of sive, patients may receive a higher rating based on
functional organ impairment and is generally the functional implications of these interventions.
Guides6e_07_129-158.indd 132 3/3/09 6:30:30 PM

Also, evaluate impairment that is related to com- CLASS 1

plications of the disease or therapy, such as cushin- 1% to 13% Impairment of the Whole Person
goid changes and osteoporosis, as they arise, and
combine the appropriate percentages with the final
EXAMPLE 7-2: UPPER URINARY TRACT
renal impairment estimate (see the Combined Values
DISEASE
From a physiologic point of view, the individual with
only 1 functioning kidney may have normal over- History: Acute renal colic. Passage of small urinary
all renal function because of the efficiency of the calculus. Two previous episodes of renal colic. All
remaining kidney.4 However, with only 1 kidney, a episodes resolve with spontaneous passage of uri-
normal safety factor is lost. Consider the individual nary calculi.
with only 1 functioning kidney as having a 10%
Current Symptoms: Occasional flank pain;
whole person impairment because of such an essen-
unlimited physical activity.
tial organ loss. Combine this percentage with the
estimate for any other permanent impairment (see Physical Exam: Normal.
the Combined Values Chart in the Appendix).
Clinical Studies: Normal excretory urograms.
Studies show no evidence of metabolic disease.
Urine, creatinine clearance, and phenolsulfonphtha-
lein study results: within normal limits.
CLASS 0
0% Impairment of the Whole Person Diagnosis: Recurrent renal calculi.
EXAMPLE 7-1: UPPER URINARY TRACT person. His intermittent symptoms are consistent
DISEASE with class 1, but the current absence of physical and
static test findings and the normal renal function
warrant moving the impairment 2 grades down from
History: Backache, fever, hematuria, headache, and the initial default middle grade of 7% to the lowest
hypertension during an attack of hemolytic strepto- grade for the class.
coccal tonsillitis at age 20 years. Evaluation at that
Comment: Class 1 assignment based on the expec-
time showed urine with red blood cells, red blood
tation that calculi will recur based on the natural
cell casts; 2.4 g protein/24 h. Creatinine clearance
history of the disease, leading to occasional renal
was 72 L/24 h (50 mL/min). At 6 months the creati-
colic, affecting sexual function and ADLs.
nine clearance was 130 L/24 h (90 mL/min).
DISEASE
Clinical Studies: Urinalysis: normal. Creatinine
clearance: 158 L/24 h (110 mL/min). Biopsy showed
no renal disease. History: Childhood nephritis; emergency appen-
dectomy; appendiceal abscess drainage. Adequate
Diagnosis: Complete recovery from post-
postoperative urine output. Serum creatinine:
streptococcal acute glomerulonephritis.
248 ␮mol/L (2.8 mg/dL). Prolonged convalescence.
Impairment Rating: 0% impairment of the whole Anemia subsided, and stamina returned to normal.
person. During recovery, is on mild to moderate dietary
restrictions.
Chapter 7
Comment: Full recovery with no permanent

impairment. Current Symptoms: Feels well 12 months after
appendectomy and engages in most usual daily
activities. Decreased exercise tolerance for competi-
tive social activities (eg, basketball).
Physical Exam: Unremarkable except for right
lower quadrant scar.
Guides6e_07_129-158.indd 133 2/17/09 2:41:40 PM

TA B L E 7-2 Criteria for Rating Permanent Impairment due to Upper Urinary Tract Disease
Upper Urinary Tract Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–13% 16%–32% 36%–52% 55%–75%
SEVERITY 1 4 7 10 13 16 20 24 28 32 36 40 44 48 52 55 60 65 70 75
HISTORYb Prior history of Only 1 kidney is Successful renal Occasional severe Occasional
upper urinary functioning transplantation or frequent mod- extreme or fre-
tract disease erate symptoms quent severe
or or
or signs of upper symptoms or
and
occasional mild occasional mod- urinary tract signs of urinary
return of disease or frequent erate or frequent disease or dys- tract disease
not expected minimal symp- mild symptoms function that are or dysfunction
toms or signs of or signs of incompletely con- despite con-
upper urinary upper urinary trolled by surgical tinuous medical
tract disease that tract disease or continuous treatment
do not require or dysfunction medical treat-
or
continuous treat- that necessitate ment (eg, renal
ment (eg, stone regular surveil- failure on inter- renal function
disease) lance and fre- mittent dialysis) deterioration
quent treatment requires long-
(eg, chronic term perito-
pyelonephritis) neal dialysis
or long-term
hemodialysis
PHYSICAL AND None Intermittent Physical signs Physical signs or Physical signs or
STATIC TEST signs of upper or tests con- tests consistent tests consistent
FINDINGS c urinary tract dis- sistent with with upper uri- with upper uri-
ease that do not upper urinary nary tract disease nary tract disease
require continu- tract disease or or dysfunction or dysfunction
ous treatment or dysfunction are are moderately are severely
surveillance mildly abnormal abnormal on abnormal on
on a continuous a continuous a continuous
basis or moder- basis or severely basis or criti-
ately abnormal abnormal cally abnormal
intermittently intermittently intermittently
OBJECTIVE Testing currently Diminution Diminution Diminution Diminution

TESTING normal of upper tract of upper tract of upper tract of upper tract
OF RENAL function, as function, as function, as function, as
FUNCTIONd evidenced by cre- evidenced by cre- evidenced by evidenced by
atinine clearance atinine clearance creatinine clear- creatinine clear-
of 75–90 L/24h of 60–74 L/24h ance 40–59 L/24h ance below 40
(52–62.5 mL/min) (40–51 mL/min) (28–39 mL/min) L/24h (below 28
mL/min)
a
If the key factor places an individual in class 4 and the physical exam and/or objective testing are also consistent with class
4, the evaluator may opt to use the highest ratings in class 4 to characterize the impairment.
Chapter 7
b
Key factor. For class 4, choose 55% if peritoneal dialysis, 65% if hemodialysis twice a week, and 75% if hemodialysis 3 times
a week. Do not anticipate that individuals in class 4 will have physical findings or objective test results that are consistent
with anything but class 4, so these are not modifiers for class 4.
c
Includes routine laboratory and urine testing.
d
The creatinine clearance falls approximately 6.5mL/min due to age every 10 years after age 40. Individuals over the age
of 40 years should consequently be evaluated using a form of Table 7-4 that has been modified to reflect these adjusted
normative levels or have the appropriate multiple of 6.5 (for every 10 years in age over age 40) added to their creatinine
clearance before calculation of the impairment rating.
Guides6e_07_129-158.indd 134 2/17/09 2:41:41 PM

Clinical Studies: Urine: trace protein (0.75 g/24 h). daily antibiotic controls urinary tract infections and
Excretory urograms show no architectural abnor- pyelonephritis attacks.
mality. Creatinine clearance: 60 to 70 L/24 h (42 to
Current Symptoms: Occasional high fever, chills,
49 mL/min).
and back pain. When she is symptomatic, she is
Diagnosis: Persistent proteinuria after childhood unable to do many of her ADLs.
nephritis, aggravated by surgery years later.
Physical Exam: Bilateral flank tenderness.
Clinical Studies: Age-adjusted creatinine clearance:
person. Impairment rating would be class 1, grade
stable 65 L/24 h (45 mL/min). Excretory urogra-
C (7%) based on symptoms but would be adjusted
phy: bilateral pyelocaliceal deformities; kidney size
upward to 13% based on the abnormal routine labo-
unchanged in 3 years.
ratory testing and the creatinine clearance.
Diagnosis: Renal calculi and bilateral chronic
pyelonephritis.
Impairment Rating: 24% impairment due to upper
CLASS 2
urinary tract impairment, as the history, physical
examination, and functional renal test results reflect
class 2, grade C. Combine urinary tract impairment
EXAMPLE 7- 4: UPPER URINARY TRACT with parathyroid impairment for impairment of the
DISEASE whole person (see the Combined Values Chart in the
Appendix).
Comment: Prevent complications with increased
History: Retroperitoneal fibrosis; left lower ure-
water and fluid intake, and by compliance with daily
ter function severely damaged; ureter surgically
medication.
reconstructed.
Current Symptoms: Upon discontinuing antibac-
terial medication, he has repeated pyelonephritis EXAMPLE 7-6: UPPER URINARY TRACT
attacks that disrupt activity. DISEASE: IMPAIRMENT RATING
Physical Exam: Left flank tenderness. Subject: 28-year-old man.

Clinical Studies: Excretory urography: vesico- History: Hemodialysis for marked azotemia and oli-
ureteral reflux with apparently normal left kidney guria from progressive chronic glomerulonephritis.
architecture and function. Age-adjusted creatinine Successful renal transplantation of mother’s kidney;
clearance: 100L/24h (69 mL/min). good renal function. Azathioprine and prednisone
maintenance treatment; close observation for osteo-
Diagnosis: Active unilateral chronic pyelonephritis
porosis development.
secondary to vesicoureteral reflux.
Current Symptoms: Asymptomatic.
person. The initial impairment rating is in class 2, Physical Exam: Cushingoid features.
grade C (24%). The findings on imaging studies are
Clinical Studies: Creatinine clearance: 108 L/24 h
consistent with class 2 disease, but the creatinine
(75 mL/min).
clearance is consistent with class 0 disease, leading
to an adjustment of the impairment rating downward Diagnosis: Functioning renal transplant.
to 16% WPI.
BOTC: 3% impairment points given for the use of
prednisone.
Chapter 7
EXAMPLE 7-5: UPPER URINARY TRACT Impairment Rating: 24% impairment initially
DISEASE assigned due to having a renal transplant. Adjusted
downward to 16% (2 grades) based on the class 1
physical examination and creatinine testing, to which
History: Successful operation for parathyroid ade- 3% is added for the BOTC, leading to an impairment
noma. Periodic pyelonephritis attacks from residual rating of 19%. Combine any permanent impairment
calculi in both kidneys with sporadic passage of percent related to a complication such as osteoporosis
stones. Continuous medication consisting of once if it develops with the renal impairment estimate (see
Guides6e_07_129-158.indd 135 2/17/09 2:41:42 PM

the Endocrine System chapter and the Combined mm Hg. Hospital bed rest for 1 week; then he was
Values Chart in the Appendix). discharged. Other pertinent findings are hyper-
tensive retinopathy. Blood pressure 2 weeks later:
Comment: Reevaluate if secondary infection or
240/160 mm Hg, 155/95 mm Hg 6 months later.
other complication develops due to immunosuppres-
Creatinine clearance at 6 months: 58 L/24 h (40
sive therapy.
mL/min). Receiving 3 antihypertensive medications
twice daily and a protein-restricted diet.
Current Symptoms: Severe headaches 16 months
CLASS 3 after accident.
Physical Exam: Blood pressure: 170/110 mm Hg.
Eyegrounds: group 2 changes (Keith-Wagener-Barker
EXAMPLE 7-7: UPPER URINARY TRACT classification). Left kidney removed.
DISEASE
Subject: 48-year-old man. (21 mL/min). Malignant hypertensive changes appar-
ent on biopsy specimen of right kidney.
History: Calculi in minor calices of both kidneys.
Multiple endoscopic and open surgical removals of Diagnosis: Bilateral malignant hypertensive vascu-
stones. Continuous antibacterial medication once lar kidney disease; status post left nephrectomy.
daily.
Impairment Rating: 50% renal impairment. The
Current Symptoms: Periodic chills, fever, and back 44% arteriolar nephrosclerosis impairment due to the
pain. Spends several days per month ill at home. inability of treatment to control symptoms and signs,
which is adjusted upward to 48% based on the cre-
Physical Exam: Bilateral flank tenderness.
atinine clearance level. This is combined with 10%
Clinical Studies: Notable diminution of a kidney; due to the nephrectomy impairment (Section 7.3),
bilateral pyelographic architectural changes com- for a urinary system impairment of 53%. Combine
pared with previous surgeries and recurrent pyelone- this with the appropriate cardiovascular impairment
phritis. Creatinine clearance: 65 L/24 h (45 mL/min). value for hypertension to determine impairment of
Infected urine. the whole person (see the Combined Values Chart in
the Appendix).
Diagnosis: Renal calculi with bilateral recurrent
pyelonephritis. Comment: Monitor renal function; protein
restriction.
person. Class 3 impairment, grade C (44%) based
on inability of treatment to completely control sig-
nificant symptoms and signs of renal disease. The
DISEASE
presence of significant abnormal architecture and
infected urine as well as the creatinine clearance Subject: 52-year-old woman.
level of 45 mL/min are also consistent with class 3
History: Receives intermittent dialysis. Needs help
and keep him at this grade.
with some everyday activities. No clear nephritis
Comment: Monitor and treat recurrent infections. history. Her doctor had placed her on a protein-
restricted diet.
Current Symptoms: Chronic fatigue.
DISEASE Physical Exam: Pale; appears weak.
Chapter 7
Subject: 48-year-old man. Clinical Studies: Hemoglobin: 80 g/L (8 g/dL).

Serum creatinine level: 0.024; gmmol/L (2.1 mg/dL).
History: Automobile abdominal crush injury leads
Diffuse bilateral glomerulonephritis on renal biopsy.
to hematuria. Patient undergoes left nephrectomy
Contracted kidneys and normal pyelocaliceal archi-
and open reduction, internal fixation (ORIF) for
tecture evident on high-dose excretory urography.
femur fracture. Kidney pathology shows ischemia
Urine culture: negative. Creatinine clearance: 32 L/24
and juxtaglomerular hypertrophy on histologic
h (age-adjusted creatinine clearance of 38.5 L/24h).
examination of left kidney. Blood pressure: 150/90
Guides6e_07_129-158.indd 136 2/17/09 2:41:42 PM

Diagnosis: Chronic glomerulonephritis with renal increased urine output. Serum creatinine level fell
atrophy.5 without peritoneal dialysis after 60 days. Performed
some ADLs despite severely compromised renal
Impairment Rating: 48% renal impairment. The
function 12 months after anuria. She is on a low-
44% initial impairment (class 3) due to continued
protein, low-sodium, and low-potassium diet and is
symptoms and signs is modified upward to 48%
receiving medications to treat hypertension.
based on the class 4 creatinine clearance. This will
be combined with the appropriate rating for anemia Current Symptoms: Fatigued; requires daily nap.
to determine impairment of the whole person (see
Physical Exam: Some skin bronzing change.
the Combined Values Chart in the Appendix). Even
with adjusting her creatinine clearance level for her Clinical Studies: Percutaneous renal biopsy: renal
age, the impairment is still class 3 as this is not the cortical necrosis. Creatinine clearance: 11.5 L/24 h
key factor. (8 mL/min).
Comment: Monitor renal function. Diagnosis: Renal cortical necrosis and severe
chronic renal failure.
person based on renal disease history. Her need for
DISEASE
dialysis is only class 3, even though renal function
Subject: 44-year-old man. and the results of static objective testing are both
class 4. Therefore, her final genitourinary impair-
History: Family history of polycystic renal disease.
ment rating is 52%, which should be combined with
Gross hematuria; protein-restricted diet. Until cur-
a rating for her hypertension from the cardiovascular
rent episode, he worked regularly and felt well.
chapter (Chapter 4).
Requires moderate dietary restrictions.
Current Symptoms: Has fatigue that sometimes
precludes work or participation in many of his usual
activities but otherwise is relatively asymptomatic. CLASS 4
Does experience periods of sudden flank pain on 55% to 75% Impairment of the Whole Person
occasion.
Physical Exam: Normal. EXAMPLE 7-12: UPPER URINARY TRACT
DISEASE
Clinical Studies: Serum creatinine: 707 to
884 ␮mol/L (8 to 10 mg/dL). Creatinine clearance: Subject: 56-year-old woman.
35 L/24 h (24 mL/min). Bilateral deformities charac-
History: Chronic progressive glomerulonephri-
teristic of severe, end-stage polycystic renal disease
tis. Severe anemia, azotemia, and oliguria/anuria.
on endoscopy and retrograde urograms.
Twice-weekly hemodialysis. Feels well for at most 1
Diagnosis: Bilateral polycystic renal disease; or 2 days after treatment. Needs to maintain a pro-
advanced renal insufficiency. tein and potassium restricted diet.
Impairment Rating: 52% impairment of the whole Current Symptoms: Nausea, lethargy, and edema
person. The initial rating is class 3, grade C (44%) due before hemodialysis.
to the presence of significant symptoms and signs,
Physical Exam: Cachetic; bilateral peripheral
which is modified upward to 52% based on the class 4
edema.
clinical findings and creatinine clearance level.
Clinical Studies: Hemoglobin 60 g/L (6 g/dL).
Chapter 7
Diagnosis: Severe chronic renal failure and refrac-

tory anemia.
DISEASE
Impairment Rating: 65% renal impairment of the
whole person. A class 4 rating of 65% is based on
History: Severe abruptio placentae. Creatinine the need for twice weekly hemodialysis. Her class 4
clearance: 35 L/24 h (24 mL/min). Bilateral defor- physical findings and inability for urine production
mities characteristic of polycystic renal disease on could raise her final impairment to 75% depending
endoscopy and retrograde urograms. Periodic perito- on the physician’s judgment. This will be combined
neal dialysis. Anuria for 49 days, then oliguria, then with the rating for her anemia.
Guides6e_07_129-158.indd 137 2/17/09 2:41:43 PM

7.4 Urinary Diversion EXAMPLE 7-14: 15% IMPAIRMENT DUE

TO NEPHROSTOMY
Impairment due to Urinary Diversion
Disorders History: Bilateral nephrostomies. Obliterative,
The impairment criteria for evaluating urinary diver- fibrotic, ureteral disease for 5 years. Renal calculi
sion disorders are given in Table 7-3. removed. Unsuccessful surgical attempt to recon-
stitute normal conduit function. Urinary infection
unresponsive to treatment. Performs most ADLs
EXAMPLE 7-13: 10% IMPAIRMENT DUE TO without assistance.
URETEROILEOSTOMY
Current Symptoms: Hematuria with change of
Subject: 52-year-old woman. nephrostomy tubes. Occasional fever and flank
pain.
History: Anterior pelvic exenteration and uretero-
ileostomy for cervical carcinoma. No recurrent Physical Exam: Nephrostomy tubes in both flanks.
cancer for 7 years. Calculi removed from both
kidneys.
(35 mL/min).
Current Symptoms: Periodic pyelonephritis, even
Diagnosis: Pyeloureteral disease requiring bilateral
with continual medication.
nephrostomy diversion.
Physical Exam: Flank tenderness.
Impairment Rating: Class 2, grade E (32%)
Clinical Studies: Pyelonephritis on radiologic impairment due to pyeloureteral disease and 15%
studies. Creatinine clearance: 50 L/24 h (20 impairment due to bilateral nephrostomies; combine
mL/min). for 42% impairment of the whole person (see the
Combined Values Chart in the Appendix).
Diagnosis: Ureteroileostomy, urinary diversion, and
chronic bilateral pyelonephritis.
bilateral pyelonephritis and ureteroilestomy. The
7.5 Bladder
rating using Table 7–2 is 28%, class 2, grade D
based on initial class 2 rating for history and static 7.5a Criteria for Rating Permanent
test findings (pyelonephritis) adjusted upward by Impairment due to Bladder Disease
one grade based on the class 3 creatinine clear- The impairment criteria for evaluating bladder
ance, and 10% impairment due to ureteroileos- disease are given in Table 7-4. History is the key
tomy. Combine these with the appropriate rating factor.
due to pelvic exenteration (ie, bladder, lower ure-
ters, uterus, cervix, vagina, fallopian tubes, and
ovarian excision) to determine impairment of the
whole person (see the Combined Values Chart in CLASS 1
the Appendix). 1% to 9% Impairment of the Whole Person
EXAMPLE 7-15: BLADDER DISEASE
TA B L E 7-3 Subject: 41-year-old woman.

Criteria for Rating Permanent Impairment due to History: Radium treatment for uterine fibroids
Urinary Diversion Disorders a
Chapter 7
20 years previously. Emergency hospitalization and

% Impairment of the blood vessel fulguration for recent urinary tract
Diversion Type Whole Person
bleeding from postirradiation bladder telangiectasia.
Ureterointestinal 10% Is not receiving any long-term medical therapy.
Cutaneous Ureterostomy 10%
Current Symptoms: Moderate frequency of
Nephrostomy 15%
a
urination.
If there is more than 1 procedure, or the procedure is bilateral,
the rating from the second procedure is to be combined with Physical Exam: Unremarkable.
that from the first procedure.
Guides6e_07_129-158.indd 138 2/17/09 2:41:43 PM

TA B L E 7- 4 Criteria for Rating Permanent Impairment due to Bladder Disease
Bladder Disease
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3a
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 11%–19% 21%–29%
SEVERITY 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
GRADE (%) (A B C D E) (A B C D E) (A B C D E)
HISTORYb Prior history of blad- Occasional mild to Moderate symptoms Little to no voluntary
der disease with no moderate symptoms such as pain or loss of control of micturition
residuals such as frequency, control of micturition or severe symptoms
nocturia, or drib- despite continuous despite treatment
bling, with normal treatment
function between
or
episodes
symptoms requiring
urinary diversion
procedure
PHYSICAL AND No signs of bladder Intermittent mild Continuous mild signs Continuous moder-
LABORATORY TEST disease signs that respond to despite treatment or ate signs of signifi-
FINDINGS c treatment or inter- intermittent moder- cant bladder disease
mittent moderate ate physical findings despite treatment or
findings controlled despite treatment intermittent severe
with continuous findings only par-
treatment tially responsive to
treatment
FUNCTIONAL Testing normal Testing, if performed, Testing, if performed, Testing, if performed,

BLADDER TEST mildly abnormal moderately abnormal severely abnormal
RESULTSd
(URODYNAMICS)
a
If patient meets all criteria for class 3 rating, move to top grade for class.
b
Key factor. Symptoms are urgency, frequency, nocturia, incontinence, dribbling, and pain.
c
May not always be physical findings for disease process. If no findings are expected, physical examination should be
considered as in the same class as history.
d
Relevant bladder tests include CT, urine cell cytology, cystoscopy, and urodynamic studies.
CLASS 2
Clinical Studies: Blood and urine studies between
attacks are normal but has significant hematuria
and discomfort when attacks occur. Has bladder
telangiectasias. EXAMPLE 7-16: BLADDER DISEASE
Diagnosis: Postirradiation telangiectasia of the Subject: 42-year-old man.

bladder.
History: Chronic renal infection resistant to
Chapter 7
Impairment Rating: 9% impairment of the whole suppressive antibiotic therapy. Insignificant relief
person. Her symptoms put her into class 1, grade C with anticholinergic medications twice daily. Good
(5%), however, her intermittent moderate hematuria general physical condition. Refused surgical urinary
and abnormal tests, both of which are consistent with diversion.
class 2, move her up to an impairment rating of 9%.
Current Symptoms: Severe cystitis. Empties blad-
Comment: Periodic cystoscopic monitoring is der every 30 minutes. Uses urine-collecting device.
required. Could not retain urine long enough to readily per-
form usual ADLs without interruption.
Guides6e_07_129-158.indd 139 2/17/09 2:41:44 PM

Physical Exam: Bladder tenderness to percussion. a twice a day ␣-blocker, periodical antibiotics, and
intermittent catheterization.
Clinical Studies: Urine: numerous white blood
cells; few red blood cells. Small bladder capacity on Current Symptoms: Perineum and perirectal
urodynamics. numbness. Total urinary and bowel incontinence.
Diagnosis: Chronic cystitis. Physical Exam: Cauda equina neurologic deficit.
Impairment Rating: Initial assignment is class 2, Clinical Studies: Urine consistently positive for
grade C (15%) impairment due to cystitis. As physical white blood cells. MRI: vertebral compression
signs and test results are also consistent with class 2, fracture. Urodynamics: areflexic bladder.
his rating stays at 15%.
Diagnosis: Neurogenic bladder impairment.5-9
Comment: Frequent urine cultures.
Impairment Rating: 29% impairment due to total
loss of urinary control. Initial rating is class 3, grade
C (25%) adjusted upward to 29% based on abnor-
EXAMPLE 7-17: BLADDER DISEASE
mal urinalysis and urodynamic studies. This is then
Subject: 35-year-old woman. combined with musculoskeletal impairment rating to
determine whole person impairment (see Combined
History: Progressive and painful urinary frequency,
Values Chart in the Appendix).
urinating every 10 to 15 minutes a day, although less
at night. Diagnosed with interstitial cystitis; ineffec-
tive treatment with bladder dilation and medication
trials. Cystectomy and ureteroileostomy performed, 7.6 Urethra
leading to resumption of most normal activities.
Current Symptoms: Adjusting to changes in bowel 7.6a Criteria for Rating Permanent
movements. Impairment due to Urethral Disease
The impairment criteria for evaluating urethral
Physical Exam: Ureteroileostomy functioning well.
disease are given in Table 7-5. Objective findings are
Clinical Studies: Normal uninfected upper urinary the key factor.
tract.
Diagnosis: Contracted, fixed bladder requiring
urinary diversion. CLASS 2
person due to combination of urinary diversion pro-
cedure and bladder removal. Her symptoms put her EXAMPLE 7-19: URETHRAL DISEASE
into class 2, grade C, with an impairment rating of
15%. This is adjusted upward to 17% based on the
cystectomy, since she does not have abnormal tests History: Urethral stricture; dilation every few weeks
now that she has had the cystectomy and diversion to months. No urinary tract infection.
procedure. This is combined with a 10% rating for
Current Symptoms: Symptom-free between dilations;
her ureteroileostomy for a total rating of 25%.
symptomatic only as urethra gradually constricts.
Physical Exam: Urethral narrowing.
Clinical Studies: Unremarkable—blockage is
CLASS 3
generally 25% to 50%.
Chapter 7
Diagnosis: Traumatic urethral stricture.

EXAMPLE 7-18: BLADDER DISEASE Impairment Rating: 13% impairment of the whole
person. Objective findings put him in class 2, grade
B, with the degree of symptoms and frequency
History: Fell from building roof; lumbar spine of dilations moving him up 1 grade to the highest
compression fracture and lumbar spinal cord contusion. impairment rating for the this class.
Initially paraplegic. Recovered use of lower extremities
Comment: Monitor renal function. If urethra closes
with surgical débridement and rehabilitation. Receives
completely, may need surgical intervention.
Guides6e_07_129-158.indd 140 2/17/09 2:41:44 PM

CLASS 3 Physical Exam: Fistulous opening on the ventral

16% to 22% Impairment of the Whole Person surface of the penis.
Clinical Studies: Urine cultures: positive for bacteria.
EXAMPLE 7-20: URETHRAL DISEASE Renal function: normal.
Subject: 23-year-old man. Diagnosis: Urethral fistula.
History: Considerable ventral surface penis lacera- Impairment Rating: 19% impairment. A class 3
tion, which caused a surgically uncorrectable fistula. rating of 19% is given due to the urethral fistula. His
Performed most ADLs and could ejaculate during symptoms are also class 3 so the rating stays at 19%,
intercourse but was infertile. Requires intermittent which is combined with the impairment for sexual
antibiotics. dysfunction. (See the Combined Values Chart in the
Appendix to determine whole person impairment.)
Current Symptoms: Could not urinate normally.
Comment: Monitor kidney function.
TA B L E 7- 5 Criteria for Rating Permanent Impairment due to Urethral Disease
Urethral Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–13% 16%–22% 24%–28%
SEVERITY 1 3 5 7 10 13 16 19 22 24 26 28
HISTORY Prior history of Occasional mild Mild symptoms Moderate symp- Severe symptoms
urethral disease symptoms of a despite continu- toms despite con- despite continu-
with no residuals urethral disorder ous treatment tinuous treatment ous treatment
that respond to
or or
noninvasive treat-
ment or symp- occasional mod- occasional severe
toms controlled erate symptoms symptoms respon-
with continuous responsive to sive to treat-
treatment treatment—if ment or stress
requires dila- urinary inconti-
tions, these are nence—dilations
performed less performed once a
than monthly month or more
OBJECTIVE None or Minor physical Residual urethral Fistula on exam Severed urethra
FINDINGS a no current abnormalities blockage of 25
or or
abnormalities of urethral area to 50% blocked
or wide body upon cystoscopy, moderate severe
stricture upon urethroscopy incontinence incontinence
cystoscopy, or performance or or
urethroscopy, or of a voiding
performance of cystourethogram residual ure- residual urethral
a voiding cysto- thral blockage blockage of
Chapter 7
urethogram with over 50 to 75% over 75% upon

less than 25% on cystoscopy, cystoscopy,
blockage urethroscopy, urethroscopy,
or performance or performance
of a voiding of a voiding
cystourethogram cystourethogramb
a
Key factor. Objective findings include findings on physical examination and/or findings on tests such as cystoscopy,
urethroscopy, or cystourethrography.
b
Use higher score if both criteria for class 4 are met or if urethra is more than 90% blocked.
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EXAMPLE 7-21: URETHRAL DISEASE Diagnosis: Stress urinary incontinence after radical
prostatectomy.11
Impairment Rating: 19% impairment due to stress
History: After delivery of third child, urinary inconti-
urinary incontinence as symptoms and objective
nence with coughing, sneezing, lifting, brisk walking,
findings place him into class 3; combine with 20%
or running. No urinary tract infections.
impairment (see the Combined Values Chart in the
Current Symptoms: Urinary incontinence. Appendix) for sexual dysfunction for a final rating
of 35%.
Physical Exam: Urethra and bladder neck hypermo-
bility; moderate uterine prolapse. Comment: Urinary incontinence requires protec-
tive padding. Incontinence may be treatable with
Clinical Studies: No neurologic abnormalities on
the placement of an artificial sphincter around the
urodynamics.
bulbous urethra, which may change the impairment
Diagnosis: Female stress urinary incontinence due rating.
to pelvic relaxation.9
Impairment Rating: Class 3, 19% due to moder-
ate urinary incontinence based both on history and
CLASS 4
objective findings; combine with 10% impairment
for uterine prolapse (see Section 7.8c) for 27%
impairment of the whole person.
EXAMPLE 7-23: URETHRAL DISEASE
Comment: Most of the urinary incontinence in
females falls under these major subtypes: stress Subject: 31-year-old man.
incontinence, overactive bladder, mixed incon-
History: Struck by vehicle. Pelvic fracture, symphy-
tinence, overflow incontinence, or functional
sis fracture dislocation, prostatomembranous and
incontinence. Severity and grading can be deter-
bulbomembranous urethral lacerations. Stabilized
mined by a physical examination, bladder diary,
and healed pelvic fracture. Repaired urethral lacera-
and urodynamics.10 Urinary incontinence requires
tions. Uncorrectable extensive urethral strictures
protective padding. Stress urinary incontinence
from postoperative fibrosis. Frequent urethral
due to pelvic relaxation is at times improved by
dilations required to urinate 2 years later.
surgery which may then change the impairment
rating. Current Symptoms: Chronic urinary tract infec-
tions with ascending pyelonephritis secondary
to urethral obstruction and frequent urethral
EXAMPLE 7-22: URETHRAL DISEASE instrumentation.
Subject: 56-year-old man. Physical Exam: Scarred undersurface of urethra
with fistulous tracts.
History: Radical prostatectomy; localized prostate
carcinoma. Discharged postoperative on day 4. Clinical Studies: Creatinine clearance: 65 L/24 h
Urethral catheter removed 2 weeks postoperatively. (45 mL/min).
Excellent compliance with Kegel exercises. Urinary
Diagnosis: Traumatic urethral stricture with chronic
incontinence requires protective padding. Normal
pyelonephritis.
sexual function before procedure.
Impairment Rating: He receives a class 4 rat-
Current Symptoms: Intermittent urine loss with
ing of 26% impairment due to urethral stricture,
coughing, sneezing, or heavy lifting 6 months
which is adjusted upward to 28% impairment due
postoperatively. No erections 6 months after
Chapter 7
to his significant symptoms. This is combined

surgery.
with 25% impairment for upper urinary tract
Physical Exam: No anastomotic stricture or damage. His final rating is 46% impairment of the
obstruction on cystoscopic examination. whole person (see the Combined Values Chart in
the Appendix).
Clinical Studies: No neurologic bladder abnor-
mality and poor urinary sphincter tone on Comment: Monitor kidney function. If hydrone-
urodynamics. phrosis develops, may need urinary diversion.
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EXAMPLE 7-24: URETHRAL DISEASE 7.7a Penis

The penis has the sexual functions of erection and
ejaculation. The urinary function of the penis is dis-
History: Factory worker crushed between forklift cussed in the first part of this chapter on the urethra
and wall. Fractured bony pelvis; totally severed (Section 7.6). Penile functional impairment symp-
urethra at prostate apex; severely lacerated toms and signs include erection and sensation abnor-
perineum. Unsuccessful immediate reconstructive malities and partial or complete loss of the penis.
urethral surgery; ureterosigmoidostomy 1 year later.
When evaluating penis impairment,10–13 consider both
Right kidney hydronephrosis. Diversion converted to
sexual and urinary function impairment. Determine
ileal conduit.
sexual function impairment according to the following
Current Symptoms: Sporadic renal infections. classifications. To determine impairment of the whole
Impotent. Periodically unable to perform usual person, combine this estimate with the appropriate
daily activities due to occasional urinary tract percentage for estimated urinary function impairment.
infections. This classification also may be used to estimate penile
implant use impairment (see the Combined Values
Physical Exam: Healed pelvic fracture. No muscu-
Chart in the Appendix). The ratings for male sexual
loskeletal impairment.
function are for physical objective loss of function. Loss
Clinical Studies: Creatinine clearance: 70 L/24 h of libido, interest, or orgasm would be considered under
(49 mL/min). Mental and Behavioral Disorders (Chapter 14) ratings.
Diagnosis: Severed urethra; hydronephrosis with Objective techniques useful in evaluating penis func-
recurrent urinary tract infection; impotence. tion include (but are not limited to) penile tumes-
cence studies, Doppler ultrasound penile blood flow
evaluations, dynamic cavernosometry and caver-
severed urethra; he does not move upward to 28%, as
nosography, and angiography.11–15
he has had his urinary symptoms per se controlled
with his ureteroileostomy. The 26% ureteral impair-
7.7b Criteria for Rating Permanent
ment will be combined with impairment due to
Impairment due to Penile Disease
upper urinary tract disease, sexual dysfunction and
The impairment criteria for evaluating penile disease
the 10% impairment due to the ureteroileostomy (see
are given in Table 7-6. History is key factor.
the Combined Values Chart in the Appendix), to
arrive at the final rating.
Comment: Monitor serum electrolytes for deteriora-
tion of renal function. CLASS 1
EXAMPLE 7-25: PENILE DISEASE

7.7 Male Reproductive Organs
The male reproductive organs include the penis,
History: Compressive penile shaft injury.
scrotum, testicles, epididymides, spermatic cords,
prostate, and seminal vesicles. See the follow- Current Symptoms: Normal sensation and ejacula-
ing sections for impairment percentages for male tion; pain when positions varied.
reproductive organs for 40- to 65-year-old men.
Physical Exam: Healing with partial cicatrization of
Evaluators can, at their discretion, adjust the rat-
left mid-corpus cavernosum. Bowstring left curvature
ing upward (for men younger than 40) or down-
occurred during erections.
Chapter 7
ward (for men older than 65) by 10% based on age

and the level of premorbid sexual functioning. For Clinical Studies: None.
example, class 3 penile impairment in a 30-year-
Diagnosis: Posttraumatic fibrosis of left mid-corpus
old man who was sexually active previously would
cavernosum.
be rated at 16.5% (15% ⫹ 0.1[15%]). New treat-
ments, when successful, may decrease the degree Impairment Rating: 3% ⫹ 0.3% ⫽ 3.3% impair-
of impairment. ment of the whole person (age of subject considered).
If penile abnormality is moderate, use 5% rating for
this class. Grade B default impairment would then
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TA B L E 7- 6 Criteria for Rating Permanent Impairment due to Penile Diseaseb
Penile Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 6%–10% 11%–15%
SEVERITY 1 3 5 6 8 10 11 13 15
GRADE (%) (A B C) (A B C) (A B C)
HISTORYa Prior history of penile Sexual function pos- Sexual function may No sexual function
disease with no sible with varying be possible but with possible
residuals degrees of difficulty insufficient erec-
with erection or tion despite the
sensation that are use of medications.
responsive to medical Patient with penile
treatment implants belong in
this category if the
implant corrects their
problem.
PHYSICAL FINDINGS No abnormalities Mild physical or test- Moderate physical or Significant physical or
OR NOCTURNAL ing abnormalities testing abnormalities test abnormalities
PENILE TUMESCENCE
a
Key factor.
b
Combine with rating for prostate disease (Table 7-9) or urinary incontinence (Bladder Disease, Table 7-4) when present.
be moved to grade C based on physical examination, Diagnosis: Posttraumatic ejaculatory dysfunction

and correcting for age, the impairment rating would and penile anesthesia.14
be 5.5%.
Impairment Rating: 8% ⫹ 0.1 (8%) ⫽ 9%
Comment: May need surgical correction. impairment of the whole person (age of subject
is considered). History and physical exam both
consistent with class 2, so he remains at the
grade B rating.
CLASS 2
6% to 10% Impairment of the Whole Person Comment: Periodically check urine flow rate and
monitor kidney function. Recurrence of a urethral
stricture likely.
EXAMPLE 7-26: PENILE DISEASE

History: Fractured pelvis; wide symphysis pubis
CLASS 3
separation; perivesical and periprostatic hematomas;
prostatomembranous urethral tear. Injuries corrected
with reconstructive surgery; no subsequent urinary
Chapter 7
difficulty. EXAMPLE 7-27: PENILE DISEASE
Current Symptoms: Erection and intercourse Subject: 18-year-old man.

possible; no penile sensation and ejaculation.
History: Traumatic penile dislocation.
Physical Exam: Scarred undersurface of the urethra.
Current Symptoms: Erection not possible.
Clinical Studies: Urinary flow: normal.
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Physical Exam: Preserved genital appearance; Impairment Rating: 5% impairment of the whole
urethral function with corporeal repair, and person. Physical exam is class 2, but intermittent
urethroplasty. symptoms are consistent with class 1, leading to the
lowest level in the class.
Clinical Studies: Doppler flow studies: markedly
diminished penile arterial blood flow.
Diagnosis: Posttraumatic vascular and neurologic
penile insufficiency. CLASS 3
Impairment Rating: 15 ⫹ 0.1(15) ⫽ 16.5%
impairment of the whole person (age of subject is
considered). EXAMPLE 7-29: SCROTAL DISEASE
Comment: Monitor urinary flow rates to forestall Subject: 50-year-old man.

urethral stricture.
History: Extensive burns on lower extremities,
genitals, and abdomen. Satisfactory skin grafting
7.7c Scrotum
on abdomen and lower extremities; testicles trans-
The scrotum covers, protects, and provides a suit-
planted to subcutaneous pouches in the thighs to
able environment for the testicles. Scrotum func-
permit adequate scrotal area skin coverage.
tion impairment symptoms and signs include pain,
enlargement, testicular immobility, inappropriate Current Symptoms: Self-conscious about grafted
testicle location, and masses. Objective techniques regions.
useful in evaluating scrotum function include,
Physical Exam: Testicles palpable in the thighs.
but are not limited to, examination and scrotal
ultrasound. Clinical Studies: Semen analysis: pending.
Diagnosis: Burn ablation of the scrotum.
7.7d Criteria for Rating Permanent
Impairment due to Scrotal Disease Impairment Rating: 11% impairment of the whole
The impairment criteria for evaluating scrotal dis- person due to testicular replantation (begins at grade
ease are given in Table 7-7. Scrotal impairments are B, 13%, then adjusted downward) without residual
generally not adjusted for age, as in those instances symptoms; combine with any fertility impairment.
when this would be appropriate, there are gener-
Comment: Rule out infertility with sperm analysis.
ally other reproductive organ impairments as well.
Physical findings are key factor.
EXAMPLE 7-30: SCROTAL DISEASE

CLASS 2
History: High-dose external beam pelvic radiation
therapy for prostate carcinoma performed 5 years ago.
Current Symptoms: Large genitals and weeping
EXAMPLE 7-28: SCROTAL DISEASE
skin, which severely limit physical activities.
Physical Exam: Penis and scrotum lymphedema.
History: Injury resulting in loss of all scrotal skin.
Clinical Studies: Prostate-specific antigen (PSA):
Good cosmetic result with split-thickness skin graft
0 ␮g/L.
reconstruction.
Diagnosis: Postirradiation lymphedema of penile
Chapter 7
Current Symptoms: Discomfort during exercise

and scrotal skin.
and certain positions.
Physical Exam: Testicular mobility affected.
person due to persisting symptoms, lack of effective
Clinical Studies: No testicular malfunction. therapy, and limitation of physical activity.
Diagnosis: Scrotal skin ablation; split-thickness skin Comment: No effective treatment.
graft scrotal reconstruction.
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TA B L E 7-7 Criteria for Rating Permanent Impairment due to Scrotal Disease
Scrotal Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–3% 5%–7% 11%–15%
SEVERITY 1 2 3 5 6 7 11 13 15
HISTORY Prior history of Mild pain or discom- Moderate pain or Continuous symp-
scrotal disease fort with activity, discomfort with mild toms of scrotal
with no evidence of activity disease that are
testicular malfunction uncontrolled by
treatment
PHYSICAL FINDINGS b No signs of scrotal Possible testicular Some scrotal loss with Testicles implanted
disease malpositioning diminished testicular somewhere other
mobility than a scrotal posi-
tion to preserve
testicular function
or
findings in addition
to limitations of
testicular mobility
on exam
a
If an individual meets physical criteria for class 3 and had symptoms consistent with class 3, the highest rating in the class
should be used.
b
Key factor. This rating is based only on history and physical findings, with physical findings the primary determinant.
7.7e Testicles, Epididymides, and 7.7f Criteria for Rating Permanent

Spermatic Cords Impairment due to Testicular, Epididymal,
The testicles produce spermatozoa and synthesize and Spermatic Cord Disease
male steroid hormones. The epididymides and The impairment criteria for evaluating testicular,
spermatic cords transport the spermatozoa. epididymal, and spermatic cord disease are given
in Table 7-8. Physical findings are key factor.
Testicular, epididymal, and spermatic cord impair-
ment signs and symptoms include local or referred
pain; tenderness and change in size, contour,
position, and texture; and testicular hormones and CLASS 1
seminal fluid abnormalities. 1% to 5% Impairment of the Whole Person
Chapter 7
Objective techniques useful in evaluating testicular,

epididymal, and spermatic cord function include (but EXAMPLE 7-31: TESTICULAR, EPIDIDYMAL ,
are not limited to) vasography; ultrasound; lymphan- AND SPERMATIC CORD DISEASE
giography; spermatic arteriography and venography;
biopsy; semen analysis; and hormone studies for
follicle-stimulating hormone (FSH), ketosteroids, History: Recurrent epididymitis and orchitis. Patient
and hydroxysteroids. declined vas deferens ligation, as he might want to
have children.
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Current Symptoms: Pain and swelling of testicles. History: Bilateral orchitis caused by mumps 2 years
Symptoms are intermittent. ago; bilateral testicular atrophy. Fathered 2 children
before illness.
Physical Exam: Normal prostate; tender testicles.
Current Symptoms: Currently infertile.
Clinical Studies: Normal seminal fluid.
Physical Exam: No abnormality.
Diagnosis: Chronic epididymitis secondary to
chronic prostatitis. Clinical Studies: Notable oligospermia on semen
analysis.
epididymitis, as both history and physical findings Diagnosis: Oligospermia.
are class 1.
person. Objective test results are class 2, which
would be consistent with a 9% rating; however,
CLASS 2 this is adjusted upward to 11%, as symptoms are
7% to 11% Impairment of the Whole Person currently continuous. This would be combined
with any impairment rating that is assigned from
the endocrine chapter (Chapter 10) for hormonal
EXAMPLE 7-32: TESTICULAR, EPIDIDYMAL ,
abnormalities (if present).
AND SPERMATIC CORD DISEASE
TA B L E 7- 8 Criteria for Rating Impairment due to Testicular, Epididymal, and Spermatic Cord Disease
Testicular, Epididymal, Spermatic Cord Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–11% 15%
SEVERITY 1 3 5 7 9 11
GRADE (%) (A B C) (A B C)
HISTORY No symptoms of Occasional symptoms Symptoms recurrent Continuous symp-

testicular, epididy- of testicular, epididy- and controlled only toms or signs despite
mal, or spermatic mal, or spermatic cord by frequent or con- treatment
cord disease disease responsive to tinuous treatment
treatment, as seen
in epididymitis or
orchitis
PHYSICAL FINDINGS None. No seminal or Occasional signs of Persistent anatomic Bilateral anatomic
OR TEST RESULTS b hormonal function testicular or epididy- alteration or physi- loss of the primary
abnormalities mal disease: pain and cal signs referable to sex organs
Chapter 7
vas deferens palpable testes, epididymis, or

or
as painful, tender spermatic cord
swelling. Ultrasound, no detectable
or
if performed, reveals seminal or hormonal
swelling of epididy- moderate detectable function
mis or testes. seminal or hormonal
abnormalities
a
Class 3 reserved for those with complete anatomic loss of sex organs or no detectable seminal or hormonal function.
b
Key factor.
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CLASS 3 CLASS 1
15% Impairment of the Whole Person 1% to 5% Impairment of the Whole Person
EXAMPLE 7-33: TESTICULAR, EXAMPLE 7-34: PROSTATE AND

EPIDIDYMAL , AND SPERMATIC CORD SEMINAL VESICLE DISEASE
DISEASE (EPIDIDMO-ORCHITIS)
History: Acute prostatitis episodes for 10 years.
History: Injury caused by farm machinery; amputa- Requires treatment only during episodes.
tion of scrotum and its contents. Examined 2 years
Current Symptoms: Some mild perineal discom-
later when in stable condition.
fort requiring pain medication. Fever with this
Current Symptoms: Normal erections; not sexually exacerbation.
active.
Physical Exam: Tender prostate.
Physical Exam: Scarred perineal area.
Clinical Studies: Prostatic massage and bacterial
Clinical Studies: None. cultures.
Diagnosis: Traumatic orchiectomy. Diagnosis: Chronic prostatitis with acute febrile
episodes.
testicle loss. Combine with impairment due to scrotal Impairment Rating: 3% impairment of the whole
loss and endocrine gland loss for whole person person; his physical findings put him in class 1 at
impairment (see the Combined Values Chart in the grade B (3%), and the mild intermittent symptoms
Appendix). keep the impairment at the same grade.
Comment: May need periodic urine cultures with
7.7g Prostate and Seminal Vesicles
sensitivity testing to control urinary tract infections.
The prostate and seminal vesicles provide the
appropriate nutrition, environment, and transport
for spermatozoa and semen. Impairments associated
with urinary functions of the parts of the urethra that
CLASS 2
are involved with the prostate and seminal vesicles
are discussed in the first part of this chapter on the
urethra (Section 7.6).
EXAMPLE 7-35: PROSTATE AND
Symptoms and signs of impairment in the pros-
SEMINAL VESICLE DISEASE
tate and seminal vesicles include local or referred
pain, tenderness, size and textural changes, Subject: 34-year-old man.
oligospermia, hemospermia, and urinary tract
History: Drainage of prostate abscess 15 months
abnormalities.
ago; continuous prostatitis symptoms and signs tol-
Objective techniques useful in evaluating pros- erated only with constant antibacterial medications
tate and seminal vesicle function include (but are once daily. Some need for oral analgesics once or
not limited to) urography, endoscopy, prostatic twice daily.
ultrasonography, vasography, biopsy, prostate
Current Symptoms: Perineal pain; low-grade fever.
secretion examination, and hormone excretion
pattern analysis. Physical Exam: Tender and enlarged prostate with
induration and fluctuance.
Chapter 7
7.7h Criteria for Rating Permanent

Clinical Studies: Hemospermia.
Impairment due to Prostate and
Seminal Vesicle Disease Diagnosis: Recurrent acute and chronic prostatitis.
The impairment criteria for evaluating prostate
and seminal vesicle disease are given in Table 7-9.
person. His physical examination and the need for
Physical or relevant test abnormalities are key factor.
continuous treatment to control symptoms are both
consistent with class 2 disease.
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TA B L E 7-9 Criteria for Rating Impairment due to Prostate Diseasea
Prostate Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–13% 15%
SEVERITY 1 3 5 7 10 13
HISTORY No symptoms of Mild to moderate Frequent moderate Frequent and

prostatic and seminal signs and symptoms of symptoms of pros- severe symptoms of
vessel dysfunction prostatic dysfunction tatic dysfunction prostatic dysfunc-
and no treatment that do not require despite continuous tion only partially
required continuous treatment treatment responsive to
treatment
PHYSICAL OR No anatomic Mild continuous or Moderate continuous Prostate and seminal

RELEVANT TEST alteration moderate occasional or severe occasional vessel ablation
ABNORMALITIES b abnormalities or ana- abnormalities or
(CYSTOSCOPY AND/ tomic alteration anatomic alteration
OR CT)
a
Combine with rating for sexual dysfunction or urinary incontinence when present.
b
Key factor.
Comment: If obstructive symptoms develop, may Impairment Rating: 15% impairment due to
need cystoscopic examination and possible transure- prostate and seminal vesicle ablation; combine
thral resection of the prostate (TURP). with impairment for loss of sexual function (see the
Combined Values Chart in the Appendix).
Comment: Monitor PSA for recurrence of cancer.
CLASS 3
7.8 Female Reproductive Organs

EXAMPLE 7-36: PROSTATE AND
SEMINAL VESICLE DISEASE The female reproductive organs include the vulva,
vagina, cervix, uterus, fallopian tubes, and ovaries.
Female reproductive system impairment is influ-
History: Radical prostatectomy for cancer of the enced by age, especially if the woman is of child-
prostate. bearing age. Consider the physiologic differences
between premenopausal and postmenopausal women
Current Symptoms: No difficulty in urinating.
when evaluating and estimating female reproductive
Occasional nocturnal incontinence. Some impair-
organ impairment.15
ment of sexual function.
Chapter 7
Physical Exam: No anastomotic stricture in the 7.8a Vulva and Vagina

urethra. The vulva has cutaneous, sexual, and urinary func-
tions. Urinary function is discussed in the first part
Clinical Studies: PSA: 0 ␮g/L.
of this chapter on the urethra (Section 7.6). The
Diagnosis: No residual disease after radical vagina has a sexual function and also serves as a
prostatectomy. birth passageway. The clitoris is an erectile organ
that has an important role in sexual functioning.
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Vulval and vaginal function impairment symp- CLASS 2

toms and signs include sensation alteration or 9% to 17% Impairment of the Whole Person
loss; lubrication loss; partial or complete absence;
vulvovaginitis; vulvitis; vaginitis; cicatrization;
EXAMPLE 7-38: VULVAL AND
ulceration; stenosis; atrophy or hypertrophy;
VAGINAL DISEASE
neoplasia or dysplasia; difficulties with sexual
intercourse, urination, or vaginal delivery; and Subject: 34-year-old woman.
underlying perineal structure support defects.
History: Surgical correction of rectovaginal fistula
The ratings for female sexual function are for
after vaginal delivery of second child. Severe
physical objective loss of function. Loss of libido,
vaginal stenosis. Intermittent vaginal dilation under
interest, or orgasm would be considered under
anesthesia; continuous use of vaginal cream. Third
psychological ratings.
pregnancy ended with cesarean delivery, but vaginal
delivery was possible.
Impairment due to Vulval and Current Symptoms: Vaginal intercourse possible,
Vaginal Disease but painful with no sexual sensation or enjoyment.
The impairment criteria for evaluating vulval and
Physical Exam: Small and shallow vagina;
vaginal disease are given in Table 7-10. Physical
erythematous; clitoral area intact.
findings are key factor.
Diagnosis: Severe postoperative vaginal stenosis.
CLASS 1 Impairment Rating: 17% impairment of the whole
1% to 7% Impairment of the Whole Person person. The limited potential for vaginal delivery
places her in class 2 and the virtual impossibility
of vaginal intercourse moves her up to the highest
grade for this class.
VAGINAL DISEASE

History: Obese; vaginal birth to 3 living chil- CLASS 3
dren. Recurrent chronic genitocrural dermatitis. 20% Impairment of the Whole Person
Treated for intense pruritus and active dermati-
tis. Discomfort more marked during warm and
humid weather. Symptom remission with control
VAGINAL DISEASE
of weight, avoidance of tight clothing, and care-
ful observance of hygienic measures. Satisfying Subject: 30-year-old woman.
sexual intercourse possible when she has no exces-
History: Two children. Invasive squamous
sive vulval irritation.
cell cervical carcinoma. Radiation treatment.
Current Symptoms: Dermatitis improved. Vesicovaginal fistula, rectovaginal fistula, and
Asymptomatic. severe vaginal stenosis. Pregnancy unlikely.
Physical Exam: Slight erythema. Current Symptoms: Sexual intercourse impossible.
Clinical Studies: Fungal infection culture results: Physical Exam: Vaginal depth 2 cm; urogenital
negative. Glucose: normal. sinus tract 5 mm diameter led to cervix carcinoma.
Mucus, feces, and urine discharged through sinus.
Diagnosis: Dermatitis of the vulva; intertrigo.
Chapter 7

person. Would be class 1, grade C, as all rating Diagnosis: Vesicovaginal fistula, rectovaginal
criteria are class 1. fistula, and severe vaginal stenosis.
person, as both her physical findings and symptoms
put her into class 3. This will be combined with
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TA B L E 7-1 0 Criteria for Rating Permanent Impairment due to Vulval and Vaginal Disease
Vulval and Vaginal Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–7% 9%–17% 20%
SEVERITY 1 4 7 9 13 17
HISTORYa No symptoms of Symptoms or signs Symptoms or signs Symptoms or signs

vulvar or vaginal of vulvar or vaginal of vulvar or vaginal of vulvar or vaginal
disease or interfer- disease or deformity disease require con- disease or deformity
ence with sexual do not require continuous treatment uncontrolled by
intercourse tinuous treatment, treatment
and
with only minor
and
interference with sexual intercourse
sexual intercourse possible only with sexual intercourse
some degree of not possible
difficulty
PHYSICAL FINDINGS b Vagina adequate Mild alteration in Moderate alteration Significant alteration
for childbirth if vaginal or vulvar in vaginal or vulvar in vaginal or vulvar
premenopausal anatomy, with anatomy, with lim- anatomy
only minor impact ited potential for
and
on potential for vaginal delivery if
vaginal delivery if premenopausal vaginal delivery
premenopausal not possible if
premenopausal
a
Someone who falls into class 2 but states that sexual intercourse is not possible would be rated at 17%.
b
Key factor. If patient is postmenopausal, all class 2 and class 3 impairments move down 2 grades as part of the rating is
based on the implications with regard to reproductive capacity.
appropriate estimates for bladder and rectal impair- Cervical and uterine functional impairment symp-
ments to determine impairment for whole person toms and signs include abnormalities of menstrua-
(see the Combined Values Chart in the Appendix). tion, fertility, pregnancy, or labor; excessive cervical
canal size, stenosis, or atresia; cervical incompetence
Comment: May need urinary diversion.
during pregnancy; noncyclic hemorrhage; uterine
displacement; dysplasia; and neoplasia.
7.8c Cervix and Uterus
The cervix serves as a passageway for sperma- Objective techniques useful in evaluating cervical and
tozoa and menstrual blood, maintains closure uterine function include (but are not limited to) cervi-
of the uterus during pregnancy, and serves as a cal mucous studies; vaginal, cervical, and intrauterine
portion of the birth canal during vaginal deliv- cytologic smears; biopsy; ultrasound; radiologic stud-
Chapter 7
ery. Hormones, elaborated by the ovaries or ies using radiopaque contrast media; blood and urine
administered exogenously, influence the uterus. hormone studies; basal body temperature recordings;
The uterus serves as the organ of menstruation, sperm concentration, mobility, and viability studies;
a means of spermatozoa transportation, and the uterus dilation and curettage; endometrium micro-
container of fertilization products. The uterus scopic study; gynecography; laparoscopy; CT; MRI;
supplies the power for the first and third stages of hysteroscopy; ultrasound placental localization tech-
labor and, in part, for the second stage. niques; and saline solution sonohysterography.
Guides6e_07_129-158.indd 151 2/17/09 2:41:51 PM

7.8d Criteria for Rating Permanent Current Symptoms: None.

Impairment due to Cervical and
Physical Exam: Slight uterine asymmetry on pelvic
Uterine Disease
examination; interior smooth; nontender mass, 4 cm
The impairment criteria for evaluating cervical and
in diameter, projected from uterus.
uterine disease are given in Table 7-11. Physical
findings are key factor. Clinical Studies: Leiomyoma confirmed on
ultrasound.
Diagnosis: Asymptomatic subserous uterine
CLASS 0 leiomyoma.
person.
EXAMPLE 7- 40: CERVICAL AND
UTERINE DISEASE
CLASS 1
History: Menarche at 14 years. Menstrual periods
lasted 3 days, normal volume; regular cyclic bleed-
ing. Pregnant after 11 ⁄2 years of marriage; no contra-
UTERINE DISEASE
ceptives. No leiomyoma growth during pregnancy;
no pain associated with tumor. Healthy 2,576-g (5 lb Subject: 60-year-old woman.
12 oz) infant delivered at 38 weeks. Menstrual peri-
History: Adenomyosis; vaginal hysterectomy
ods after delivery averaged 32 days between cycles;
20 years previously; vaginal vault prolapse.
normal volume and duration.
TA B L E 7-11 Criteria for Rating Permanent Impairment due to Cervical and Uterine Disease
Cervical and Uterine Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–7% 9%–17% 20%
SEVERITY 1 4 7 9 13 17
HISTORYa No symptoms or signs Cervical or uterine Cervical or uterine Cervical or uterine

of cervical or uterine disease or deformity disease or deformity disease or deformity
disease or deformity symptoms and signs symptoms and signs symptoms and signs
require intermittent require continuous are not controlled by
treatment treatment treatment
or or
cervical stenosis, if cervical stenosis, if
present, requires no present, requires
Chapter 7
treatment periodic treatment
PHYSICAL FINDINGS b No current anatomic Significant anatomic Significant cervical Complete cervical
cervical or uterine cervical or uterine stenosis or significant stenosis or complete
pathology loss or deformity in cervical or uterine functional cervical
the postmenopausal loss or deformity in and uterine loss in
period the premenopausal the premenopausal
period period
a
Someone who falls into class 2 with uncontrolled symptoms would be rated as 17%.
b
Key factor, as it is anatomic pathology and reproductive status that drive the impairment. Maximum postmenopausal rating
is 7%.
Guides6e_07_129-158.indd 152 2/17/09 2:41:52 PM

Current Symptoms: Pelvic pressure; large bulge Surgical anterior and posterior vaginal wall repair,
protruding from vulva. extensive cervical amputation, and posterior uterine
fixation by broad ligament plication.
Physical Exam: Vaginal vault prolapse; no significant
rectocele, cystocele, or uterine-vaginal angle descent. Current Symptoms: Three carefully managed,
subsequent pregnancies each ended in spontaneous
Clinical Studies: Discharge: no infection.
abortion between 12 and 16 weeks’ gestation due to
Diagnosis: Posthysterectomy vaginal vault prolapse. premature cervical dilation.
Impairment Rating: 1% uterine loss impairment, as Physical Exam: Large, prolapsed uterus that causes
the loss of the uterus in the postmenopausal period discomfort.
places her in class 1, grade A which is combined
Clinical Studies: Papanicolaou test: pending.
with impairment for vaginal prolapse.
Diagnosis: Partial cervical absence and incompe-
Comment: Preferred nonoperative approach.
tence; uterine prolapse.
Doughnut pessary reduced vaginal prolapse; pessary
changed twice weekly. Povidone-iodine douche Impairment Rating: 20% impairment. Her cervical
diminished vaginal discharge. Symptoms resolved. incompetence and symptoms put her into class 3.
Comment: Repair of incompetent cervix unlikely to
be successful due to partial cervical absence. Could
CLASS 2
try abdominal route cerclage.

UTERINE DISEASE
UTERINE DISEASE
History: Gravida 0. Stage IB invasive cervical
History: Cervical conization. Para 2. Partial cervical
squamous cell carcinoma. Lymph nodes did not
stenosis; menstrual blood retention. Cervical dilation
show metastatic disease. Radical hysterectomy with
necessary at 2- to 4-month intervals due to hemato-
pelvic lymphadenectomy; ovaries conserved.
metra and dysmenorrhea. Pregnant 2 years after con-
ization. Infant delivered by cesarean delivery before Current Symptoms: Asymptomatic.
labor onset at 38 weeks; abruptio placentae.
Physical Exam: Normal vagina.
Current Symptoms: Requires cervical dilation at
2-month intervals.
Diagnosis: No uterus in a reproductive-age woman
Physical Exam: Narrowed cervix.
secondary to treatment of invasive cervical squa-
Clinical Studies: None. mous cell carcinoma.
Diagnosis: Incomplete cervical stenosis. Impairment Rating: Absence of a uterus puts her
into class 3, 20% impairment of the whole person.
person. Her cervical stenosis puts her in class 2,
7.8e Fallopian Tubes and Ovaries
grade B (13%), as she only requires periodic treat-
The fallopian tubes transport ova and spermatozoa.
ment; her history is also consistent with class 2, and
The ovaries develop and release ova and secrete sex
her impairment level remains at 13%.
and reproductive hormones.
Symptoms and signs of fallopian tube and ovarian dys-
Chapter 7
CLASS 3 function include pelvic pain, vaginal bleeding or dis-

20% Impairment of the Whole Person charge; fallopian tube stenosis or obstruction; abnormal
morphologic characteristics; pelvic masses; neoplasms;
absent, infrequent, or abnormal ovulation; abnormal
hormone secretion; and menstrual dysfunction.
UTERINE DISEASE
Objective techniques useful in evaluating fallopian
tube and ovarian function include (but are not lim-
History: Severe uterine prolapse due to vaginal ited to) cervical and vaginal cytologic smears; pelvic
delivery of large infant after long, difficult labor.
Guides6e_07_129-158.indd 153 2/17/09 2:41:52 PM

roentgenography; hysterosalpingography; gynecog- menarche at age 12. Administered clomiphene

raphy; ovarian biopsy; blood and urine hormonal citrate to induce ovulation; conceived in second
assays; ultrasound; CT; MRI; laparoscopy; and basal cycle. Delivered healthy, full-term infant.
body temperature studies.
7.8f Criteria for Rating Permanent
Impairment due to Fallopian Tube
and Ovarian Disease Clinical Studies: Bilateral tubal patency on hystero-
Evaluate any associated endocrine impairment in salpingogram. Normal sperm count on husband’s
accordance with the criteria set forth in the Guides’ semen analysis.
Chapter 10, The Endocrine System.
Diagnosis: Irregular ovulation secondary to hypo-
The impairment criteria for evaluating fallopian thalamic-pituitary dysfunction.
tube and ovarian disease are given in Table 7-12.
Objective test results are the key factor.
person, as there is no ovarian impairment. Patient
should be evaluated for rating under the endocrine
chapter (Chapter 10).
CLASS 0
CLASS 1
EXAMPLE 7- 45: FALLOPIAN TUBE 1% to 5% Impairment of the Whole Person
AND OVARIAN DISEASE
Subject: 28-year-old woman. EXAMPLE 7- 46: FALLOPIAN TUBE

AND OVARIAN DISEASE
History: No pregnancy after 6 years of marriage.
Average frequency of sexual intercourse; no con- Subject: 32-year-old woman.
traceptives. Menstruated every 40 to 60 days since
History: Two children.
TA B L E 7-12 Criteria for Rating Permanent Impairment due to Fallopian Tube and Ovarian Disease
Fallopian Tube and Ovarian Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–11% 15%
SEVERITY 1 3 5 7 9 11
HISTORYb No symptoms or signs Intermittent symptoms Fallopian tube or Fallopian tube or

of fallopian tube or or signs of fallopian ovarian disease or ovarian disease or
ovarian disease tube or ovarian disease deformity symptoms deformity symptoms
that do not require and signs require and signs do not
continuous treatment continuous treatment respond to treatment
Chapter 7
OBJECTIVEc TEST No current anatomic Only 1 normally Significant fallopian Bilateral fallopian
RESULTS or functional abnor- functioning fallopian tube or ovarian tube or ovarian loss
mality of the fallopian tube or ovary in the disease, but tubal in the premenopausal
tube or ovary premenopausal period patency persists and period
ovulation is possible
a
Only 1 rating, as someone who meets criteria based on objective testing is at the highest level. On the other hand, if patient
is in class 2 but unresponsive to treatment (class 3 by history), impairment would be at 11%. These ratings are combined
with ratings from the endocrine system for loss of hormonal function.
b
The history is what modifies the impact of the objective test results.
c
Key factors that drive the impairment are anatomic pathology and reproductive status. There is no impairment given if the
loss occurs in the postmenopausal period or when no further childbearing is expected.
Guides6e_07_129-158.indd 154 2/17/09 2:41:53 PM

Current Symptoms: Severe pelvic infection left her Clinical Studies: Cultures: no infection.
with complete proximal and distal occlusion of right
Diagnosis: Recurrent pelvic endometriosis.
fallopian tube. She is currently asymptomatic.
Physical Exam: Uterus: normal size; enlarged
person. Although tubal patency is retained, she has
fallopian tube on the right.
significant disease, and continuous symptoms move
Clinical Studies: Total right proximal and dis- her from the middle to the highest level of class 2.
tal fallopian tube occlusion with unilateral 6-cm
hydrosalpinx and salpingectomy.
Diagnosis: Unilateral salpingectomy.
CLASS 3
Impairment Rating: 1% impairment of the whole 15% Impairment of the Whole Person
person. Her unilateral salpingectomy puts her in
class 1 at 3%; however, the absence of symptoms
EXAMPLE 7- 48: FALLOPIAN TUBE
moves her 1 grade down.
AND OVARIAN DISEASE

History: Childhood Wilms’ tumor; radical nephrec-
CLASS 2
tomy; chemotherapy and abdominal radiation.
Current Symptoms: Erratic menstruation. Never
pregnant. No pregnancy after 5 years of unprotected
EXAMPLE 7- 47: FALLOPIAN TUBE
intercourse.
AND OVARIAN DISEASE
Physical Exam: Nephrectomy scar.
Clinical Studies: Normal sperm count on husband’s
History: Two children. Increasing pain second-
semen analysis. Bilateral tubal patency on hystero-
ary to severe pelvic endometriosis. Laparotomy for
salpingogram. Primary ovarian failure on hormonal
bilateral ovarian endometrioma resection, peritoneal
studies.
implant resection, and fulguration; presacral neurec-
tomy. Normal pregnancy resulting in birth of healthy Diagnosis: Infertility due to primary ovarian failure.
infant. Breast-fed for 14 months. Continuous medi-
Impairment Rating: 15% impairment due to loss
cal therapy consisting of twice a day analgesics and
of ovarian function (age of subject is considered);
anti-inflammatory drugs for suppression of chronic,
combine with appropriate impairment rating for
recurring pain.
upper urinary tract disorder and endocrine disorder
Current Symptoms: Pelvic pain secondary to for impairment of the whole person (see Combined
recurrent endometriosis. Values Chart in the Appendix).
Physical Exam: Tender uterus and adnexae.
Chapter 7
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7.9 Urinary and Reproductive

Systems Impairment Evaluation
Summary
Table 7-13 gives an evaluation summary for the assess-
ment of urinary and reproduction systems impairment.
TA B L E 7-13
Urinary and Reproductive Systems Impairment Evaluation Summary
Disorder History, Including Examination Record Assessment of Function

Selected Relevant
Symptoms
General Urinary Urology symptoms (eg, Comprehensive physical Serum urea nitrogen (BUN); creatinine;
change in frequency of examination; abdominal electrolytes; 24-h creatinine clearance;
micturition, dysuria, chills, palpation for tenderness; fasting blood sugar; renal isotope studies
fever, hematuria, infec- scrotal exam; testes and for kidney function; intravenous pyelogram
tion, loin or abdominal or epididymis exam; rectal (urogram) for tumors or stone disease; or
costovertebral pain, loss exam; prostate exam; vagi- spiral CT; voiding and retrograde
of appetite, weight loss, nal and rectal exam; urine: cystourethrogram to rule out a stricture;
impaired stamina, edema, gross for sugar and albumin; urodynamics; bladder pressure studies
dry, dusky skin) microscopic; culture and cell for neurogenic bladder dysfunction
cytology; ultrasound kidney;
cystograde exam with retro-
grade exam if needed
Male Sexual history of erec- Genital and rectal examina- Evaluation of penile blood flow; urinalysis;
Reproductive tions, ejaculation, dis- tion; prostatic exam semen analysis; ultrasound; vasography;
charge, scrotal pain, hormone levels
tenderness, reproduc-
tion, dysuria, hematuria,
nocturia
Female Abnormalities of men- Pelvic examination Cervical and vaginal smears; ultrasound;
Reproductive struation, pain, discharge, hormonal assays; hysterosalpingography;
change in sensation, laparoscopy; CT; MRI
altered lubrication
Chapter 7
Guides6e_07_129-158.indd 156 2/17/09 2:41:54 PM

End-Organ Damage Diagnosis(es) Degree of Impairment
Renal failure leading to uremia; con- Cystitis; bladder tumor; testicular tumor; trau- Criteria outlined in this chapter;
gestive heart failure; hepatorenal matic loss of testes; urethral damage and stric- Tables 7-1, 7-2, 7-3, 7-4, and 7-5
failure; damage due to metastatic ture; enlarged prostate
disease—spine, prostate, lungs
Absent kidney; polycystic kidney disease; mal-
positioned kidneys; renal stone disease; renal
tumors; neurogenic bladder
Erection disorders; fertility disorders
Penile or prostatic; if cancer, distant Impotence; ejaculatory dysfunction; infertility; Tables 7-1, 7-6, 7-7, 7-8, and 7-9
metastatic sites prostatitis; benign prostatic hypertrophy; cancer
of reproductive organs (penile, testicular, pros-
tatic), congenital
Pelvic area; abdomen Vaginitis; infection; ulceration; atrophy or Tables 7-1, 7-10,7-11, and 7-12
hypertrophy; dysplasia; infertility; endome-
triosis; cancer; strictures; stenosis; congenital
Chapter 7
Guides6e_07_129-158.indd 157 2/17/09 2:41:54 PM

8. Khan Z, Hertanu J, Yang WC, Melman A, Leiter E.

References Predictive correlation of urodynamic dysfunction and
brain injury after cerebrovascular accident. J Urol.
1981;126:86–88.
1. Perkash I. Detrusor-sphincter dyssynergia and detrusor
hyperreflexia leading to hydronephrosis during Some characteristics are described for detrusor-sphincter
intermittent catheterization. J Urol. 1978;120:620–622. dyssynergia and the dyssynergic response in spinal-injured
patients with complete lesions. The urodynamic evaluation and
2. Perkash I. Autonomic dysreflexia and detrusor-sphincter
clinical problems are analyzed in 53 patients to identify the
dyssynergia in spinal cord injury patients.
importance of early recognition of sphincter dyssynergia.
J. Spinal Cord Med. 20, 365, 1997.
9. McGuire EJ, Fitzpatrick CC, Wan J, et al. Clinical
Cystometric examination can define DSD and severity of
assessment of urethral sphincter function. J Urol.
autonomic dysreflexia which is associated with paroxysmal
1993;150(5):1452–1454.
hypertension.
Measurements of urethral pressures, such as maximum
3. Perkash I. Transurethral sphincterotomy provides
urethral pressure, are widely believed to have relevance in the
significant relief in autonomic dysreflexia in spinal cord
management of urinary incontinence despite evidence to the
injure male patient: Long-term follow up results. J.Urol.
contrary. In this study, maximum urethral pressure and the
177, 1026–1029, 2007.
abdominal pressure required to cause stress incontinence were
Two cases of spinal cord injury with detrusor-sphincter measured in 125 women with stress incontinence. In women,
dyssynergia and detrusor hyperreflexia are presented. The the abdominal pressure required to cause stress incontinence
importance of early diagnosis and appropriate management was unrelated to maximum urethral pressure.
of detrusor-sphincter dyssynergia associated with detrusor
10. Shabsigh R, Fishman IJ, Quesada ET, Seale-Hawkins
hyperreflexia is discussed.
CK, Dunn JK. Evaluation of vasculogenic erectile
4. Cassidy MJ, Beck RM. Renal functional reserve in impotence using duplex ultrasonography. J Urol.
live related kidney donors. Am J Kidney Dis. 1988; 1989;142:1469–1474.
11:468–472.
A total of 140 patients underwent penile vascular evaluation
The single kidney responds appropriately to a meat-protein with intracavernous papaverine injection combined with
load. There is no evidence from this study to suggest that duplex ultrasonography. Of these patients, 8 were potent men
hyperfiltration damaged the remaining kidney. who were evaluated for reasons other than erectile failure.
These potent men were used as controls to obtain normal
5. Schena FP, Cameron JS. Treatment of proteinuric
values. The remaining 132 patients had erectile impotence of
idiopathic glomerulonephritides in adults: a
various causes.
retrospective survey. Am J Med. 1988;85:315–326.
11. American Association of Clinical Endocrinologists.
A review of the worldwide medical literature was undertaken
AACE clinical practice guidelines for the evaluation
to determine whether treatment with currently available drugs
and treatment of male sexual dysfunction. Endocr
was beneficial in patients with glomerulonephritides.
Pract. 1998;4:4.
6. Nitti VW, Adler H, Combs AJ. The role of urodyamics
12. Kaplan H. Psychosexual dysfunctions. In Cooper,
in the evaluation of voiding dysfunction in men after
Frances, Sacks, eds. The Personality Disorders
cerebrovascular accident. J Urol. 1996;155:263–266.
and Neurosis. Philadelphia, Pa: JB Lippincott Co;
The cause of voiding dysfunction was determined in men who 1986:467–479.
were at risk of obstructive uropathy after a cerebrovascular
13. NIH Consensus Conference. Impotence: NIH
accident to evaluate whether the cause of voiding dysfunction
consensus development panel on impotence. JAMA.
could be predicted by the type (obstructive or irritative) or by
1993;270:83–90.
the onset of symptoms.
14. Walsh PC, ed. Campbell’s Urology. 7th ed.
7. Burney TL, Senapati M, Desai S, Choudhary ST,
Philadelphia, Pa: WB Saunders Co; 1998.
Badlani GH. Acute cerebrovascular accident and lower
urinary tract dysfunction: a prospective correlation of 15. Danforth DN, ed. Textbook of Obstetrics and Gynecology.
the site of the brain injury with urodynamic findings. 5th ed. Philadelphia, Pa: JB Lippincott Co; 1986.
J Urol. 1996;156:1748–1750.
Evaluates the effects of an acute cerebrovascular accident
on the lower urinary tract and correlates the site of
cerebrovascular accident with findings on urodynamic study.
Chapter 7
Guides6e_07_129-158.indd 158 2/17/09 2:41:54 PM

CHAPTER 8
The Skin
8.2 Disfigurement
8.3 Scars and Skin Grafts
8.4 Contact Dermatitis
8.5 Natural Rubber Latex Allergy
8.6 Skin Cancer

Introduction
due to Skin Disorders
nent impairment of the skin and its appendages and
8.8 Skin Impairment Evaluation Summary
estimating the extent to which skin impairments affect
the ability to perform Activities of Daily Living, or
ADLs (see Table 1-2). Permanent impairment of the
skin is any dermatologic abnormality or loss that
persists after medical treatment and rehabilitation, is
unlikely to change significantly in the next year with
or without medical treatment, and affects ADLs.
Table 8-1 summarizes skin components, functions,
and disorders. Skin functions include: (1) providing
a protective covering; (2) participating in sensory
perception, temperature regulation, fluid regulation,
electrolyte balance, immunobiologic defenses, and
trauma resistance; and (3) regenerating the epidermis
and its appendages.1
Protective skin functions include barrier defenses
against chemical irritants and allergic sensitizer
damage, microorganism invasion, and ultraviolet
light injuries. Temperature regulation involves proper
functioning of sweat glands and small blood vessels.
The barrier defense against fluid loss is related to the
Chapter 8
intactness of the stratum corneum.
159
Guides6e_08_159-182.indd 159 2/17/09 2:42:11 PM

TA B L E 8 -1
Structure, Functions, and Disorders of the Skina
Structure or Component Functions Disorders
Epidermis
Stratum corneum Barrier against microorganisms, chemi- Infection; contact dermatitis; xerosis
cals, and water loss
Squamous and basal cells Stratum corneum regeneration; wound Squamous or basal cell carcinoma;
repair ulceration
Melanocytes Protection from ultraviolet radiation Vitiligo; sunburn; hyperpigmentation;
melanoma
Langerhans cells Immune surveillance Allergic contact dermatitis
Dermis
Blood vessels and mast cells Nutrition; thermoregulation; vasodilation Ulceration; heat stroke; urticaria (contact,
systemic); hand-arm vibration syndrome
Lymphatics Immune surveillance; lymphatic Lymphedema
circulation
Nerve tissue Sensory perception Neuropathies; pain; itching; sensory
changes
Connective tissue Protection from trauma; wound repair Hypertrophic and atrophic scars;
scleroderma
Eccrine (sweat) glands Thermoregulation Heat intolerance
Sebaceous glands Synthesis of skin surface lipids Acne; chloracne; xerosis
Hair Insulation; outward appearance Folliculitis; alopecia
Nails Manipulation of small objects Paronychia; dystrophy; onycholysis; diffi-
culty with grasping
a
Modified from Mathias CGT. The skin. In: Zenz C, ed. Occupational Medicine. 2nd ed. Chicago, Ill: Year Book Medical Publishers; 1988.
Revisions from the Fifth Edition include updated physical examination, and judicious use of diagnostic
clinical information and references and a new procedures. Ancillary diagnostic and laboratory pro-
impairment rating system using the updated prin- cedures include patch, open, prick, intracutaneous,
ciples for Chapters 1 and 2. and serologic allergy tests; Wood’s light examinations;
cultures and scrapings for bacteria, fungi, and viruses;
and biopsies.1
To determine the appropriate impairment class
8.1 Principles of Assessment (Table 8-2) for an affected individual, first evalu-
ate the severity of the skin condition; the frequency,
intensity, and complexity of the medical condition
and treatment regimen; and the impact of the skin
condition on the ability to perform ADLs. Burden of
Treatment Compliance (BOTC) can be significant in
dermatologic disorders, with patients being required
to soak affected skin daily, apply topical medications
by many specialties in impairment evaluation.
to large areas of the body on a regular basis, avoid
Skin disorders may develop from exposure to physi- sun exposure, or present to the dermatology office
cal, mechanical, biological, and chemical agents. several times weekly for phototherapy. This BOTC
Identification and avoidance of these agents may pre- can affect the ability of patients to complete ADLs
vent ongoing skin disorder aggravation. Physicians and should be considered in the history when ini-
need to determine the clinical course and perma- tially determining the appropriate impairment class.
nence of skin disorders associated with possible
After defining the class of impairment using these fac-
intermittent exposures.
tors, consider the physical exam and diagnostic testing
Clinical evaluation requires sound clinical judg- to determine the exact number in the class that best
Chapter 8
ment based on a detailed medical history, thorough represents the individual. The skin impairment
Guides6e_08_159-182.indd 160 2/17/09 2:42:13 PM

The Skin 161
ratings are all provided in terms of whole person be intolerable. Like pain, pruritus may be defined as
impairment. All patients must be accurately diagnosed a unique complex of afferent stimuli that interacts
using the evaluation summary found in Table 8-3 before with the individual’s emotional or affective state
an impairment rating is provided. of mind.1 Peripheral neural stimulation varies from
absence of sensation to awareness that stimuli are
The maximum impairment rating for skin disease
producing a usual or unusual sensation. Central
in this edition of the Guides is 58%. Patients with
nervous system reaction is modified by the state of
severe skin disease are likely to experience higher
attentiveness, experience, motivation at the moment,
levels of impairment than this rating, but in these
and stimuli such as exercise, sweat, and temperature
situations, it would be expected that other body
change.
systems are impaired as a result of the skin disease.
Examples would include musculoskeletal impair- When evaluating pruritus associated with skin dis-
ment due to loss of joint mobility in scleroderma orders, consider (1) how the pruritus interferes with
or epidermolysis bullosa, arthritis associated with performance of the ADLs and (2) to what extent the
severe psoriasis, and difficulty eating due to oral or pruritus description is supported by such objective
esophageal involvement of pemphigus vulgaris. skin signs as lichenification, excoriation, or hyper-
pigmentation. Subjective itching complaints that can-
When a patient experiences a permanent impairment
not be substantiated objectively may require referral
of other body systems, such as restriction of motion
or consultation.
or ankylosis of joints, respiratory, cardiovascular,
endocrine, or gastrointestinal tract disorders, then
8.1b Description of Procedures
the rater should evaluate the extent of whole person
Common clinical investigations for dermatologic
impairment related to each system. The rater should
conditions include skin testing, biopsy, and relevant
then combine the estimated impairment percentages
laboratory studies.
(see the Combined Values Chart in the Appendix) to
determine total impairment.
Patch Testing: Performance, Interpretation,
and Relevance6
8.1a Interpretation of Symptoms
The sine qua non for the diagnosis of allergic contact
and Signs
dermatitis is a properly performed and interpreted
In some cases, limitations in the ability to perform
patch test. The information from patch testing com-
daily activities are based on symptoms. This infor-
plements an appropriate, detailed history. Patch test-
mation may be subjective and possibly misinter-
ing may significantly contribute to the diagnosis and
preted, and it should not serve as the sole criterion
management of contact dermatitis.
for impairment rating decisions. Rather, obtain
objective data about the extent of the limitation and Be aware that patch testing may yield false-posi-
integrate findings with subjective data to estimate tive and false-negative results. Selecting the proper
the permanent impairment rating. concentration of the suspected allergen, vehicle,
site of application, and type of patch test is critical
Objective Testing for procedure validity. Making such selections and
A number of dermatology-specific quality-of-life determining the relevance of test results require con-
indexes exist, such as the Dermatology Life Quality siderable skill and experience.
Index (DLQI),2 the Skindex-16, and the Skindex-29.3
Interpret a positive or negative patch test result in
In addition, there are a number of disease-specific
conjunction with the clinical history and a detailed
severity and quality-of-life indexes, such as the
knowledge of testing procedures. Although appropri-
SCORing Atopic Dermatitis (SCORAD) scale and
ate test concentrations and vehicles have been estab-
the Psoriasis Disability Index (PDI).4,5 All have been
lished for many sensitizers, there are no established
successfully used and validated in the research set-
vehicle and concentration standards for many of the
ting, but none have been widely accepted for use in
chemicals in use.
clinical practice, and therefore these scales have not
been incorporated into Table 8-2. Patch test results require careful interpretation to
discern allergic from irritant responses, as well
Pruritus as to appropriately interpret whether the result is
Pruritus is a common symptom of dermatologic relevant to the individual’s dermatitis and expo-
conditions. Pruritus is a subjective, unpleasant sures. When a positive patch test occurs, the physi-
sensation and symptom that provokes the desire to cian must determine if the allergen has definite,
Chapter 8
scratch and rub the skin. The itching sensation may probable, possible, past, or unknown relevance to
Guides6e_08_159-182.indd 161 2/17/09 2:42:13 PM

the patient’s dermatitis. Allergens to which the may be a residual of injury or disease, or it may
patient is definitely exposed and for which the accompany a recurrent or ongoing disorder.
areas of exposure correlate with the areas affected Examples of disfigurement include giant pigmented
with dermatitis are graded as definitely relevant. nevi, nevus flammeus, cavernous hemangioma, and
If, based on known exposures, it is highly likely pigmentation alteration. Facial disfigurement is rated
that the patient is exposed to the allergen in areas in Chapter 11 (Table 11-5). All other disfigurement is
affected by dermatitis, then the relevance is graded rated in this chapter.
as probable. If there are possible exposures to the
Disfigurement usually has no effect on body function
allergen, but exposure cannot be confirmed, then
and may have little or no effect on the ability to per-
relevance is graded as possible. If no exposures
form ADLs, except if the disfigurement causes social
to the allergen can be identified, then relevance is
rejection or an unfavorable self-image with self-
graded as unknown, as it is impossible to rule out
imposed isolation, lifestyle alteration, or other behav-
the possibility of exposure.
ioral changes. If impairment in the ability to perform
For example, a patient with hand dermatitis is ADLs due to disfigurement does exist, it may be
patch tested and found to be allergic to a rubber manifested by a behavior change, such as withdrawal
accelerator. from social contacts. This may be taken into account
under Table 8-2 when the examiner believes the
1. If the manufacturer confirms that the gloves the
behavior is clearly related to severe disfigurement.
patient wears contain the accelerator and the
patient reacts positively to a patch test with a Evaluate impairments related to disfigurement or
sample of the glove, then the relevance would be altered pigmentation in accordance with the criteria
graded as definite. given in Table 8-2 and described later in this chapter.
Describe disfigurement and enhance with good color
2. If the manufacturer confirms that the gloves the
photographs that show multiple views of the defect.
patient wears contain the accelerator but a glove
Estimate the probable duration and permanency
sample is not available for patch testing, then the
of the disfigurement. Describe the possibility of
relevance would be graded as probable.
improving the condition through medical or surgical
3. If it cannot be determined if the gloves contain therapy and the extent to which it can be concealed
the accelerator, then the relevance would be cosmetically, as with hairpieces, wigs, or cosmetics.
graded as possible. Depict with photographs if possible.
4. If the manufacturer states that the gloves do not
contain the accelerator, then the relevance would
be graded as unknown, as it is possible that there
is a different exposure to the accelerator of which
8.3 Scars and Skin Grafts
neither the patient nor the physician is aware, or
Scars are cutaneous abnormalities that result from
it is possible that the manufacturer is providing
the healing of burned, traumatized, or diseased
incorrect information.
tissue. They represent a special type of disfigure-
In general, an allergen that is graded as definite, ment. Give the scars’ dimensions in centimeters and
probable, possible, or past relevance is considered to describe their shape, color, anatomic location, and
be a relevant positive patch test. any evidence of ulceration, depression, or elevation.
Indicate whether the scar is atrophic or hypertro-
Patch tests are used only to detect contact allergy
phic; soft and pliable or hard and indurated, thin or
and are only one component in a complete evalua-
thick, and smooth or rough; and whether there is any
tion. Further details about patch testing, its values,
attachment to underlying bones, joints, muscles, or
and its limitations are discussed in standard texts,
other tissue. Good color photographs with multiple
some of which are listed in the references at the end
views of the defect enhance the scars’ description.
of this chapter.
Consider the tendency of a scar to disfigure when
evaluating whether there is permanent impairment
due to scarring. Also consider whether the scar
8.2 Disfigurement can be changed, made less visible, or concealed.
Function may be restored without improving appear-
Skin disfigurement is an altered or abnormal appearance, and appearance may be improved without
ance that may be an alteration of color, shape, or altering function.
Chapter 8
structure, or a combination of these. Disfigurement
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The Skin 163
Skin grafts may be used to replace skin losses Allergen cross-sensitivity is an important phenom-
resulting from trauma or disease. Grafts commonly enon in which an individual who is allergic to one
lack hair, lubrication, pliability, and sensation, chemical (eg, urushiol in poison ivy or poison oak)
and they may demonstrate altered pigmentation. also will react to structurally related chemicals (eg, in
These changes affect the function and appearance Japanese lacquer, mango, and cashew nutshell oil).
of the graft site. The altered lubrication, pliability,
Accurate diagnosis is the key to proper management
and sensation may result in diminished protection
of contact dermatitis. If the specific agent or agents
against microorganisms and diminished resistance
can be identified (see Section 8.1b on patch testing)
to mechanical, chemical, and thermal trauma. The
and successfully avoided, full recovery is antici-
altered appearance may be significant if the area
pated. However, if contact continues, the dermatitis
involves exposed parts, such as the dorsum of the
may become chronic and disabling, and it may pre-
hand, the face, or the neck.
vent the individual from performing some ADLs. It
If a scar involves the loss of sweat gland function, hair should be noted that in rare cases, especially those
growth, nail growth, or pigment formation, evaluate involving occupational allergy to chromates, there
the effect or effects on the performance of the ADLs. can be long-term persistence of dermatitis, despite
Evaluate burns and scars according to the criteria in avoidance of all known sources of the allergen.19
this chapter; give special consideration to the injury’s
Three special situations should be considered in
impact on the individual’s ability to perform ADLs.
contact dermatitis. First, patients who have special-
When impairment resulting from a burn or scar is
ized occupations and who develop severe contact
based on peripheral nerve dysfunction or loss of range
dermatitis may be unable to continue working in their
of motion, evaluate the skin impairment separately
occupation. In this setting, the patient may no longer
and combine the impairment rating with that from
have any active dermatitis after being removed from
Chapter 15, The Upper Extremities; or Chapter 16,
the work environment; however, they have clearly
The Lower Extremities. If chest wall excursion is
experienced a permanent immunologic change that
limited, consult Chapter 5, The Pulmonary System.
may affect them in the future and that has limited
their employment opportunities. For the permanent
change in cutaneous immunology and physiology,
they should receive 3% impairment if they have not
8.4 Contact Dermatitis6–18 met any other criteria in Table 8-2 for a rating and the
chemical is one they may encounter in other settings.
Contact dermatitis is an inflammatory skin reaction
induced by exposure to an external agent and is the The second special situation is the patient with an
most frequent cause of occupational skin disease. occupational contact dermatitis who continues to
Contact dermatitis most often involves the hands, have dermatitis because that person continues to
wrists, and forearms, although any area may be work but whose disease would be expected to clear
affected. Two types of contact dermatitis are gener- completely if he or she stopped working. In this set-
ally recognized: irritant, which results from direct ting, once all reasonable workplace accommodations
tissue damage, and allergic, in which tissue damage have been made, if the dermatitis continues despite
is mediated through type IV delayed cellular hyper- therapy, the patient should be rated in his or her cur-
sensitivity. Irritant and allergic contact dermatitis rent condition with the assumption that the patient
may coexist in the same person and are often dif- has reached maximum medical improvement (MMI).
ficult to differentiate on physical examination and on
The third special situation is the patient with extreme
histopathology.
sensitivity to a relevant allergen or with sensitivity
Irritants may be strong (absolute) or weak (marginal). to multiple relevant allergens. In these situations, it
Cumulative exposure to marginal irritants causes is anticipated that the number of allergies or degree
most cases of irritant contact dermatitis and may of allergy would lead to greater restrictions in the
impair the barrier function of the skin, allowing the patient’s activities than a patient with a lower sensi-
penetration of potential allergens. Many cutaneous tivity or with allergy to only a single substance, and
allergens, such as chromates, nickel salts, epoxy hence that the allergies would have a greater impact on
resins, and preservatives, are also primary irritants. the patient’s ability to perform ADLs. This is reflected
Allergy can be induced or maintained by chemicals in in the “Diagnostic Test Findings” portion of Table 8-2.
concentrations insufficient to irritate nonallergic skin.
Chapter 8
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8.5 Natural Rubber condition called the basal cell nevus syndrome or
Latex Allergy20–24 Gorlin syndrome in which patients develop hun-
dreds or thousands of basal cell carcinomas starting
at a relatively young age.
Latex allergy generally refers to an immunoglobu-
lin E (IgE)-mediated immediate hypersensitivity Basal cell carcinoma is usually locally invasive, with
reaction to one or more protein allergens present a small metastatic potential. The goal of therapy
in natural rubber latex (NRL) devices, especially is complete eradication of the tumor, using either
gloves. Individuals with spina bifida and health surgical techniques, destructive techniques, or
care workers are at particular risk. Allergy to NRL topically applied agents, with the least amount of
has become a significant medical and occupational disfigurement.
health problem. Clinical manifestations range from
Squamous cell carcinoma is more common in indi-
contact urticaria and angioedema to allergic rhini-
viduals with light skin coloration. Long-term sun
tis and conjunctivitis, asthma, and anaphylaxis. A
exposure typically leads to precancerous actinic
number of NRL-allergic individuals are atopic, with
keratoses which may progress to SCC. In addition
asthma, other environmental type I allergies, and
to sunlight, other environmental risk factors include
hand eczema. Symptoms and signs of contact urti-
arsenic, polycyclic aromatic hydrocarbon, chronic
caria to NRL may be masked by preexisting hand
infrared heat, and therapeutic radiation exposure.
eczema. Also evaluate individuals with NRL allergy
Additionally, SCC may occur in chronic scars
for manifestations in other organ systems (eg, respi-
from burns, trauma, and inflammatory processes.
ratory symptoms and asthma). Contact dermatitis to
Several clinical and histologic types exist, but SCC
rubber accelerators and antioxidants added during
is more likely to metastasize than is BCC. The risk
manufacture has also been associated with NRL
of SCC metastasis is especially high for neoplasms
exposure.
arising on the lip or ear, as well as in larger, deeper,
Allergen avoidance is the current treatment of NRL and more anaplastic lesions. Therapeutic options
allergy and contact dermatitis. Glove powder (an are the same as for basal cell carcinoma. Sun avoid-
NRL-allergen carrier) can produce respiratory symp- ance and close follow-up are essential in patients
toms in susceptible individuals. Affected workers with SCC.
may have to avoid contact with NRL gloves and
Cutaneous malignant melanoma is an increasingly
other NRL-containing products, avoid areas where
common and lethal malignancy of melanocytes and
they might inhale the powder from NRL gloves worn
nevus cells. The increasing frequency of melanoma
by other workers, and wear a medical alert bracelet.
is well documented—rates of incidence are rising
All health care facilities should use nonlatex gloves
more rapidly for this than for any other cancer. The
where possible. When latex gloves must be used,
salient challenge for clinicians is to detect and excise
they should be nonpowdered.
melanoma in its earliest stage, as tumor thickness
remains the most important prognostic indicator for
this malignancy. Early diagnosis and surgical exci-
sion of either in situ or early invasive melanomas are
8.6 Skin Cancer1 curative in most individuals. Despite advances in
chemotherapy and immunotherapy, the efficacy of
Skin cancer is the most prevalent of all cancers.
treatment of advanced melanoma remains limited,
Three main types exist: basal cell carcinoma,
and the prognosis of metastatic disease remains
squamous cell carcinoma (SCC), and malignant
poor.
melanoma. In the early 21st century, it is estimated
that there were 800,000 basal cell carcinomas and
200,000 cutaneous SCCs diagnosed per year. In the
year 2004, it is estimated that there were approxi-
mately 100,000 melanomas diagnosed, with slightly
8.7Criteria for Rating Permanent
less than half of these being in situ at diagnosis. Impairment due to Skin Disorders
Predisposing factors include light skin color, inabil-
ity to tan, sun exposure, blond or red hair, freck- To use Table 8-2, follow these steps:
ling in childhood, and therapeutic radiation. Each
1. Establish the diagnosis using the objective
type of skin cancer (BCC, SCC, and melanoma)
physical exam findings and lab tests. If neces-
has several different clinical and histologic types.
sary, consult a dermatologist. Table 8-3 provides
Chapter 8
There is also a much less common, inherited
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The Skin 165
suggestions for physical exam findings and lab in a lower class than that selected from the his-
tests that should be noted. Place the individual tory, move the accordant number of steps lower
in the appropriate class based on the history within the class selected from step 1. For class
and focusing on impact of the skin disease on 4, if the physical exam findings are particularly
ability to perform ADLs. Begin by selecting the severe, you may move to the highest number. For
middle number in that class. The classes have classes 2, 3, and 4, most ratings are complete at
discrete numbers. They are not a range. You this step.
will need to consider the percentage of time that
3. Assess the class of the patient using the diag-
symptoms are present and the amount of treat-
nostic findings. If diagnostic test findings are
ment required. Facial disfigurement is rated in
not necessary or are not expected to be positive
the Ear, Nose, and Throat chapter in Table 11-5.
for the given diagnosis, ignore this step and use
Scars and burns are present permanently; there-
the number obtained after assessing the physical
fore, time is not a factor considered in the rating.
exam findings as the final impairment rating. If
When different elements of the history would
positive findings are expected for the given diag-
lead to placement in different classes (eg, when
nosis, assess the class based on the comparison
the impact on ADLs is out of proportion to the
between the findings in the individual and those
frequency of symptoms), the overriding factor
expected. Using the number you have arrived at
should remain objectively established interfer-
in step 2, move again up or down depending on if
ence with ADLs. Individuals with mild interfer-
the class is lower than the class originally selected
ence in ADLs would be unable to engage in or
by the history or higher than the class originally
must seriously diminish engagement in nones-
selected by the history. You may not move out of
sential ADLs, such as previously performed
the class you have originally selected from your
recreational activities. Individuals with moderate
history. For example, if the patient were found to
interference in daily-living activities would, in
be in class 1 originally by the history, you would
addition to the above, have significantly limited
begin at 5% as the middle number in class 1. If
ability to perform some essential ADLs, such
the physical exam were in class 3, you would
as bathing or household tasks. Individuals with
move up to 9%, staying within class 1 but moving
severe interference with ADLs would be unable
up 2 numbers. If the diagnostic test were in class
to perform many essential ADLs and would be
2, it is 1 class higher than the original class, but
expected to have serious limitations in the abil-
it would not change your rating since you can-
ity to maintain employment.
not exceed 9% and remain within class 1. On the
2. Assess the correct class for the physical exam other hand, if the diagnostic tests were in a class
findings. If the class selected is 1 class higher 0, you would move down 1 step and the final
than the class selected from step 1, move up 1 rating would be 7%.
number higher within the class selected using the
4. Ratings that begin in class 4 are an exception
history. If it is 2 levels higher move up 2 levels
because there are no classes higher than 4; there-
within the history-selected class only when 2
fore, the rating increases by 1 category whenever
numbers are available. Otherwise move only to
the physical exam or diagnostic findings are also
the top number available in the class selected by
in category 4.
the history. If the class from the physical exam is
Chapter 8
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TA B L E 8 -2 Criteria for Rating Permanent Impairment due to Skin Disorders
Skin Disorders
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 11%–27% 30%–42% 45%–58%
SEVERITY 1 3 5 7 9 11 15 19 23 27 30 33 36 39 42 45 48 51 54 58
HISTORYa,c Skin disorder Skin disorder Skin disorder Skin disorder Skin disorder
signs have been signs and symp- signs and symp- signs and symp- signs and symp-
present in the toms consistent toms consistent toms consistent toms consistent
past but are cur- with Table 8-3 are with Table 8-3 with Table 8-3 with Table 8-3 are
rently present present 1%–30% are present are present present ⬎90% of
⬍1% of the time b of the time b ⬎30%–60% of ⬎60%–90% of the time b
the time b the time b
and and and
and and
no medication is may intermit- require treat-
necessary tently require often require require inter- ment with topi-
treatment treatment mittent to cal or systemic
and
with topical with topical constant treat- medications on a
there is essen- medications a or systemic ment with topi- regular basis
tially no inter- medications cal or systemic
and and
ference with medications
and
activities of daily when signs and there is severe
and
living (ADLs) symptoms are when signs and interference with
present, there is symptoms are when signs and most ADLS to the
minimal interfer- present, there is symptoms are extent that con-
ence with ADLs mild interference present, there is finement may be
with some ADLs moderate inter- required.
ference with
All cancers not in
some ADLs
remission, other
than basal cell car-
cinoma, automati-
cally receive 58%
combined with
all other systemic
or musculoskel-
etal impairments
or 100% when
terminal.
PHYSICAL EXAM Physical exam Physical exam Physical exam Physical exam
FINDINGS c findings in findings in accor- findings in accor- findings in accor-
accordance with dance with Table dance with Table dance with Table
Table 8-3 are 8-3 are present 8-3 are usually 8-3 are present
present when when symptoms present. The find- almost all the
symptoms are are present. ings generally time. The find-
present. When When present, (1) cover 20%– ings generally
present, the find- the findings gen- 40% of the body cover ⬎40% of
ings (1) do not erally (1) cover and can be at the body and
cover 10% of the 10%–20% of the least partially are not able to
body, (2) exclude body but can usu- concealed in be concealed
the face and/or ally be concealed most social situa- in most social
(3) are usually and/or (2) signifi- tions and/or situations.
transitory or can cantly involve the (2) involve the
May move to
be concealed. face or anterior entire palmar
highest number
part of the neck aspect of the
in class 4 depend-
and/or hands. hand.
ing on extent of
involvement and
ability to conceal.
Chapter 8
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The Skin 167
TA B L E 8 -2 (C O N TI N U E D) Criteria for Rating Permanent Impairment due to Skin Disorders
Skin Disorders
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 11%–27% 30%–42% 45%–58%
SEVERITY 1 3 5 7 9 11 15 19 23 27 30 33 36 39 42 45 48 51 54 58
DIAGNOSTIC Diagnostic test Diagnostic test Diagnostic test Diagnostic test Diagnostic test
TEST FINDINGSd findings expected findings expected findings expected findings expected findings expected
to be positive to be positive to be positive to be positive to be positive
are either nega- are equivocal. are positive and are positive and are positive and
tive or the test For example, in the range of are somewhat are significantly
or tests have not for allergic con- results expected beyond the beyond the
been performed. tact dermatitis, in typical cases of range of results range of results
For example, class 1 would the given diagno- expected in typi- expected in typi-
for allergic con- be assigned for sis. For example, cal cases of the cal cases of the
tact dermatitis, patch test reac- for allergic con- given diagnosis. given diagnosis.
class 0 would be tions that are tact dermatitis, For example, For example,
assigned if there equivocal but class 2 would be for allergic con- for allergic con-
were no relevant would be consid- assigned if there tact dermatitis, tact dermatitis,
positive patch ered relevant if was at least one class 3 would be class 4 would
test reactions positive. RPPTR. e assigned for mul- be assigned if
(RPPTRs)e tiple RPPTRs. e multiple RPPTRs e
were present
that indicated
that the patient
must avoid many
widespread
substances or
crucial occupa-
tionally related
substances.
a
Determine the patient’s class using the history, focusing on medically documented interference with ADLs. Objective exam
findings must have been documented by a physician on at least 1 occasion to perform a rating.
b
Scars are present permanently, and thus the time element is not used as part of the rating.
c
Any facial scarring should be graded according to Table 11-5 and then combined with other impairments from this chapter
when applicable.
d
The category of Diagnostic Test Findings is not applied to scars. If no diagnostic tests are necessary or expected to be
positive, then use number obtained after assessing physical exam findings as final impairment rating.
e
Patch test reactions graded as having definite, probable, possible, or past relevance should all be considered to be RPPTRs
(see Section 8.1b for a discussion of assigning relevance to patch test reactions).
CLASS 0 Current Symptoms: None.

Physical Exam: Hands and arms: no signs of
dermatitis.
EXAMPLE 8-1: ALLERGIC CONTACT
Clinical Studies: Patch test: 2⫹ relevant
DERMATITIS
positive reaction to 0.1% petrolatum mixture of
Subject: 27-year-old man. a nonmercurial preservative, 2-n-4-isothiazolin-
3-one, used in the company’s latex paints, not
History: Prepared batches of latex paint for small
allergic to methylisochlorothiazolinone or
paint manufacturing company. Had related skin dis-
methylisothiazolinone.
ease onset and exacerbation. Despite some accom-
modations, individual unable to avoid latex paint
Chapter 8
completely; dermatitis continued. No dermatitis for

1 year after job change.
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Diagnosis: Resolved allergic contact dermatitis CLASS 1

caused by preservative. 1% to 9% Impairment of the Whole Person

person. History places this case in class 0 since skin EXAMPLE 8-3: OCCUPATIONAL LEUKODERMA
findings are no longer present.
Comment: While used widely in paint manufac-
History: Janitor; 13 years’ transient hand dermatitis
turing, the preservative is not widely used in other
from wet work with detergents, including germi-
industries, nor is it used in personal care products.
cidal disinfectant with para-tert-butyl-phenol (TBP).
While the allergy to the preservative prevents
Developed depigmentation on sides of most fingers,
him from performing this particular job, it does
dorsa of the hands, and distal forearms 10 years ago.
not significantly limit his ability to be gain-
Recent depigmentation of portions of the upper torso
fully employed, so this ADL is not significantly
and thighs. Psoralen plus ultraviolet A (PUVA) light
impaired. There is no limitation in the perfor-
therapy with oral methoxsalen 2x per week for over
mance of other daily activities. Latex paint does
1 year failed to stimulate repigmentation. Cosmetic
not contain NRL allergens and does not cause
covering was unsatisfactory. Required outdoor main-
NRL allergy. No additional rating is provided, as
tenance work resulted in frequent sunburn of skin
it is unlikely the individual will encounter this
that lacked pigmentation; needs frequent and regular
chemical in other settings. Patch test is graded as
use of protective sunscreen, averaging twice a day
probably relevant, as the preservative is confirmed
during sunny times.
to be present in the paint to which his hands were
exposed. It is not possible to patch test with a sam- Current Symptoms: None.
ple of the paint the patient used, so the examiner
Physical Exam: Depigmentation covering less than
cannot conclude definite relevance, however both
10% of the body. Early actinic changes with skin
probably and definitely relevant patch test reac-
wrinkling, bruising, and scaling.
tions are considered RPPTRs, so this distinction is
not important in determining a rating. Clinical Studies: Patch testing showed no positive
results.
Diagnosis: Depigmentation, most likely occupa-
EXAMPLE 8-2: THERMAL BURN SCARRING
tional leukoderma.
History: Second-degree flame burn to forearm; person due to occupational leukoderma. The rating
spontaneously healed. begins in class 1 at 5%, the middle number, based on
the history of the presence of a skin disorder and the
Current Symptoms: None. No interference with
need for sunscreen and sun avoidance. The physical
ADLs.
exam findings fit a class 1, and thus the rating does not
Physical Exam: 7 ⫻ 12-cm depigmented area of the change, staying at 5%. No diagnostic test findings are
arm. Healed skin: normal pliability, hair, lubrication, expected, so this portion of the impairment rating table
and sensation. does not affect the final rating, which remains at 5%.
Clinical Studies: None. Comment: Occupational leukoderma is a difficult
diagnosis to confirm. Although patch testing with
Diagnosis: Scarring caused by thermal burn.
the causative chemical will sometimes lead to depig-
Impairment Rating: 0% impairment of the whole mentation, this is not a reliable occurrence and test-
person. ing is not well standardized. Therefore, no positive
diagnostic test results are required for the diagnosis
Comment: No interference with ADLs.
of chemical leukoderma, and this element is there-
fore not considered in determining a rating.
Chapter 8
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The Skin 169
EXAMPLE 8- 4: THERMAL BURN WITH Regular glove use and moisturizer application
HYPERTROPHIC SCARRING required to prevent dermatitis flares. Needs to use
topical steroids approximately once per month when
dermatitis flares. Chronic hand dermatitis causes
History: Healed second-degree burn of anterior pain and burning of hands at least several times a
part of neck; hypertrophic scar formation involves week.
approximately 1% of body surface area (BSA).
Physical Exam: Lichenification on dorsal hands;
Itching and burning temporarily interrupt some
otherwise normal.
ADLs. Treatment with topical steroids is required
several times per month. Clinical Studies: Patch test: various food, house-
hold, cosmetic, and diagnostic and therapeutic mate-
Current Symptoms: Scar susceptible to ultraviolet
rials nonreactive. A 2⫹ positive patch test reaction to
light; wears sunscreen when outdoors. Scar easily
thimerosal on patch testing.
irritated and lacks durability; patient unable to wear
clothes that rub his neck. Intermittent itching and Diagnosis: Chronic irritant dermatitis of the hands.
burning episodes confined to scarred areas stops all
activities for 5 to 10 minutes.
person. The combination of minimal interference
Physical Exam: Scar raised, red, and hard and con- with ADLs and the need for treatment places the ini-
trasts markedly with adjacent normal skin. Limited tial rating in class 1 at 5%. The physical exam find-
neck flexion, extension. ings are in class 2 due to hand involvement, so the
rating is increased to 7%. Because no diagnostic tests
are necessary for irritant dermatitis, the category
Diagnosis: Hypertrophic scar secondary to thermal does not affect the rating.
burn; limitation of neck motion.
Comment: The patch test reaction to thimerosal
Impairment Rating: 7% impairment of the whole is of unknown relevance, as no exposures could be
person. Daily living activities, such as shaving, bath- identified. Patch test reactions of unknown relevance
ing, and dressing are frequently interrupted due to are graded as not relevant and are not considered as
scar irritation, but only to a minimal degree and area positive diagnostic test finding.
involved is only 1%. Rating begins in class 1 at 5%.
The rating is increased by 1 step because the physi-
cal exam findings are in class 2 due to involvement EXAMPLE 8-6: ALLERGIC CONTACT
of the anterior part of the neck, which is difficult or DERMATITIS
impossible to conceal. No diagnostic tests are neces-
Subject: 32-year old woman.
sary, so the final rating is 7%.
History: Approximately 5 years earlier the patient
began to experience dermatitis after having her
EXAMPLE 8-5: CHRONIC HAND DERMATITIS hair dyed. She discontinued this practice but began
to experience constant itchy eruptions of the eye-
lids, face, neck, hands, ears, feet, and upper back.
History: Eczematous eruption beneath wedding Improved after patch testing and lifestyle modifica-
ring on fourth finger of left hand began shortly after tion to avoid identified allergens. No personal or
birth of first child 6 years earlier. Gradually spread family history of eczema, hay fever, or asthma.
to areas on several fingers of both hands despite
Current Symptoms: Dermatitis occurs approxi-
treatment and avoidance of jewelry use. Eruption
mately 4 times per year, with each episode being
persisted for several months, then subsided slowly.
fairly mild and lasting 3 weeks. Main affected areas
Severe hand dermatitis flare-up after birth of second
during flares are eyelids and lateral jaw. During
child 2 years later, which followed a similar pattern.
episodes she is quite itchy and requires therapy with
No eczema, hay fever, or asthma; no family history
prescription topical agents. Between flares, no spe-
of atopy.
cific therapy except allergen avoidance is necessary.
Current Symptoms: Good general health. Chronic,
Physical Exam: No dermatitis at the time of exam.
low-grade dermatitis despite special precautions.
Chapter 8
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Clinical Studies: 1 or 2⫹ relevant positive patch EXAMPLE 8-7: ALLERGIC CONTACT

test reactions (RPPTRs) to cocamidopropyl betaine DERMATITIS
(CAPB), fragrances, formaldehyde, quaternium-15,
DMDM hydantoin, parabens, paraphenylenediamine,
carba mix, thiuram mix, lanolin, methylchloroiso- History: Construction worker; blistering dermati-
thiazolinone/methylisothiazolinone, para-tert- tis of hands and feet after work with wet concrete.
butyl-phenol formaldehyde resin (PTBFR), and Severe dermatitis twice treated with oral prednisone.
samples of the rubber gloves she wears while Condition improved away from concrete contact
washing dishes. but did not clear completely. Currently, treatment
requires administration of a topical agent on most
Diagnosis: Allergic contact dermatitis to multiple
days and 1 to 2 brief courses of prednisone annually.
allergens.
Current Symptoms: Daily mild, chronic dermatitis
Impairment Rating: Initial rating is in class 1
of both hands, including palms, with approximately
due to mild severity, need for intermittent topi-
1 flare a year that necessitates time off from work.
cal therapy, and mild interference with ADLs.
Must modify performance of a few specific ADLs,
Physical exam is in class 1 due to transitory nature.
such as dishwashing; has significant limitation of
Diagnostic test findings are class 3 due to multiple
ADLs with flares once per year. Handling dry rock
RPPTRs, so rating moves up to 9%.
or concrete usually aggravates dermatitis.
Comment: This patient has had to significantly
Physical Exam: Mild dermatitis of fingers, palms,
curtail performance or have limitations placed on a
and feet.
number of ADLs, such as cleaning the home, groom-
ing, clothing selection, shoe selection, glove use, and Clinical Studies: Patch test: 2⫹ to chromate, princi-
child care, due to the need to avoid a large number pal allergen in cement and leather shoes.
of allergens, as demonstrated by multiple RPPTRs.
Diagnosis: Allergic contact dermatitis to chromate
Major exposures were personal care products such
from occupational cement exposure.
as soap, shampoo, moisturizer, makeup, hair dye,
dishwashing liquid, other cleaning products, and Impairment Rating: 9% impairment of the whole
personal care products used to care for her children, person. This rating begins in class 1 at 5% due to the
such as diaper wipes and baby shampoo. She has requirement for treatment and minimal interference
had to significantly curtail or limit many ADLs that with ADLs. The physical exam findings are in class
would entail use of these products, including bath- 2 due to the involvement of the palmar aspects of the
ing her children, a task that her husband now per- hands. This moves the rating to 7%. The diagnostic
forms as a result of her allergies. Reactions to rubber test findings are in class 2, so the final rating moves
allergens and glues limits her choices of shoes and to 9%. If flares causing modifications of ADLs were
clothing, which consequently limit the activities in more frequent, the examiner could consider an ini-
which she can participate. Some of the above reac- tial rating in class 2. Patch test is rated as possibly
tions are considered to be of possible relevance, such relevant, because chromate is known to be present
as PTBFR, a glue found in shoes. It correlates with in leather and cement, and exposures to these sub-
the foot dermatitis and is known to be in shoes, but stances correlate with the sites of the rash, but no
its presence cannot be confirmed in any of her shoes. testing was done to confirm that the actual cement
Other reactions are of possible relevance, such as the and leather the patient is exposed to contain chro-
quaternium-15, which was confirmed to be present mate. However, since possibly relevant reactions are
in the baby shampoo she was using to bathe her chil- graded as RPPTRs, differentiating between possible,
dren and which therefore correlates with her hand probable, or definite relevance does not affect deter-
dermatitis. She could not be patch tested to the baby mination of impairment ratings.
shampoo, so relevance cannot be called definite. The
reaction to carba mix and to the kitchen glove is
considered definitely relevant, as the manufacturer EXAMPLE 8-8: LATEX ALLERGY AND ECZEMA
of the glove confirmed that carba was present in
the glove and she reacted directly to a sample of
the glove. History: Dental assistant; 18 years’ progressively
worsening chronic hand dermatitis, angioedema of
the face, rhinitis, and asthma; flared with powdered
NRL gloves. Treatment with topical and systemic
Chapter 8
corticosteroids. Has history of eczema; jewelry
Guides6e_08_159-182.indd 170 2/17/09 2:42:18 PM

The Skin 171
allergy. Some lotions, creams, and frequent hand and banana allergy. Determine impairment due to
washing with antibacterial soap aggravate dermatitis. rhinitis and asthma separately and combine with
Nonpowdered NRL gloves cause itching within min- skin impairment rating (see the Combined Values
utes, hives on wrists and forearms. Visited urgent Chart in the Appendix) to determine total impair-
care center for disseminated urticaria, angioedema, ment. All of the patch test reactions are considered
and wheezing. as probably relevant, as the exposures were con-
firmed and correlated with the site of dermatitis,
Current Symptoms: Temporary improvement with
but no patch testing with the actual substances was
hypoallergenic, powder-free NRL gloves. With no
carried out to allow assignment of definite relevance.
NRL exposure, mild hand dermatitis persists; inter-
Probably relevant patch test reactions are considered
mittent fingertip fissuring. Occasional difficulty
to be RPPTRs, so assigning definite relevance would
grasping and holding instruments; occasionally uses
not affect the rating.
topical corticosteroids and hand creams. Asthma
improved but persists despite use of non-NRL gloves
by all office employees.
Physical Exam: Erythema of fingers and wrists with CLASS 2
fine scaling. 11% to 27% Impairment of the Whole Person
Clinical Studies: Patch test: Relevant positive reac-

tions to thiuram mix (rubber chemical accelerators, EXAMPLE 8-9: ATOPIC DERMATITIS
confirmed present in her NRL gloves), glutaraldehyde
(active ingredient in cold sterilizing solution used
at office), and quaternuim-15 (preservative in hand History: Atopic dermatitis was diagnosed at 2 years
lotion used by patient). Latex radioallergosorbent test of age; asthma developed at age 5, and seasonal
(RAST) (Pharmacia CAP): positive (class 3). Prick test: rhinitis, at age 11. Treated with topical, inhaled, and
confirmed allergy to latex, bananas, avocado, house nasal steroids throughout childhood, with good dis-
dust mites, and various molds. After patch testing, ease control. Atopic dermatitis went into remission
avoidance of detected allergens (rubber accelerators, during adolescence, but symptoms returned in his
glutaraldehyde, quaternium-15) resulted in significant late 20s with a rash on antecubital fossae, popliteal
improvement, with continued regular use of moistur- fossae, and hands. Since then, he has had persistent
izers and topical steroids. A plateau was reached where dermatitis on hands, arms, and legs, with flares
symptoms are minimal, and the physical exam reveals lasting 2 to 3 weeks, occurring 1 to 2 times per year,
only mild erythema and scale between fingers and on and requiring short courses of systemic steroids.
dorsal hands. Flares typically occur during allergy season (spring)
and involve most of body. Patient requires daily
Diagnosis: Latex allergy and allergic and irritant
therapy with moisturizers and application of topical
contact hand eczema.
steroids approximately 2 weeks per month.
Current Symptoms: Experiences daytime itching
person. Rating begins in class 1 due to minimal
that is often worse in evenings and interferes with
interference with ADLs after allergen identifica-
sleep 3 to 5 times per week. Exercise makes itching
tion and occasional topical medication use. Physical
and skin symptoms worse, and he is therefore unable
exam findings are in class 2; thus, the rating is raised
to exercise.
to 7%. Diagnostic test findings are in class 3 due to
multiple relevant positive patch tests and a positive Physical Exam: Lichenification of antecubital and
latex prick test. This moves the rating up to the popliteal fossae. Redness and scaling of the interdig-
highest category in class 1, 9% impairment of the ital web spaces and the flexor aspects of the wrists.
whole person.
Clinical Studies: Elevated IgE level at 0.2 mg/L
Comment: This case demonstrates the importance (246 ␮g/L); patch tests negative; skin biopsy
of comprehensive patch testing and of not assigning shows spongiotic dermatitis, consistent with atopic
an impairment rating until MMI has been reached. dermatitis.
The impairment rating would have been significantly
Diagnosis: Atopic dermatitis.
higher if the rating had been determined without
first performing patch testing and having the patient Impairment Rating: 15% impairment of the whole
avoid the detected allergens. She was also referred person. Symptoms are continuously present but
Chapter 8
to an allergist due to worsening rhinitis, asthma, are relatively mild and require only intermittent
Guides6e_08_159-182.indd 171 2/17/09 2:42:19 PM

treatment with prescription topical medications. diagnostic test findings are necessary, so this does
There is mild interference with several ADLs, not affect rating, leading to a final rating of 23%.
including ability to sleep and exercise; therefore, the
Comment: Atopic dermatitis exacerbations precipi-
impairment is initially rated in class 2 at 19%. On
tated by variety of agents. Estimated impairment
exam, less than 10% of the body is involved, hand
based on essentially constant presence of at least
involvement is minimal, and involvement can usually
some of signs and symptoms, but only intermittent
be concealed, so physical exam is class 1, and the
significant interference with ADLs during flares.
rating changes to 15%. Diagnostic test findings are
Need for and complexity of medical treatment also
positive and in the expected range (elevated IgE level
important. If flared a greater percentage of the time,
and skin biopsy showing spongiotic dermatitis), so
over 60%, then initial rating would have been in
diagnostic test findings are class 2 and the impair-
class 3. The IgE level is often checked in patients
ment rating remains at 15%.
with atopic dermatitis but is not necessary and is not
Comment: Additional ratings for asthma and sea- elevated in all cases, so even if it was checked and
sonal rhinitis may be warranted, and if so, would be was normal, it would not affect the rating.
combined with the skin impairment rating (see the
Combined Values Chart in the Appendix) to deter-
mine total impairment.
CLASS 3
EXAMPLE 8-10: ATOPIC DERMATITIS
Subject: 25-year-old man. EXAMPLE 8-11: ATOPIC DERMATITIS
History: Family history of eczema and hay fever; Subject: 50 year-old woman.
personal history of infantile eczema with chronic,
History: Atopic dermatitis beginning in infancy.
intermittent, oozing lesions of face, scalp, neck, and
Required constant therapy with prescription topi-
upper extremities. Persistent lichenified patches in
cal agents during childhood and frequent courses of
antecubital, popliteal, and neck areas during remis-
systemic antibiotics and systemic steroids. Disease
sions. Severe exacerbations during high school; fre-
slowly worsened during adulthood and typically
quency increased during college.
involves most of the body except during aggressive
Current Symptoms: Exacerbations once a month for systemic therapy. Current treatment includes pho-
7 to 10 days; involves shoulders, arms, hands, legs, totherapy in dermatologist’s office 3 times a week,
and trunk. Eczema during exacerbations limits some azathioprine (150 mg/d), nightly soaks in the bath-
ADLs: difficulty sleeping, washing dishes, and con- tub followed by application of heavy emollients or
centrating on complex tasks. Lichenified dermatitis topical steroid ointments, and hydroxyzine (50 mg)
an annoyance but does not significantly limit daily before bed. Has improved significantly with this
activities. Intermittent application of topical steroid regimen. Treatment regimen and need for controlled
creams during relative remissions. Constant topical environment have resulted in patient being able to
steroids, antihistamines, and oatmeal starch baths work only from home.
during flare-ups, which occur monthly. Systemic
Current Symptoms: Continuously itchy and has
steroids once a year induce brief remissions.
moderate difficulty sleeping, even while taking
Physical Exam: Lichenified areas at lateral aspects hydroxyzine before bed. Skin is continuously scaly
of neck and arm, leg creases. Erosions, excoriations, and occasionally painful, especially immediately
erythema, scaling, and crusting of most of the arms after phototherapy sessions. Sweating makes symp-
and legs also present. toms much worse, so she must avoid situations likely
to cause sweating. Must also avoid low humidity
Diagnostic Test Findings: None necessary.
environments. Unable to shave legs due to dermatitis
Diagnosis: Atopic dermatitis. and worsening of itch. Must wear loose-fitting cotton
clothing at all times.
person. Rating begins in class 2 at 19% due to Physical Exam: About one third of the skin of arms
interference with ADLs during flares, which occur and legs is mildly erythematous with moderate scal-
approximately 33% of the time. It increases to 23% ing. There is mild lichenification of the periorbital
due to the class 3 physical exam findings of involve- skin.
Chapter 8
ment of between 20 and 40% of the body. No
Guides6e_08_159-182.indd 172 3/3/09 6:31:09 PM

The Skin 173
Clinical Studies: The IgE level is normal; skin Impairment Rating: 30% impairment due to chemi-
biopsy shows spongiotic dermatitis, consistent with cally induced nail dystrophy. Significant interference
atopic dermatitis. with ADLs is present constantly, leading to initial
assignment of class 3 and a rating of 36%. Physical
Impairment Rating: 33% due to atopic dermatitis.
exam findings are in class 2 due to involvement
Multiple effects on ADLs, including sleep, bathing,
of the hands, and only partial social concealment.
clothing selection, environmental restrictions, exer-
Diagnostic test findings are also in class 2 due to
cise restrictions, employment restrictions, and high
presence of RPPTR, so rating changes to 30%.
BOTC; therefore, initial rating is in class 3 at 36%.
Physical exam shows 20% of skin involved, with Comment: Impairment due to neurologic find-
only mild facial findings, so impairment is rated at ings (paresthesias) could be combined with skin
class 2 and rating declines to 33%. Although test impairment rating (see the Combined Values Chart
findings are positive, as expected, with skin biopsy in the Appendix) to determine total impairment.
showing spongiotic dermatitis, skin biopsy is not Rater should use caution not to double rate the ADL
necessary for the diagnosis and is not useful in gaug- impairment. The AMA Guides Sixth Edition does
ing severity of disease, therefore this does not affect not recommend additional rating for depression,
the rating, which remains at 33%. as the overall effect on ADLs and functioning is
reflected in the history.
Comment: In this case, the high BOTC must be
considered when determining the initial rating:
3 trips per week to dermatologist’s office for
EXAMPLE 8-13: NEURODERMATITIS AND
phototherapy, monthly blood tests to monitor for
OCCUPATIONAL CONTACT DERMATITIS
azathioprine toxicity, 30 minutes to an hour spent
soaking in bathtub and applying topical medications Subject: 45-year-old man.
daily. If more body surface area was involved, could
History: Nurseryman; exposure to many irritant
lead to a higher rating.
pesticides. Six years’ persistent, pruritic dermatitis
involving ankles, forearms, hands, and occasion-
ally face and neck. Recurrent pyogenic infection
EXAMPLE 8-12: NAIL DYSTROPHY
with occasional regional lymph node swelling and
AND ANONYCHIA
tenderness. Dermatitis initially responded to topical
Subject: 40-year-old woman. therapy and irritant avoidance; condition flared up
after re-exposure. Symptoms continued despite job
History: Swelling, redness of eponychial, paronych-
change, avoidance of incriminated agents. No prior
ial areas of all fingers; severe pain, paresthesia after
dermatologic problems. Symptoms are present
repeated use of sculptured artificial nail kit consist-
every day and require use of topical agents and
ing of liquid methylmethacrylate monomer and pow-
systemic medication. Noteworthy: 3-year history
dered methylmethacrylate polymer. Lost nails on all
of headache, memory loss, and anxiety with nausea
10 fingers. Individual observed for several years; no
and vomiting.
fingernail regrowth.25
Current Symptoms: Neurodermatitis (itch-scratch
Current Symptoms: Persistent paresthesia; diffi-
syndrome). Warm environments, sweating, chemical
culty grasping small objects such as coins and diffi-
irritants, and stress provoke severe itching on a daily
culty using many everyday items such as toothbrush,
basis, usually for at least several hours.
hairbrush, controls on stove, and computer keyboard;
cold sensitivity, burning, and tingling. Hand use, in Physical Exam: Weeping, excoriated, lichenified
general, aggravates symptoms. Wears adhesive ban- plaques and patches of eczema of the face, forearms,
dages over petroleum jelly on nail beds; wears gloves and dorsal hands; axillary adenopathy.
most waking hours. Woman anxious and depressed;
Clinical Studies: Patch tests: negative to standard
requires occasional psychiatric consultation.
tray and work chemicals. Bacterial culture of skin
Physical Exam: Exposed and keratinized nail beds; drainage: Staphylococcus aureus, coagulase positive.
paronychial areas swollen and tender.
Diagnosis: Persistent neurodermatitis with impetigi-
Clinical Studies: Patch test: Bullous eruption to nization secondary to occupational irritant contact
2% methylmethacrylate monomer in petrolatum. dermatitis.
Diagnosis: Chemically induced nail dystrophy and Impairment Rating: 33% impairment due to the
Chapter 8
anonychia. skin disorder. The rating begins in class 3 due to the
Guides6e_08_159-182.indd 173 2/17/09 2:42:19 PM

constant symptoms, need for systemic treatment, EXAMPLE 8-15: PSORIASIS WITH
and moderate interference with some ADLs and the PUSTULAR FLARES
need to avoid many situations and environments.
Dermatitis involves approximately 20% of the body
surface, including the face, so physical exam is at History: Initially presented with pretibial erythema-
class 2 and the impairment rating moves from 36% tous, scaly eruption; spread to upper extremities and
to 33%. Although there is currently impetiginization, hand. Pain, swelling, and erythema of knees; sterile
this is a temporary finding and is expected to resolve urethral discharge. Condition improved only with
with appropriate antibiotics, and it therefore does not systemic steroids and cytotoxic agents. Initial pos-
contribute to the rating. Patch testing is not expected sible diagnoses: Reiter’s syndrome, keratoderma
to be positive, as this is a case of irritant dermatitis. blennorrhagica, or pustular psoriasis with psoriatic
Since no diagnostic test findings are expected to be arthritis. Rehospitalized 3 months later with acute,
positive, this is not considered in the rating, and the severely exacerbated skin eruption; severe pain, swell-
final rating is 33%. ing, and deformity of all extremity joints. Over the
ensuing year, failed to respond to monotherapy with
Comment: If a neurologic disorder can be diag-
methotrexate, infliximab, adalimumab, or etanercept.
nosed, the attendant impairment should be combined
Combination therapy with methotrexate and inflix-
with the skin impairment rating (see the Combined
imab partially controls disease for the last 2 years.
Values Chart in the Appendix).
Current Symptoms: Persistent eruption present on
small areas of trunk and extremities. Periodic flare-
EXAMPLE 8-14: THERMAL BURN SCARRING ups of psoriasis require 5- to 7-day hospitalization
1 to 2 times per year, and it takes up to 1 month
to return to baseline disease. Exacerbations with
History: Burns to palms of both hands during indus- generalized pustulation involve 100% of BSA and
trial accident. Required skin grafts to palms of both are associated with fevers, chills, and generalized
hands. malaise. During acute phase of flare-ups it is dif-
ficult to care for himself, stand, sit, walk, or drive,
Current Symptoms: Well-healed grafts; residual
leading to brief hospitalization. At baseline, involved
dryness and cracking, easily injured by minor
skin is itchy and painful, and it is difficult to sit or
trauma, noxious chemicals. Bathes, shampoos
drive for long periods. Skin regularly bleeds, cracks,
with gloves on since water and soap irritate hands.
and flakes, which limits ability to perform activi-
Trouble grasping toothbrush, comb, or writing
ties such as doing laundry and outdoor maintenance
instrument due to cracking, decreased sensation, and
of home.
skin stiffness. Frequent moisturizer prevents worsen-
ing of the symptoms. Physical Exam: Red, scaly plaques with adherent
silvery scale present over 60% of the body. Pitting of
Physical Exam: Dry, somewhat atrophic, and stiff
the nails is noted.
grafts on palms of hands.
Clinical Studies: Biopsy: Extreme thickening of the
Clinical Studies: Basic laboratory findings: normal.
stratum corneum and many neutrophils in the stra-
Diagnosis: Scarring due to thermal burns. tum corneum.
Impairment Rating: 36% impairment of the whole Diagnosis: Psoriasis with pustular flares.
person.
Impairment Rating: 39% impairment due to psoria-
Comment: There is significant impairment of many sis. Disease is present 100% of the time, but severe
ADLs at most times, leading to an initial rating in flares of skin disease are present 1 to 2 months per
class 3 at 36%. Physical exam findings involve the year. If there were no severe flares, one could consider
entire palms of both hands; thus, the class 3 physical class 2, whereas if the disease flared all the time, class
exam finding keeps the rating at 36%. No diagnostic 4 would be appropriate, Therefore, assigned class 3,
test findings are expected, so this does not affect 36%, initially based on presence of regular severe
the rating, leading to a final rating of 36%. Range flares and continued presence of moderate disease
of motion impairments of the hands can be between flares. Necessity for continuous therapy with
taken into account if they do not overlap the multiple systemic agents also contributes to rating in
impairment given for inability to grasp in the skin class 3 rather than class 2. Physical exam findings
impairment. show involvement of 60% of BSA, which supports
Chapter 8
a rating in class 4, which increases rating to 39%.
Guides6e_08_159-182.indd 174 2/17/09 2:42:20 PM

The Skin 175
Biopsy, although consistent with psoriasis, is not nec- CLASS 4

essary for the diagnosis and is not a useful indicator 45% to 58% Impairment of the Whole Person
of disease severity, so diagnostic test findings do not
contribute to the rating, which remains at 39%.
EXAMPLE 8-17: FOLLICULAR
Comment: Radiologic findings and joint symptoms OCCLUSIVE TRIAD
and signs should be considered and rated separately
from skin disease and combined with skin rating
(see the Combined Values Chart in the Appendix) to History: A 12-year history of acne vulgaris,
determine whole person impairment. hidradenitis suppurativa, and dissecting cellulitis
of the scalp (follicular occlusive triad). Temporary
improvement with topical and systemic antibiotics,
EXAMPLE 8-16: SKIN CANCER intralesional corticosteroids, aspiration, marsupial-
ization, zinc sulfate, and 2 courses of isotretinoin.
Over last 5 years, large cystic lesions developed,
History: Laborer; noted to have multiple basal mainly involving posterior scalp, face, neck, upper
cell carcinomas since age 15 years involving both part of the trunk, axilla, and inguinal area.
exposed and covered body areas. History of cardiac
Current Symptoms: Lesions accompanied by fever
fibromas.
and aching joints. Large lesions on back, chest, and
Current Symptoms: Multiple weeping, oozing, scalp and in the inguinal area make resting difficult
ulcerated lesions on trunk present at all times; reclu- in warm weather. Clothing and sweating aggravate
sive behavior because of inability to go into the sun. disorder. Due to severe axillary and groin pain when
Need for continuous surgical removal of skin tumors, moving arms and legs, he has severe difficulty with
continuous application of antibiotic ointments, and many household and personal care activities. Due
application of dressings to ulcerated skin cancers. to pain and exudate from abscesses, he is unable
to participate in some social and recreational
Physical Exam: More than 50 nodular and ulcerated
activities.
dome-shaped tumors of face and trunk with serosan-
guineous foul-smelling drainage; some tumors larger Physical Exam: Inflamed cystic lesions located on
than 5 cm in diameter. Palmar and plantar pits and posterior scalp, face, neck, upper trunk, axilla, and
facial milia. inguinal area. Skin severely scarred.
Clinical Studies: Skin biopsies: basal cell carci- Clinical Studies: White blood cell (WBC) count is
noma. Radiographs: macrocephaly, hypertelorism, between 18 and 22.0 ⫻ 109 L (18 to 22.0 ⫻ 103/␮L)
frontal bossing, odontogenic keratocysts of the jaws, on multiple lab tests.
calcification of the falx cerebri, and bifid ribs.
Diagnosis: Acne conglobata; hidradenitis suppu-
Diagnosis: Basal cell nevus syndrome with multiple rativa; dissecting cellulitis of the scalp; severe scar
basal cell carcinomas. formation.
Impairment Rating: 42% impairment of the whole Impairment Rating: 48% impairment of the whole
person. person.
Comment: Although there is a lack of pain and only Comment: Many ADLs affected constantly.
a moderate level of interference with physical abil- Requires frequent systemic medications. These fac-
ity ADLs, the BOTC, due to dressings and frequent tors lead to initial rating in class 4 at 51%. Physical
surgeries, is extremely high and affects ability to exam findings involve 20% to 40% of the body, and
perform ADLs, as does need to avoid sun. Initial the odor and exudate are sometimes difficult to con-
rating, therefore, is in class 3. Thus, the rating begins ceal, leading to a rating in class 3, which changes
at 36%. Physical exam findings are in class 4, as the impairment rating to 48%. Repeated elevated
over 40% of the body has at least minimal involve- WBC count is an unexpected finding and indicates
ment or residual scarring and the findings cannot severe disease, so diagnostic test findings are in
be concealed; the rating therefore increases to 39%. class 4, leading to a final rating of 48%. Radical
Multiple diagnostic test findings are positive (many excision of affected areas might lead to improve-
skin biopsies, radiographs), and diagnostic test find- ment. If this happened, would be appropriate to
ings are therefore rated class 4, and the final rating reconsider rating.
is 42%. If metastatic disease develops, rating would
Chapter 8
automatically increase to 58%.
Guides6e_08_159-182.indd 175 2/17/09 2:42:20 PM

EXAMPLE 8-18: PEMPHIGUS VULGARIS Current Symptoms: Unable to work with heavy
equipment. Skin fragile, dried, and cracked. Hot,
dizzy, and unable to perspire in warm environ-
History: Persistently sore mouth for 22 months. ments. Marked difficulty with writing, walking, and
Vesicles and bullae over face, trunk, and extremities. nonspecific hand activities due to stiff, shiny skin.
High doses of oral corticosteroids administered to Scar formation causes pain and decreased range of
control disease. motion. Feels disfigured. Greatly limited ability to
participate in group activities. No sexual relations
Current Symptoms: Persistent blisters and erosions
after injury; short of breath with physical activity.
result in chronic, unremitting pain on swallowing
or speaking. Erosions and skin fragility involving Physical Exam: Healed atrophic scars over 85%
mouth, trunk, and genital area; unable to have sexual of body; minimally atrophic skin grafts and donor
intercourse, eat solid foods, brush teeth, speak above sites. Several depigmented areas, including some on
a whisper, or sleep well. Azathioprine therapy added cheeks and backs of hands. Partial destruction of
to high-dose corticosteroids; limited disease control. left ear; distorted fingernails. Diminished range of
Complex therapy requires frequent physician visits motion of both hands.
for checkups and laboratory monitoring.
Clinical Studies: Basic laboratory findings: normal.
Physical Exam: Many eroded lesions of tongue
Diagnosis: Extensive scarring due to thermal burns
and oral mucous membranes; lesions over trunk and
and dyspnea.
extremities. Infected bullae of mouth and trunk.
Clinical Studies: White blood cell count: leuko-
person.
penia (secondary to therapy). Biopsy: pemphigus
vulgaris with positive immunofluorescence and high Comment: Continuous, severe interference with
titers of desmoglein antibodies. ADLs is present, leading to initial rating in class 4
at 51%. Also, 85% BSA involved, including several
Diagnosis: Pemphigus vulgaris.
facial and hand areas. Physical exam rating is in
Impairment Rating: 51% impairment of the whole class 4, but severity of involvement leads to increase
person. of rating to highest level, 58%. Diagnostic test find-
ings are not expected or necessary, so no effect on
Comment: Severe interference with most ADLs due
rating from diagnostic test findings, leading to final
to lesions and pemphigus pain, despite continuous
rating of 58%. Combine the skin (burn) impair-
systemic therapy. These factors lead to initial assign-
ment with impairments due to musculoskeletal and
ment of class 4 and a rating of 51%. More than 40% of
pulmonary dysfunction (see the Combined Values
the BSA is involved, so physical exam is also in class
Chart in the Appendix) to determine whole person
4, but severity of oral involvement argues for increase
impairment.
to 54%. Positive skin biopsy and immunofluorescence
are expected. High titer of desmoglein antibodies
despite therapy is unexpected and indicates severe dis-
EXAMPLE 8-20: MYCOSIS FUNGOIDES
ease, so diagnostic test findings are class 3 and final
rating is 51%. Laboratory findings of leukopenia are Subject: 56-year-old man.
rated separately in the hematology chapter (Chapter 9)
History: Over 20 years, progressive pruritic rash;
and combined using the Combined Values Chart (see
pruritic patches on back and extremities. Topical
Appendix). Experimental new therapeutic modalities,
therapy; eruption gradually generalized. Treated
such as rituximab or intravenous immunoglobulin
with topical nitrogen mustard, PUVA, photophoresis,
(IVIG), could lead to improvement in condition. If
and electron beam therapy. Eruption uncontrolled
this occurred, reassessment of impairment would be
with cytotoxic agent or radiation therapy.
appropriate.
Current Symptoms: Confined to home; unable to
care for himself, walk, travel, grasp, or participate in
EXAMPLE 8-19: THERMAL BURN SCARRING sexual activity.
AND DYSPNEA
Physical Exam: Diffuse, erythematous, scaly
Subject: 25-year-old man. plaques; some quite firm. Many trunk and extrem-
ity excoriations; foul-smelling and draining nodular
History: Three years ago suffered severe burns over
tumors on face, palms, and soles. Palpable axillary
Chapter 8
85% of total BSA and smoke inhalation; some skin

and inguinal lymph nodes.
grafts.
Guides6e_08_159-182.indd 176 2/17/09 2:42:21 PM

The Skin 177
Clinical Studies: Biopsy: skin, lymph node positive EXAMPLE 8-22: EPIDERMOLYSIS
for mycosis fungoides. Other lab findings: normal. BULLOSA DYSTROPHICA
Diagnosis: Mycosis fungoides. Subject: 19-year-old man.

Impairment Rating: 100% impairment of the whole History: Bullous lesions and open wounds devel-
person. oped shortly after birth and have been continuously
present since then, despite extreme lifestyle altera-
Comment: Mycosis fungoides is a form of lym-
tions designed to minimize cutaneous trauma. Bullae
phoma, and as per the rating table, any malignancy
appeared after slightest trauma; healed with severe
(other than basal cell carcinoma) that is not in remis-
scarring and milia. Fingers and toes have fused into
sion automatically qualifies for 58% impairment. The
mitten and sock deformities. Several operations to
58% skin impairment would be combined with other
release fingers have been of only temporary benefit,
system impairments. However, this patient has termi-
and patient currently has no use of hands.
nal disease at this point and is undergoing palliative
therapy only, therefore, the rating goes to 100%. Current Symptoms: Requires continuous assis-
tance, as he is unable to perform any ADLs.
Physical Exam: Fingers are fused, tapered stumps
EXAMPLE 8-21: XERODERMA PIGMENTOSUM
(mitten deformities for hands). Constant bullae in
Subject: 18-year-old woman. mouth and pharynx; probably extended to epiglottis.
Over half of body involved with erosions and
History: Photophobia for 13 years. At 5 years of
scarring, requiring extensive bandaging 100% of
age, marked pigmentation of sun-exposed areas of
the time. Weight 40% below desirable for height.
face, chest, arms, and legs. Since then, generalized
freckling of skin, several areas of telangiectasia, and Clinical Studies: Roentgenography: esophageal
multiple basal cell carcinomas and multiple SCCs stricture. Complete blood cell count: Iron deficiency
(squamous cell carcinomas) that are appearing and anemia and anemia of chronic disease. Albumin
growing too rapidly to allow curative therapy. level: 26 g/L (2.6 g/dL). Wound cultures yielded
methicillin-resistant Staphylococcus aureus (MRSA)
Current Symptoms: Condition progressing in
that is sensitive to clindamycin and trimethoprim-
severity; continuous observation and treatment.
sulfamethoxazole. Prior skin biopsy showed
Confined to home for past year.
subepidermal split.
Physical Exam: Multiple large, nodular, ulcerated
Diagnosis: Epidermolysis bullosa dystrophica.
tumors in all sun exposed areas. Some keratinized,
some black. Extreme freckling, scaling, and skin Impairment Rating: 58% impairment due to
fragility in all sun exposed skin that is not involved epidermolysis bullosa dystrophica.
with tumor. Face is the worst area, exposed arms
Comment: This autosomal recessive disorder is
also involved.
one of the most impairing of all hereditary diseases;
Clinical Studies: Basic lab findings: normal. impairment approaches 100% and death. In this
Fecal, urinary porphyrin studies: negative. Multiple case, due to extreme interference with ADLs, initial
biopsies and excisions showing basal cell carcinoma, rating is class 4 at 51%. Extreme nature of physical
SCC, and melanoma. findings leads to increase of rating to 54%. Multiple
diagnostic test findings, including skin biopsy,
Diagnosis: Xeroderma pigmentosum.
iron deficiency, anemia of chronic disease, low
Impairment Rating: 100% impairment of the whole albumin level, and positive wound cultures lead to
person. class 4 rating and a final rating of 58% for this skin
disease. Combine with impairment estimates for
Comment: Has active SCC that is not curable, and
esophageal stricture, anemia, and any other related
as per the rating table, any malignancy (other than
musculoskeletal and internal medicine impairments
basal cell carcinoma) that is not in remission would
(see the Combined Values Chart in the Appendix) to
automatically qualify for a rating of 58%. However,
determine whole person impairment.
this patient has terminal disease and would therefore
be rated at 100%.
Chapter 8
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8.8 Skin Impairment

Evaluation Summary
assessment of permanent impairment due to skin
disorders.
TA B L E 8 -3
Skin Impairment Evaluation Summary
Disorder History, Including Selected Examination Record Assessment of Skin Function
Relevant Symptoms
General1 Duration, location; itch, Detailed skin exam: location, Biopsy
redness, welts, eczema, symmetry, demarcation
Cultures; microscopic scrapings
blisters, pimples; nail or
Extent, pattern of involvement, (KOH test, etc)
pigment change; hair loss;
% of body surface involved
ulcers, scars, growth, grafts Allergy tests (patch, prick,
Sun-exposed or covered area RAST, etc)
Progression, remission,
involvement, infection, cellulitis,
exacerbation, % of time Specialty consult as
acute/chronic dermatitis, welts;
present appropriate
pigment, hair, or nail changes;
Treatment history, response to scar, grafts, growths
treatment
Comprehensive physical exam as
Work history, hobbies, etc appropriate
Associated conditions: atopy,
eczema, asthma, rhinitis
Impact on activities of daily
living (ADLs)
Urticaria Acute; chronic Extent; duration (⬎48–72 hours?) Laboratory studies as appro-
priate and directed by
Duration; frequency; loca- Location, distribution
history and physical (may not
tion; progression, % of days
be necessary)
present
Biopsy if individual hives
Identifiable cause? (food,
present ⬎24 hours
infection, allergy, medication,
systemic disease, physical Complement profile if angio-
agent, familial, etc) edema or vasculitis; rheuma-
tology evaluation if vasculitis
Response to antihistamines,
on biopsy
sedation from antihistamines
affect on ADLs (automo- Allergy tests (RAST, open
bile/machinery operation prick, etc) (usually negative in
specifically) chronic urticaria)
Complete review of systems
focusing on possible localized
infections
Dermatitis15, 26–29 Duration, location, itch, red- Papules; papulovesicles; Clinical presentation and
ness, nail or pigment change erythema; serous discharge; history
crusting; edema; scale; lichenified
Episodes of superimposed Biopsy (may not be necessary);
or thickened plaques
infection cultures (may not be neces-
% of skin surface involved; hand, sary); patch testing (only
Progression and remission fac-
foot, face involvement positive in allergic contact
tors, response to therapy, side
dermatitis)
effects from therapy
Atopy; childhood eczema
Effects on work, hobbies, etc
Pigmentary Increased, decreased pigment Local, disseminated; extent, Labs as appropriate (may not
Changes pattern; Wood’s light exam be necessary)
Congenital; acquired;
dermatomal See general skin disorders Biopsy (may not be necessary)
Duration; location; Scrapings for KOH (may not be
progression necessary)
Chapter 8
Preceding dermatosis See general skin disorders
Guides6e_08_159-182.indd 178 2/17/09 2:42:22 PM

The Skin 179
End-Organ or System Damage Diagnosis Degree of Impairment
Includes assessment of other organs: Record all pertinent diagnoses, Criteria outlined in chapter
sinuses, respiratory, systemic compo- medical status, and further
Description of clinical findings and how these
nents to skin disease treatment plans
relate to Guides’ criteria
Includes assessment of skin damage Prognosis
Explanation of each estimated impairment
or sequelae (susceptibility to contact
Impact on ADLs
irritants, contact allergens, scars, List all impairment percentages; estimate
pigmentation, alopecia, etc) Date of MMI; list whole person impairment percentage (see
accommodations Table 8-2)
Mucosal angioedema; rhinitis; Acute or chronic urticaria; See Table 8-2

asthma; anaphylaxis recurring urticaria; angioedema
Exfoliative erythroderma; atopy; Atopic See general skin disorders, Table 8-2
rhinitis; asthma
Allergic contact, irritant contact
Acute, subacute, chronic
Urticaria, photosensitivity,
seborrheic, exfoliative, stasis,
hand and foot, nummular
Systemic changes; deafness; visual Vitiligo, postinflammatory, See Section 8.2, Disfigurement, and Table 8-2
acuity, neurologic disorders, skin hyper-hypopigmentation;
malignancy susceptibility to sunburn chemical; scars
Chapter 8
Guides6e_08_159-182.indd 179 2/17/09 2:42:22 PM

TA B L E 8 -3
Skin Impairment Evaluation Summary (con’t)
Disorder History, Including Selected Examination Record Assessment of Skin Function
Relevant Symptoms
Pigmentary Causes: vitiligo, inflammation,
Changes chemical contact, occupation,
cont. infection, physical, metabolic,
endocrine, drugs, neoplasm,
etc
Effects on ADLs
Scars Causes: Burns; trauma; sur- Detail scar dimensions, shape, If skin graft or large scar, note
gery; family history (Ehlers- location, nature; any ulceration, presence or absence of sweat,
Danlos, keloids); other causes depression, or evaluation sensation, and hair growth
Neoplasm; ulcer; dermatitis
Psoriasis30–33 Family history; age at onset; Extent and location of involve- Usually not necessary
presence of arthritis, joints ment; type of lesion (plaque,
involved pustular, etc)
Type: Plaque; guttate; Extent of involvement (% body
erythrodermic; pustular; surface area [BSA] involved)
palmoplantar
Frequency of flares
Treatment history, response to
treatment,
Side effects from treatment
(Liver damage, kidney
damage, skin cancer)
Bullous Disorders Congenital; acquired Localized; generalized (% BSA Biopsy (routine, immunofluo-
involved) rescence); serologic studies
Treatment history, response to
(immunofluorescent
treatment, Vesicles; bullae; erosions; oral
antibodies), culture;
involvement; hand changes;
Treatment side effects nutritional assessment
neoplasms
(osteoporosis/fractures,
diabetes, infection, obesity)
Duration; extent; location;
mucosal
Family history
Pruritus; hand changes;
neoplasm
Chapter 8
Guides6e_08_159-182.indd 180 2/17/09 2:42:23 PM

The Skin 181
End-Organ or System Damage Diagnosis Degree of Impairment
None usually necessary Scar; hypertrophic scar; keloid See Table 8-2
graft
Biopsy if suspect neoplasm
Consider rheumatology consult if Psoriasis vulgaris; pustular; See general skin exam and Table 8-2
arthritis is present exfoliative
Consider psychologic effects, consider
referral
Consider X ray if arthritis is present
Consider CBC and calcium level if
pustular psoriasis
Neoplasm; esophageal; neurologic; Impetigo; contact dermatitis; See general skin exam and Table 8-2
mental, behavioral; ophthalmologic insect bites; pemphigoid;
(conjunctival, symblepharon) pemphigus; dermatitis
herpetiformis; epidermolysis;
bullosa (congenital, acquired);
linear IgA disease
Chapter 8
Guides6e_08_159-182.indd 181 2/17/09 2:42:23 PM

18. Kadyk DL, McCarter K, Achen F, Belsito DV. Quality

References of life in patients with allergic contact dermatitis. J Am
Acad Dermatol. 2003;49(6):1037–1048.
1. Freedberg IM, Eisen AZ, Wolff K, Austen KF, 19. Sajjachareonpong P, Cahill J, Keegel T, Saunders
Goldsmith LA, Katz S. Fitzpatrick’s Dermatology H, Nixon R. Persistent post-occupational dermatitis.
in General Medicine. New York, NY: McGraw-Hill Contact Dermatitis. 2004;51(5–6):278–283.
Professional; 2003.
20. Preventing Allergic Reaction to Natural Rubber Latex
2. Finlay AY, Khan GK. Dermatology Life Quality Index in the Workplace. Cincinnati, Ohio: National Institute
(DLQI)—a simple practical measure for routine clinical for Occupational Safety and Health; 1997. Publication
use. Clin Exp Dermatol. 1994;19(3):210–216. 97–135.
3. Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski 21. Tarlo SM, Sussman GL, Holness DL. Latex sensitivity
SJ. Skindex, a quality-of-life measure for patients with in dental students and staff: a cross-sectional study. J
skin disease: reliability, validity, and responsiveness. Allergy Clin Immunol. 1997;99:396–401.
J Invest Dermatol. 1996;107(5):707–713.
22. Taylor JS, Wattanakrai P, Charous BL, Ownby DR.
4. Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, Year Book focus: latex allergy. In: Thiers BH, Lang PG,
Taieb A. Clinical validation and guidelines for the eds. 1999 Year Book of Dermatology and Dermatologic
SCORAD index: consensus report of the European Surgery. St Louis, Mo: Mosby, St Louis University
Task Force on Atopic Dermatitis. Dermatology. Press; 1999:1–44.
1997;195(1):10–19.
23. Fink JN, ed. Latex allergy. Immunol Allergy Clin North
5. Jemec GB, Wulf HC. The applicability of clinical Am. 1995;15:1–179.
scoring systems: SCORAD and PASI in psoriasis
24. DeGroot H, DeJong N, Duijoter E, VanWyk RG, et al.
and atopic dermatitis. Acta Derm Venereol.
Prevalence of natural rubber latex allergy (Type I and
1997;77(5):392–393.
Type IV) in laboratory workers in the Netherlands.
6. Rietschel RL, Fowler JF, Fisher AA. Fisher’s Contact Contact Dermatitis. 1993;38:159–163.
Dermatitis. Philadelphia, Pa: Lippincott Williams &
25. Fisher AA. Permanent loss of fingernails from
Wilkins; 2001.
sensitization and reaction to acrylics in a preparation
7. Adams RM. Occupational Skin Disease. 3rd ed. designed to make artificial nails. J Dermatol Surg
Philadelphia, Pa: WB Saunders Co; 1999. Oncol. 1980;6:70–71.
8. Taylor JS, ed. Occupational dermatoses. Dermatol Clin 26. Zuberbier T, Orlow SJ, Paller AS, et al. Patient
North Am. 1994;12:461–600. perspectives on the management of atopic dermatitis.
J Allergy Clin Immunol. 2006;118(1):226–232.
9. Sherertz EF, Storrs FJ. Occupational contact dermatitis.
In: Rosenstock L, Cullen M, eds. Textbook of 27. Holm EA, Wulf HC, Stegmann H, Jemec GB. Life
Clinical Occupational and Environmental Medicine. quality assessment among patients with atopic eczema.
Philadelphia, Pa: WB Saunders Co; 1994. Br J Dermatol. 2006;154(4):719–725.
10. Nethercott JR, Gallant C. Disability due to occupational 28. Holm EA, Esmann S, Jemec GB. The handicap caused
contact dermatitis. Occup Med. 1986;1:199–204. by atopic dermatitis—sick leave and job avoidance.
J Eur Acad Dermatol Venereol. 2006;20(3):255–259.
11. Hogan DJ, Dannaker CJ, Maibach HI. The prognosis
of contact dermatitis. J Am Acad Dermatol. 29. Fowler JF, Ghosh A, Sung J, et al. Impact of chronic
1990;23:300–307. hand dermatitis on quality of life, work productivity,
activity impairment, and medical costs. J Am Acad
12. Wigger-Alberti W, Elsner P. Preventive measures in
Dermatol. 2006;54(3):448–457.
contact dermatitis. Clin Dermatol. 1997;15:661–665.
30. Gelfand JM, Feldman SR, Stern RS, Thomas J,
13. Drake L, Dorner W, Goltz RW, et al. Guidelines of
Rolstad T, Margolis DJ. Determinants of quality of
care for contact dermatitis. J Am Acad Dermatol.
life in patients with psoriasis: a study from the US
1995;32:109–113.
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14. Skoet R, Zachariae R, Agner T. Contact dermatitis
31. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr,
and quality of life: a structured review of the literature.
Reboussin DM. Psoriasis causes as much disability as
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other major medical diseases. J Am Acad Dermatol.
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Johansen JD, Agner T. Prognosis of occupational
32. Pettey AA, Balkrishnan R, Rapp SR, Fleischer AB,
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Chapter 8
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Chapter 9
CHAPTER 9
The Hematopoietic System
9.2 Anemia
9.3 Myeloproliferative Disorders, including

Polycythemia, Myelofibrosis, and Essential
Thrombocytosis
9.4 White Blood Cell Diseases or Abnormalities
9.5 Hemorrhagic and Platelet Disorders
9.6 Thrombotic Disorders

Introduction
due to Lymphoma and Metastatic Disease
nent impairment of the hematopoietic system. The
hematopoietic system, including the bone marrow,
9.8 Hematologic Impairment Evaluation
lymph nodes, and spleen, produces a heterogeneous
Summary
population of blood-circulating cells (eg, red blood
cells, white blood cells, and platelets) and a complex
family of proteins critical for blood clotting and
immune defenses. Cells from this system also pro-
duce proteins that affect daily physiologic responses
(eg, granulocyte stimulating factors and granulocyte-
macrophage stimulating factors) and respond to
many pathologic stimuli (eg, by producing tumor
necrosis factor and interleukins). Because the hema-
topoietic system supports other cells or organs of
the body, identifiable defects in these organs due to
hematologic disease are assigned impairment ratings
directly; the hematologic rating does not generally
include the physiologic effects of hematologic dis-
ease or cancer on the function of other end-organs.
For example, very severe anemia can reduce oxygen
delivery to the point where the individual suffers
a myocardial infarction. The impairment ratings
183
Guides6e_09_183-212.indd 183 2/17/09 2:42:45 PM

Chapter 9
for both the anemia and the myocardial infarction Status Scale1 and the Eastern Cooperative Oncology
would be rated separately and then combined. Age Group Performance Status Scale2 (ECOG-PSS). It
and comorbid conditions further complicate the would appear logical to use these scales rather than
determination of impairment. Most of the products the generic scale; they are used as part of the basis
of the hematopoietic system also include remarkable for rating the leukemias, metastatic disease, and HIV
compensatory biologic mechanisms. infection. Both are described in this chapter, with
guidelines provided for their use.
Clinical alterations can be hereditary or acquired.
Because of functional adaptation of the young, Another significant change in this chapter is with
hereditary defects manifested in childhood are com- regard to the ratings used for each class. The model
monly modest in degree of impairment. With age, described in Chapter 1 of the Guides is used, with
alterations become more significant and functional a key factor driving the impairment class assign-
impairment more evident. Abnormalities can be ment and the other factors determining at what grade
quantitative—production of too many cells (ie, leu- (percentage) the rating falls in a particular class. The
kemia or polycythemia) or too few cells (ie, anemia ratings for all classes, especially class 4, have been
or thrombocytopenia)—or they can be qualitative, decreased, as once one moves to higher levels of
with production of a defective protein (ie, factor impairment, there is inevitably involvement of other
V Leiden or prothrombin 20210A) resulting in an organ systems or other hematologic processes. These
increased propensity for thrombosis. should be identified, rated, and combined with the
hematology-oncology impairment rating. The Burden
The new hematopoietic chapter in the Sixth Edition
of Treatment Compliance, as discussed in Section
of the Guides differs significantly from the hema-
9.1c, contributes further to the impairment rating.
tology chapter in the Fifth Edition. There are new
tables for use in rating leukemia and lymphoma, The differences in clinical implications regarding
metastatic disease, neutropenia, thrombocytopenia, movement from one class to another are large. The
and bleeding disorders. There are also expanded difference in the choices for ratings in classes 3 and
sections on human immunodeficiency virus (HIV) 4 as opposed to lower classes reflects the difference
and thrombotic disorders, as well as an overall revi- between having signs and symptoms that are gener-
sion of tables to comply with the format described ally controlled by treatment versus those that are
in Chapter 1. As with other chapters, the goal is to uncontrolled by treatment. As hematologic and onco-
provide tools that enable evaluators to more accu- logic diseases are systemic in their manifestations,
rately and consistently choose an impairment per- uncontrolled disease is highly significant clinically
centage that reflects the unique characteristics of the and warrants the high levels of impairment seen in
disease process rated. This has led to an increased these classes.
emphasis on combining ratings to reflect the impact
of hematologic or oncologic disease on myelogenous
elements rather than implicitly incorporating these
effects in the initial rating, as well as to an increased 9.1 Principles of Assessment
emphasis on explicit use of functional scales in the
ratings for HIV and cancer. Before using the information in this chapter, the
The class ratings for some of the processes consid-
ered reflect factors that have an impact on the abil-
ity of the individual with that disease to perform
Activities of Daily Living (ADLs); no separate
functional scale is used for these. On the other hand,
by many specialties in impairment evaluation.
there is a wide variation in the ability of patients
with HIV, leukemias, lymphoma, or metastatic dis-
ease to maintain ADLs, which is to a large extent
Some impairment classes refer to symptoms that
dependent on their ability to tolerate medications
limit the ability to perform daily activities. When
or chemotherapy. The use of a functional scale is
this information is subjective and open to misinter-
consequently a component of the rating for these
pretation, it should not serve as the sole criterion on
diseases. Although the Fifth Edition used a generic
which decisions about impairment are made. Rather,
functional scale, there are 2 scales commonly used
the examiner should obtain objective data about the
in oncology and for the classification of impairment
extent of the limitations and integrate those findings
due to HIV disease, the Karnofsky Performance
Guides6e_09_183-212.indd 184 2/17/09 2:42:46 PM

Chapter 9
with the subjective data to estimate the degree of TA B L E 9 -2
permanent impairment. Eastern Cooperative Oncology Group
Performance Status Scale (ECOG-PSS)
Impairment percentages may reflect severity
of symptoms, physical and laboratory findings, Class 0 (none) Fully active; able to carry on all
predisease performance without
and estimated functional limitations resulting restriction (Karnofsky 90% to 100%)
from hematologic abnormality. The Karnofsky
Class 1 (mild) Restricted in physically strenuous
Performance Status Scale has 10 different categories activity but ambulatory and able to
for patients and is widely used to describe the func- carry out work of a light or seden-
tional ramifications of both oncologic disease and tary nature; eg, light housework,
office work (Karnofsky 70% to 80%)
acquired immunodeficiency syndrome (AIDS; Table
9-1). The ECOG-PSS is also used widely to classify Class 2 (moderate) Ambulatory and capable of all
self-care but unable to carry out
functional deficits as related to oncologic disease, it any work activities; up and about
refers to the Karnofsky scores when assigning func- more than 50% of waking hours
tional grades, and assigns patients into functional (Karnofsky 50% to 60%)
classes ranging from grade 0 to grade 4 (Table 9-2). Class 3 (severe) Capable of only limited self-care;
As the use of 5 grades in the ECOG-PSS is con- confined to bed or chair more than
sistent with the general structure of the grids used 50% of waking hours (Karnofsky
30% to 40%)
for impairment ratings, it will be used explicitly for
Class 4 (extreme) Completely disabled; cannot carry
the functional classification of patients with AIDS
out any self-care; totally confined to
and oncologic disease, and as one of the implicit bed or chair (Karnofsky 10% to 20%)
criteria for assessing the functional impact of hema- Source: Comis R, Oken MM, Creech RH, et al. Toxicity and
tologic disease. In general, the class structure used Response Criteria of the Eastern Cooperative Oncology Group.
in impairment ratings for specific disease processes Am J Clin Oncol. 1982;5:649–655.
will follow that used in the ECOG-PSS. Activities of

daily living are listed in Table 1-1 and the Glossary.
include a complete blood cell count, examination of
9.1b Description of Procedures
peripheral blood smear, bone marrow aspiration and
Aids to diagnose hematologic impairment vary
biopsy, hemoglobin electrophoresis, direct and indi-
depending on the suspected diagnosis. Common tests
rect antiglobulin test and cold agglutinin assay, flow
cytometry, cytogenetics of peripheral blood and/or
TA B L E 9 -1
bone marrow, immunochemical analysis of immuno-
Karnofsky Performance Status Scale Definitions globulins, fat pad biopsy with Congo red stain, and
Rating (%) Criteria
hemostasis studies.
100 Normal; no complaints; no evidence of disease
90 Able to carry on normal activity; minor signs or 9.1c Burden of Treatment
symptoms of disease Compliance (BOTC)
80 Normal activity with effort; some signs or While treatment for hematologic and oncologic
symptoms of disease disease often leads to a diminution of symptoms
70 Cares for self; unable to carry on normal and/or signs of disease, side effects (both local and
activity or to do active work
systemic) can be considerable. Part of this Burden of
60 Requires occasional assistance, but is able to Treatment Compliance is reflected in the impairment
care for most of his personal needs
ratings given for the disease process; however, there
50 Requires considerable assistance and frequent is widespread variation between patients with regard
medical care
to the need for medications, procedures, or treat-
40 Disabled; requires special care and assistance ments such as corticosteroids, anticoagulant therapy,
30 Severely disabled; hospital admission is transfusions, hemophoresis, and both oral and intra-
indicated, although death not imminent venous chemotherapy. Table 9-3 is to be used to
20 Very sick; hospital admission necessary; active assign additional impairment percentage points to
supportive treatment necessary reflect the BOTC for hematologic disease. A sum-
10 Moribund; fatal processes progressing rapidly mary of rules for assigning impairment percentages
0 Dead for BOTC is given in Table 9-3.
Source: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Anticoagulant therapy can completely control signs
Textbook of Palliative Medicine. New York, NY: Oxford
University Press. 1993;109. or symptoms of disease yet clearly carries some
Guides6e_09_183-212.indd 185 2/17/09 2:42:46 PM

Chapter 9
TA B L E 9 -3 would be reserved for situations in which the che-

Burden of Treatment Compliance motherapy leads to systemic effects that have a clear
Intervention % Impairment impact on the ability to perform ADLs. Intravenous
Chronic anticoagulant therapy 5%
chemotherapy is more complex. While the functional
impact of medication intolerance or side effects
Chronic oral corticosteroids Up to 3%
(discretionary) will be reflected by the ECOG-PSS or Karnofsky
Scale, additional impairment develops when patients
Chronic other immunosuppressant Up to 3%
therapy (discretionary) must receive multiple cycles of chemotherapy over
a relatively short period (as frequently as weekly),
Iron chelation or other systemic therapy Up to 3%
especially if multiple agents are employed. The
Chronic oral chemotherapy Up to 5%
(discretionary)
evaluator is encouraged to defer rating those diseases
that will require only limited courses of chemo-
Intravenous chemotherapy: per cycle 1%
given over the prior 6 months a
therapy to induce remission, as it is preferable to
wait until Maximum Medical Improvement (MMI)
Radiotherapy: per week given over the 1%
prior 6 months a has been reached. Some conditions will require
repeated cycles of chemotherapy; there are also situ-
Transfusions: per unit per month 1%
ations when a rating must be done as a consequence
Phlebotomy: per treatment per month 1%
of other conditions (eg, a musculoskeletal injury
Aphoresis: per treatment per month 3% sustained at work) regardless of whether the patient
Bone marrow transplant 10% has reached MMI with regard to the management
a
Up to a total of 6% of other conditions. Under these circumstances, the
evaluator can add discretionary additional impair-
ment percentages of 1% for each cycle of chemo-
degree of risk. Although in prior editions of the
therapy, up to a maximum of 6%, to reflect the effect
Guides an additional 10% impairment rating could
of chemotherapy on ADLs, with the total additional
be given to patients who are controlling signs or
impairment equal to the number of cycles of chemo-
symptoms of their disease with anticoagulant ther-
therapy provided during the 6-month period before
apy, a rating of 5% would seem more appropriate.
the rating. The same concept is also applicable to
An impairment rating of 10% is applied to individu-
patients receiving regular radiotherapy to control
als who have had a bone marrow transplant.
signs and symptoms of disease, although in this case
The long-term use of corticosteroids can be associated the additional impairment will be 1% per week of
with ratable entities such as osteoporosis, avascular radiotherapy during the prior 6 months.
necrosis, diabetes mellitus, and Cushing’s disease;
Lastly, the need for transfusions, phlebotomy, or
however, other effects are not easily rated but impose
aphoresis on a regular basis has an impact on the
some degree of impairment. To the extent that these
ability to sustain ADLs, at least intermittently.
are deemed present and not captured by the rating
As there is wide variation in the degree to which
for any organ system or systems, the evaluator is
patients with a given diagnosis will require these
permitted to add up to 3% additional impairment. As
interventions, the impairment ratings provided in
there is a great deal of variation in the severity and
the tables in this chapter do not include the addi-
degree of side effects from steroids, the rationale for
tional impairment that results from their use. When
assigning additional impairment percentages must be
applicable the evaluator is to assign an additional 1%
documented. The use of chelation therapy or immuno-
impairment per unit of blood transfused each month,
suppressive drugs may also result in significant side
1% per episode of therapeutic phlebotomy per
effects in susceptible individuals. In these cases an
month, and 3% impairment per episode of aphoresis
additional 1% to 3% impairment to reflect the BOTC
per month.
can also be added to the final rating.
Oral forms of chemotherapy also vary widely in the 9.1d Methodology for Determining the
degree to which they are tolerated. Although there Grade in an Impairment Class
is no impairment rating that will ordinarily be given This chapter employs impairment grids to use in
for use of oral chemotherapy in addition to that for determining the appropriate impairment class (class)
the disease being rated, the evaluator can add a dis- and severity grade (grade) within a class for the
cretionary rating of 1% to 5% for BOTC but must condition or conditions being rated at Maximum
justify the rationale for doing so (eg, menopausal Medical Improvement (MMI). As was stated in chap-
symptoms in a woman receiving tamoxifen as jus- ter 1, the decision regarding which factor is the pri-
tification for a 3% additional rating). The 5% rating mary determinant of impairment (key factor) will be
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Chapter 9
clearly stated in each organ system impairment grid. level. Specific tables will indicate if a rating schema
The examiner will use this key factor to determine other than this is used.
the appropriate class with the middle grade (integer)
The impairment criteria generally used in this chap-
in that class as the initial (default) rating (Refer to
ter on the hematopoietic system may include the his-
Table 9-4).
tory, physical findings, and objective test results. The
The examiner will then use non-key factors to assign assignment of a key factor and relative importance
grades for factors other than that considered “key,” of the criteria will vary according to each regional
with it being impossible to move upward or down- disorder.
ward between classes based on these non-key factors.
The number of potential grades for each impairment
class varies based on the number of relevant factors.
When there are 2 non-key factors, there are generally 9.2 Anemia
5 impairment grades per class; the presence of only
one relevant factor other than the key factor reduces The functional effects of chronic anemia depend on
the number of possible grades to 3 per class. the degree of the cardiovascular system’s compensa-
tory response. Regardless of the pathogenesis of the
If the examiner determines that the other factors
anemia, impairment is related to the heart’s inability
affecting the rating are in the same class that had
to deliver adequate oxygen to tissues. To compen-
been used for the key factor rating, the final rating
sate for the anemia, the heart increases cardiac out-
will generally stay in the middle of that class. On
put by acceleration of heart rate and also increases
the other hand, if the classes chosen are higher or
oxygen extraction from the tissues (ie, increases
lower than that used for the baseline impairment rat-
arteriovenous difference). Therefore, a person with a
ing, the level will be moved to the right or to the left
mild anemia—a hemoglobin level of approximately
100 g/L (10 g/dL)—and a normal cardiovascular
system receives a lower impairment rating than a
person with underlying dysfunction of the cardio-
vascular system.
factor would move the grade down 2 levels to grade Symptoms of anemia include shortness of breath
A and the second would move it back up 1 level to or chest pain on exertion, dizziness, throbbing
grade B. However, if both non-key factors were class headaches, and fatigue. The speed at which anemia
1, the rating could not go any lower than class 3, develops at any hemoglobin level correlates to the
grade A, the lowest value for the class. An exception complexity of symptoms. Greater degrees of anemia
to this rule may occur when the key factor is in the may be associated with lack of stamina, fatigue on
highest impairment class for the disorder, as non-key exertion, fatigue at rest, and dyspnea at rest. Thus,
factors falling in the same class can be used to adjust no specific concentrations of hemoglobin determine
the impairment rating upward to the highest grade impairment. Anemia impairment is measured by the
within the class rather than keep it at the middle limitations of cardiovascular response and may be
TA B L E 9 - 4 Methodology for Determining the Grade in an Impairment Class
SEVERITY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GRADE (%) (A B C D E) (A B C D E) (A B C D E) (A B C)
c c c c
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Chapter 9
lessened by a successful blood transfusion. Given hemolysis becomes more severe. An additional impair-
the wide variation in symptoms seen at a particular ment percentage of 1% is given to reflect the BOTC for
level of hemoglobin, it appears most appropriate each unit of blood transfused per month. As noted pre-
to consider the history as the key factor in rating viously, since the degree to which individuals require
anemia. The functional ramifications of anemia are transfusions is often independent of their disease or
included in the rating and, hence, are not considered the severity of symptoms, it is appropriate to add the
separately. BOTC for transfusions to the baseline impairment rat-
ing in those situations when it is used.
Many forms of anemia are reversible with specific
therapy. Anemias resulting from decreased red In congenital hemolytic anemias, particularly those
blood cell production due to nutrient deficit (eg, iron- related to altered hemoglobin synthesis (eg, hemo-
deficiency anemia, megaloblastic anemia secondary globinopathies and thalassemias), tissue impairment
to folic acid, and vitamin B12 deficiency) are correct- beyond the hematopoietic system results in perma-
able with specific nutrient therapy. nent impairment.3 Sickle cell anemia is commonly
associated with severe, painful vaso-occlusive crisis
A permanent impairment may develop from
that can result in functional impairment of varying
sequelae of the anemia. Often this is due to
degrees.4 These vascular occlusive lesions result in
decreased oxygen to a vital organ such as the heart,
end-organ damage to the bones, heart, kidneys, and
leading to a myocardial infarction. In megaloblastic
liver, compounding the degree of impairment. These
anemia due to vitamin B12 deficiency, significant
disorders can also require chronic exchange transfu-
neurologic deficits caused by demyelinization (par-
sion every few weeks.
ticularly of the posterolateral spinal tracts) may
occur and result in permanent neurologic impair-
ment. Folic acid deficiency during pregnancy may
Impairment due to Anemia
result in lifelong impairment of the newborn with
The impairment rating criteria for anemia are given
varying degrees of neural tube defects. In some
in Table 9-5. As there are only two relevant factors in
circumstances of hypoproliferative anemia resulting
the rating, each class in the impairment grid is only
from chronic renal failure, the anemia is correct-
divided into three grades. History is the key factor.
able with exogenous erythropoietin, even though
the renal failure is irreversible. Similarly, many
forms of anemia due to increased and, particularly,
acquired red blood cell destruction (ie, hemolytic
CLASS 0
anemias) are reversible with therapy and therefore
do not result in permanent impairment.
Persistent hemolytic anemia may cause a degree of
EXAMPLE 9-1: ANEMIA
impairment that is related to the severity of the ane-
mia. This impairment consideration also applies to Subject: 18-year-old man.
aplastic or refractory anemia caused by defective bone
History: Seen for medical clearance for regular
marrow function. Persistent refractory anemia may
physical education class.
cause impairment regardless of the cause; the degree
of impairment is related to the severity of the anemia, Current Symptoms: Asymptomatic.
need for transfusion, and impact on the ability to
perform ADLs. Additional organ system impairment
due to anemia can be combined using the Combined Clinical Studies: Hemoglobin: 140 g/L (14.0 g/dL)
Values Chart in the Appendix. If bone marrow trans- with anisocytosis. Hemoglobin electrophoresis:
plantation has been performed and was unsuccessful, hemoglobin sickle cell type AS.
an additional 10% impairment is assigned in addition
Diagnosis: Sickle cell trait.
to the impairment assigned for the primary disorder,
which will often be considerable. Impairment Rating: Class 0, 0% impairment of the
whole person. Although he has a diagnosis of sickle
The benefits of red blood cell transfusion normally last
cell trait, his lack of symptoms and normal hemoglo-
less than 3 weeks. In individuals with hemolytic ane-
bin level puts him in class 0.
mia caused by serum factors, and in some who have
had many transfusions, the survival rate of transfused Comment: No impairment in function currently
cells is shortened and transfusions must be repeated exists or is anticipated during performance of routine
as often as every few days. Impairment increases as sports or daily activities. Ensure that adequate
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Chapter 9
TA B L E 9 - 5 Criteria for Rating Permanent Impairment due to Anemia
Anemia
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–15% 25%–45% 55%–75%
SEVERITY 1 3 5 7 11 15 25 35 45 55 65 75
HISTORYb History of anemia History of chronic History of History of ane- History of anemia
now resolved; anemia; mild chronic anemia mia with con- with continuous
no treatment signs and symp- with continuous tinuous moderate severe symp-
required toms that inter- mild symptoms symptoms and toms and occa-
mittently require and occasional occasional severe sional extreme
treatment c moderate exacerbations exacerbations
exacerbations
and or and/or
or
no transfusions transfusion of 2 transfusions or 2
required occasional trans- to 3 U required to 3 U required
fusions required every 4 weeks every 2 weeks
OBJECTIVE TEST Testing normal Hemoglobin ⱖ10 Hemoglobin ⱖ8 Hemoglobin ⱖ6 Hemoglobin

RESULTS C but ⬍12 g/dL but ⬍10 g/dL but ⬍8 g/dL ⬍6 g/dL
a
The highest level of impairment (75%) is used when both criteria for history and that for hemoglobin level are met.
Otherwise, if just 1 element from the history and the hemoglobin level or 2 from the history are met, the rating will be 65%.
b
Key factor. The degree and extent of symptoms implicating other organs will lead to additional ratings that will be combined
with the rating for hematology. Add additional BOTC points per unit of blood transfused per month to final impairment, as
the need for transfusions results in an impairment level that is higher than the baseline rating for a given class.
c
The hemoglobin level will vary if transfusions are required. The number used as the basis for the rating should be the
average hemoglobin level, with the value immediately before and immediately after transfusion used if no other means of
assessing this value are available.
hydration occurs with physical exertion to prevent Clinical Studies: Hemoglobin: 102 g/L (10.2 g/dL).
severe dehydration. The student should avoid pro- Hematocrit: 31. Mean corpuscular volume: 79. Serum
longed exposure to hypoxia. ferritin: 250 ␮g/L (250 ng/mL). Remainder of labora-
tory findings normal except for rheumatoid factor.
Diagnosis: Anemia with rheumatoid arthritis.
CLASS 1 Impairment Rating: Class 1, grade B impairment
1% to 5% Impairment of the Whole Person of 3% due her fatigue (mild symptom). Her hemoglo-
bin of 102 g/L (10.2 g/dL) is also class 1, so her rat-
ing remains 3%. Combine with an impairment rating
EXAMPLE 9-2: ANEMIA WITH RHEUMATOID
for joint changes from rheumatoid arthritis.
ARTHRITIS
Comment: Unlike the rheumatoid arthritis, the ane-
mia is mild. In some people with rheumatoid arthri-
History: More than 10-year history of rheumatoid tis or chronic inflammatory lesions, iron-deficiency
arthritis, managed with acetylsalicylic acid, non- anemia develops due to medication and gastrointes-
steroidal anti-inflammatory drugs, and intermittent tinal blood loss. This woman’s normal serum ferritin
corticosteroid therapy. level does not necessarily rule this out, as ferritin
levels are increased in the context of inflammation,
Current Symptoms: Occasional fatigue, stiffness in
which may elevate a low ferritin level due to iron
hands, and difficulty performing ADLs.
deficiency to normal levels. Her anemia is that seen
Physical Exam: Joint deformities in both hands con- in the anemia of chronic disease.
sistent with rheumatoid arthritis.
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Chapter 9
CLASS 2 Current Symptoms: Slight fatigue; takes naps when

7% to 15% Impairment of the Whole Person not having a pain crisis. Usually off work several
times per year for several days per occurrence due to
pain crisis episodes.
EXAMPLE 9-3: AUTOIMMUNE HEMOLYTIC
ANEMIA Physical Exam: Sickle cell habitus.
Subject: 59-year-old man. Clinical Studies: Hemoglobin: 82 g/L (8.2 g/dL).
Hemoglobin electrophoresis review: confirms sickle
History: Found to be anemic 2 years after a lung
cell hemoglobin (SS) with normal fetal and A2
infection.
hemoglobin.
Current Symptoms: Fatigue; takes naps several
Diagnosis: Sickle cell anemia.
days per week; doesn’t do vigorous work such as
shoveling snow or prolonged yard work. Impairment Rating: 25% impairment of the whole
person. Her history is consistent with class 3, grade
Physical Exam: Normal; no palpable liver or spleen.
B (35%) but her relatively good hemoglobin level and
Clinical Studies: Hemoglobin: 95 g/L (9.5 g/dL). the need for only infrequent transfusions moves her
Hematocrit: 29. Serologic evidence of cold agglu- down 1 grade to a 25% impairment rating.
tinins. Low-grade hemolysis with agglutination on
Comment: Increased risk of other, potential
peripheral smear; elevated mean corpuscular volume
sequelae—avascular necrosis of the femoral heads,
and reticulocyte count, positive direct Coombs’ test.
cardiomyopathy, renal failure, and so on—requires
Diagnosis: Autoimmune hemolytic anemia of the careful monitoring and, if present, will lead to the
cold antibody IgM type. assignment of additional impairment percentages.
Transfusions provide transient support and are
mainly used for crisis intervention.
person. His symptoms put him in class 2, grade B
(11%). His hemoglobin level is also consistent with
this class, so he remains at that level.
EXAMPLE 9-5: CHRONIC ANEMIA WITH
Comment: Chronicity of anemia is established; MYELODYSPLASTIC SYNDROME
there is no specific therapy. Anemia limits perfor-
mance of daily activities. Exposure to colds or viral
illnesses carries a risk of abrupt, enhanced red blood History: Fatigue, decreased appetite, and limited
cell destruction with a further anemia. In some indi- energy 1 year ago led to recognition of a progressive
viduals, particularly in older age groups, a malig- anemia. Erythropoietin has not increased red blood
nant lymphoma may develop. Regular follow-up is cell values. Requires transfusions of 1 to 3 U of
recommended. packed red blood cells every 4 to 5 weeks.
Current Symptoms: Fatigue; decreased energy;
needs to rest and take an afternoon nap daily. Can
perform light ADLs with help. Feels better for 7
CLASS 3
to 10 days after transfusions and then declines in
function.
Physical Exam: Signs of anemia; otherwise normal.
EXAMPLE 9- 4: SICKLE CELL ANEMIA
Clinical Studies: Bone marrow: myelodysplasia
with excess blasts. Hemoglobin: 69 g/L (6.9 g/dL)
History: Sickle cell anemia since birth. Repeated but often lower, although usually not lower than
pain crises. Hemoglobin 85 to 95 g/L (8.5 to 9.5 60 g/L (6 g/dL).
g/dL) for the last 5 years, without adequate response
Diagnosis: Chronic anemia with myelodysplastic
to hydroxyurea. Pain crises occur 4 to 6 times per
syndrome.
year and usually require hospitalization, narcotics,
and sometimes transfusion (approximately 4 times a BOTC: Average transfusion requirements of 2 U per
year). Performance of daily activities limited since month leads to the assignment of an additional 2%
moderate physical work can provoke a pain crisis. impairment.
She receives folic acid and narcotics as needed.
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Chapter 9
Impairment Rating: 37% impairment of the whole CLASS 4
person. Her history is consistent with class 3, grade 55% to 75% Impairment of the Whole Person
B (35%) and transfusion requirements, so she stays at
grade B (35%), to which 2% for BOTC is added.
EXAMPLE 9-7: ANEMIA
Comment: Condition is likely to progress in terms
of the severity of the anemia, with an increase in the
frequency of transfusions required since isoimmu- History: 2-year history of cerebrovascular accident,
nization is an inevitable sequela. If her hemoglobin with a severe anemia associated with iron deficiency.
levels were often under 60 g/L (6 g/dL) necessitating Budd-Chiari syndrome developed 4 months ago, for
more frequent transfusions, she would move to class which she has been placed on a regimen of warfarin
4. Individual is at increased risk of transformation to sodium (Coumadin).
acute leukemia and iron overload due to transfusion
Current Symptoms: Weakness and fatigue; pale
requirements, although this could be managed with
skin.
deferasirox (Exjade). Some unusual forms of myelo-
dysplasiamay respond to treatment with lenalido- Physical Exam: Pallor; residual left-sided weakness.
mide (Revlimid) or 5-azacytidine. Pulse: 100 beats per minute.
Clinical Studies: Hemoglobin: 65 g/L (6.5 g/dL).
White blood cell count: 2.5 ⫻ 109/L (2.5 ⫻ 103/␮L).
EXAMPLE 9-6: APLASTIC ANEMIA
Platelets: 80 ⫻ 109/L (80 ⫻ 103/␮L).
Diagnosis: Aplastic anemia, paroxysmal nocturnal
History: Severe aplastic anemia diagnosed 4 years hemoglobinuria, and Budd-Chiari syndrome.
ago. Failed immunosuppressive agents and bone
BOTC: She received a rating of 5% due to the use of
marrow transplantation. Now requires 3 U of packed
warfarin.
red blood cells every 4 weeks.
Impairment Rating: 60% hematologic impairment
Current Symptoms: Fatigue, especially before
of the whole person. Her history puts her in class 4
transfusions. Very limited exercise tolerance; able
and starts at 65% (grade B), her hemoglobin level of
to walk for only 5 to 10 minutes before fatigue and
65 g/L (6.5 g/dL), in class 3, moves her to a lower
shortness of breath occur.
impairment grade (55%) for this class and the use of
Physical Exam: Signs of anemia. warfarin leads to the addition of 5% for a total rat-
ing of 60%. Additional impairment will be assigned
Clinical Studies: Hemoglobin: 67 g/L (6.7 g/dL)
based on her white blood cell count and platelets,
but average hemoglobin level usually below 60 g/L
which will be combined with the anemia rating using
(6 g/dL).
the Combined Values Chart in the Appendix, as will
Diagnosis: Aplastic anemia. the rating she receives for residual impairments from
her stroke.
BOTC: 3% additional impairment is assigned for
her transfusions. Comment: Corticosteroids or androgens may con-
trol the hemolysis from the paroxysmal nocturnal
hemoglobinuria. She will most likely require lifelong
person. Her symptoms and transfusion requirements
anticoagulation.
put her in class 3 (35%), which is adjusted to the
highest grade in this class (45%) based on her hemo-
globin level. To this is added 10% for failed bone
marrow transplantation and 3% for BOTC, yielding
a total rating of 58%.
9.3 Myeloproliferative Disorders,
including Polycythemia,
Comment: Chronic, severe anemia with contin-
ued, significant transfusion needs; ongoing risks of Myelofibrosis, and Essential
hemochromatosis and comorbid problems likely, Thrombocytosis
which may lead to the assignment of additional
impairment.5 Polycythemia vera is manifested by hematocrit
values above 52% in men and 49% in women,
and by red blood cell volumes above 0.036 L/kg
(36 mL/kg) in men and 0.032 L/kg (32 mL/kg) in
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Chapter 9
women. Other associated signs and symptoms are although in those rare occasions when symptoms
normal arterial oxygen tension, an enlarged spleen, develop the rating should be based on the organ sys-
slight elevation of the white blood cell and platelet tem affected or on the degree to which hemorrhagic
counts, and increased leukocyte alkaline phos- or thrombotic events occur.
phatase. Diagnostic criteria might include analysis
The criteria for diagnosis of myelofibrosis, of pri-
for a mutation in JAK2. An increase in red blood
mary (idiopathic) or secondary (postpolycythemic)
cell numbers (polycythemia) can be due to car-
etiology, include progressive anemia with red blood
diopulmonary disease, smoking, or inappropriate
cell changes of anisocytosis and poikilocytosis, a
secretion of erythropoietin. If the primary cause of
shift to the left of the granulocytic white blood cell
erythrocytosis can be treated and the erythrocytosis
series, and, often, nucleated red blood cells in the
corrected, there should be no permanent impair-
peripheral blood. Bone marrow biopsy indicates
ment. Phlebotomy to normal hematocrit levels might
fibrosis with dilated sinusoids and clustering of
minimize the symptoms of all forms of polycythe-
megakaryocytes. The level of impairment due to
mia. Polycythemia can lead to other organ system
myelofibrosis is reflected by the level of impairment
impairments, such as cerebrovascular or cardiovas-
due to the anemia and/or neutropenia. The primary
cular occlusions.
deficiency is rated first and combined with the
Myelofibrosis (bone marrow fibrosis) may also impairment rating due to deficiencies in other cell
occur in individuals with polycythemia. Although lines. (See Tables 9-5 through 9-7.)
some individuals remain relatively asymptomatic
for several years, others experience fatigue, weak-
ness, weight loss, perspiration, low-grade fever, and
an enlarged spleen. Currently, no therapy exists that CLASS 1
consistently relieves the symptoms of myelofibro- 1% to 5% Impairment of the Whole Person
sis. Transfusions may be needed for severe anemia.
Exogenous erythropoietin increases red blood cell
EXAMPLE 9-8: USE OF PHLEBOTOMY
production in some people.
Essential thrombocytosis is a disorder of unknown
etiology manifested clinically by the overproduc- History: History of bladder cancer.
tion of platelets without a definable cause. The dis-
ease can occur at any age, and patients affected by
this disorder are largely asymptomatic and do not Clinical Studies: Was found to have a hematocrit of
experience either hemorrhage or thrombosis. Anemia 62% and a hemoglobin level of 205 g/L (20.5 g/dL)
rarely develops; a mild leukocytosis can occur at on routine screening. He had no symptoms, but was
times. Symptomatic treatment with salicylates may started on a phlebotomy program (1 U of blood
help those patients in whom neurologic symptoms each month) and has required continuation of this
such as headache do develop. If platelet reduction is program to maintain his hematocrit between 45 and
deemed necessary, interferon-␣ or anagrelide can 50. He is receiving aspirin but no other medication
reduce platelet count, but in the absence of symp- for his polycythemia and requires no other treatment
toms no treatment is required. for it.
Diagnosis: Polycythemia vera without an underlying
cause identified.
Impairment due to Polycythemia,
Myelofibrosis, or Essential BOTC: He is given an impairment rating of 1% due
Thrombocytosis to the need for monthly phlebotomy.
Polycythemia can produce end-organ damage to car-
Impairment Rating: 1%.
diovascular or cerebrovascular areas due to vascular
occlusion. Vascular obstruction of the portal venous Comment: If he had sustained damage to other
system similarly can produce end-organ injury to the organ systems due to thrombosis, additional impair-
liver. There is no specific rating given for the polycy- ment ratings would be given and combined with the
themia, with the impairment rating based on the end- 1% rating using the Combined Values Chart in the
organ involved and the degree of injury, to which is Appendix.
added any impairment rating given for phlebotomy
(if used to control disease) or chemotherapy. There
is also no rating given for essential thrombocytosis,
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Chapter 9
CLASS 3 9.4a Granulocytes
25% to 45% Impairment of the Whole Person Granulocytes protect against infection through the
phagocytosis of invading organisms. They function
primarily at the site of tissue invasion; the observa-
EXAMPLE 9-9: PRIMARY MYELOFIBROSIS
tion or enumeration of granulocytes in the circulation
Subject: 55-year-old woman. indicates inflammation or infection. Granulocytes
have a brief half-life of approximately 6 hours.
History: 2-year history of progressive fatigue,
The granulocyte precursor pool is in the bone
abdominal fullness, early satiety, and a 4.5-kg (10-lb)
marrow, where a very large production capacity
weight loss in the past 6 months. Requires 2 U of
exists.
pack cells once a month.
Abnormal granulocyte function is usually congeni-
Current Symptoms: Weakness; night sweats;
tal, although acquired functional abnormalities may
tender, full feeling in abdomen.
result from drug use or toxin exposure. Frequent
Physical Exam: Evidence of protein wasting. Spleen infection is an indicator of defective granulocyte
8 cm beneath left costal margin. function; infection may vary from localized,
self-limited infections such as furunculosis to
Clinical Studies: Hemoglobin: 7.9 g/dL. Hematocrit:
life-threatening infections such as recurring
23.7. White blood cell count: 12.0 ⫻ 109/L (12 ⫻ 103/
septicemia. Type, frequency, and severity of the
␮L) with shift to left of granulocytes, nucleated red
recurring infections are the basis for evaluating
blood cells, and abnormal platelets. Platelet count:
impairment. An affected individual will have a
45 ⫻ 109/L (45 ⫻ 103/␮L). Uric acid: 0.54 ␮mol/L
reasonably consistent infection pattern that facili-
(9.0 mg/dL). Bone marrow: dry aspirate.
tates treatment and enables a judgment concerning
Diagnosis: Primary myelofibrosis (agnogenic prognosis.
myeloid metaplasia).
Two different forms of quantitative granulocyte
BOTC: She receives an impairment rating of 2% abnormalities are granulocytopenia and leukemia.
due to the need for transfusions. Granulocytopenia is characterized by a significant
decrease in the total number of granulocytes in the
Impairment Rating: 42%. She is in class 3, grade
blood. Severe infections due to low numbers are
B (35%), based on her symptoms and transfusion
uncommon, unless the granulocyte count is less
requirements, with her hemoglobin level keeping her
than 0.50 ⫻ 109/L. Irreversible chronic neutropenia
in this class. An additional 2% is added for BOTC,
with counts below 0.50 ⫻ 109/L is associated with a
as well as another 5% for symptomatic splenomegaly
substantially increased risk of infection; the infec-
(Section 9.4g).
tion defines impairment. Table 9-6 is used for rating
Comment: Clinical symptoms and limitations in impairment due to neutropenia. Objective findings
function parallel the degree of anemia. are the key factor.
9.4White Blood Cell Diseases or CLASS 3
Abnormalities 25% to 35% Impairment of the Whole Person
The primary function of white blood cells (leu- EXAMPLE 9-10: NEUTROPENIA
kocytes) is providing protection against invad-
ing microorganisms, foreign proteins, and other
materials. Three separate white blood cell “fami- History: Diagnosed with cyclical neutropenia;
lies”—granulocytes, lymphocytes, and monocytes- cycles every 6 weeks. She is receiving filgastrim
macrophages—interact to provide this protection. (Neupogen) and antibiotics every 6 weeks and is not
Each white blood cell family has a fixed tissue com- prescribed any other medications.
ponent that provides the renewal or precursor pool
Current Symptoms: Generally well; regular use of
and also functions at fixed sites, including the bone
antibiotics and filgastrim results in good control of
marrow, spleen, and lymph nodes. Abnormalities in
her disease.
white blood cells are expressed as both numbers and
alterations in function. Physical Exam: Normal.
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Chapter 9
TA B L E 9 - 6 Criteria for Rating Permanent Impairment due to Neutropenia
Neutropenia
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–15% 25%–35% 40%–50%
SEVERITY GRADE 1 3 5 7 11 15 25 30 35 40 45 50
(%) (A B C) (A B C) (A B C) (A B C)
HISTORY Requires no Occasional anti- Requires chronic Requires chronic Requires chronic
treatment biotic therapy intermittent intermittent oral intermittent oral
required for bac- antibiotic ther- antibiotic therapy antibiotic therapy
terial infection apy to prevent with acute bac- with acute bac-
acute bacterial terial infections terial infections
infections requiring hos- requiring hospi-
pitalization no talization at least
more than once twice a year
a year
or
home intrave-
nous antibiotics
requiredb
OBJECTIVE Absolute neu- Absolute neutro- Absolute neutro- Absolute neutro- Absolute neutro-
FINDINGS c trophil count of phil count ⬎750 phil count ⬎500 phil count ⬎250 phil count ⬍250
⬎1000 but ⱕ1000 but ⱕ750 but ⱕ500
a
If both are present, one should use the higher of the 2 impairment ratings.
b
If patient meets both criteria for history and neutrophil count is ⬍250, use highest rating.
c
Key factor. If absolute neutrophil count is responsive to colony-stimulating factors, use counts before and afterward and
average them. If individual has a cyclic condition, use double the count at the nadir as the absolute neutrophil count.
Clinical Studies: Her nadir is an absolute neutrophil Current Symptoms: Generalized fatigue. He has
count of 200 for approximately 5 days and then, over been stable but predisposed to infection, requiring
1 week, increases to 1500. occasional oral antibiotic therapy as well as hospital-
ization for more severe infection once a year.
Diagnosis: Cyclic neutropenia.
Physical Exam: Cachetic. Moderate splenomegaly
Impairment Rating: 25%. She is at 30%, class 3,
(4 cm below costal margin).
grade B based on the value for double her absolute
neutrophil count of 400 (2 ⫻ 200). The need for only Clinical Studies: Hemoglobin: 101 g/L (10.1 g/dL),
occasional antibiotics moves her down to 25%, the white blood cell count: 2 ⫻ 109/L (2 ⫻ 103/␮L) with
lowest level for this class. 22% neutrophils (absolute neutrophil count of 440),
nucleated red blood cells, and abnormal platelets.
Platelet count: 78 ⫻ 109/L (78 ⫻ 103/␮L). Bone
EXAMPLE 9-11: NEUTROPENIA marrow: dry aspirate. Myelofibrosis on section.
Subject: 58-year-old man. Diagnosis: Myelodysplasia.
History: A 5-year history of myelodysplasia. Has Impairment Rating: 30% due to neutropenia. He
had chronic neutropenia, anemia, and thrombocyto- is at 30%, class 3, grade B based on the value for his
penia, with the neutropenia the most significant of absolute neutrophil count. The annual hospitaliza-
the 3. Requires 2 U of packed red blood cells each tion for neutropenia keeps him at this level. This will
month. be combined with the rating of 9% for his anemia
(class 2 due to the need for occasional transfusions,
adjusted downward from grade B (11%) to grade
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Chapter 9
A (7%) based on his hemoglobin level, to which is years. However, since complete cure can be obtained
added 2% based on his monthly transfusion needs) with chemotherapy for hairy cell leukemia, defini-
for a rating of 37%. To this will be added the rating tive treatment should be initiated once the diagnosis
for his thrombocytopenia. is made. Multiple myeloma and macroglobulinemia
may be asymptomatic initially, manifested only by
9.4b Lymphocytes certain laboratory abnormalities, and constitute no
Lymphocytes provide humoral and cellular defense impairment. All leukemias, regardless of cell line
mechanisms. Circulating lymphocytes originate in derivation, will be rated using Table 9-7. History
lymphoid tissues: the bone marrow, spleen, lymph is key factor. Lymphomas behave more like solid
nodes, and thymus. Lymphocytes circulate between tumors than leukemias and should be rated using
the blood and the tissues. Lymphocyte cells have Table 9-13, combined with any rating for the effect
heterogeneous functions. They produce cytokines, of the lymphoma on a specific organ system.
which is a usually a normal function. There are no
data to support cytokine testing for any causation 9.4c Impairment from Leukemias
impairment rating or to assess disability. Leukemias are classified as acute or chronic. The 4
major classifications are: acute myelogenous leuke-
Of the 2 major subgroups, the “T,” or thymus-
mia (AML), chronic myelogenous leukemia (CML),
derived lymphocytes, are primarily responsible
acute lymphocytic leukemia (ALL), and chronic
for protection from viral and other infections and
lymphocytic (lymphoid) leukemia (CLL). They
for cellular immunity, and are involved in delayed
result in impaired function of the individual and
hypersensitivity reactions and transplant rejection.
limited life expectancy, even with currently available
The “B,” or bone marrow-derived lymphocytes, are
therapy. Impairment is based on symptoms, physi-
primarily responsible for humoral immunity related
cal findings, the requirement for and frequency of
to the production of immunoglobulins. Subtypes of
therapy, and the ability to carry out ADLs. Use Table
both T and B lymphocytes have distinct functions
9-7 for both myeloid and lymphocytic leukemias.
and abnormalities that produce distinct clinical
syndromes. Symptoms resulting from the lymphocytic and
myeloid leukemias are due to the leukemia, its
Lymphocytes can be abnormal in function and/or
effects on the number or function of other types of
number, often leading to recurrent infections.
blood cells, or its effects on other organ systems.
Individuals with Hodgkin’s disease or connective
Leukocytosis, leukopenia, anemia, or thrombocyto-
tissue diseases and those who have been exposed
penia are the main hematologic consequence. There
to ionizing radiation all have acquired functional
is also a relative loss of function of the cell type
defects. Some “autoimmune” diseases may be a
causing the leukemia, because while the cell count
result of functionally altered or numerically pre-
may be high, many of the cells are immature blast
dominant subsets of lymphocytes. Impairment rat-
forms and therefore nonfunctional. There also are
ings due to abnormal numbers of lymphocytes, as
occasions when some of the leukemias lead to eryth-
with lymphopenia, are based on the severity of the
rocytosis or thrombocytosis. In all of the leukemias
condition, as indicated by recurrent infection, and a
one should first rate the disease (based on Table 9-7)
limited ability to perform ADLs.
and then rate the hematologic manifestations of
The best documentation of defective lymphocyte disease or the effect of disease on other organ sys-
function or numbers is to determine failure of end tems. These should be combined to arrive at a final
functions like generalized immunoglobulin defi- rating using the Combined Values Chart in the
ciency or delayed hypersensitivity reaction failure. Appendix, which will lead to the final rating for the
Lymphocyte abnormalities are associated with 3 leukemia or lymphoma.
forms of neoplastic transformation: (1) leukemias
In AML and ALL, there are large quantities of
(including chronic lymphatic leukemia, acute
immature, and hence poorly functional, cells,
lymphatic leukemia, and hairy cell leukemia)6;
leading to the development of bacterial, fungal, or
(2) lymphomas (including Hodgkin’s disease, non-
viral infections; symptomatic anemia; or bleeding.
Hodgkin’s lymphoma, and mycosis fungoides); and
Patients with CLL are often fully functional dur-
(3) multiple myeloma and macroglobulinemia.
ing early-stage disease, because while the cell count
Chronic lymphatic leukemia, hairy cell leukemia, may be high, the function of other cell lines is nor-
and some low-grade lymphomas may be relatively mal. Indeed, given the general indolence of disease,
indolent, require no initial therapy unless severe and early stages often do not require treatment, with
irreversible, and constitute no impairment for several institution of treatment based on the development of
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Chapter 9
TA B L E 9 -7 Criteria for Rating Permanent Impairment due to the Leukemias
Leukemias
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 3%–15% 20%–30% 35%–55% 65%–85%
SEVERITY 3 9 15 20 25 30 35 45 55 65 75 85
HISTORYb Requires no Any leukemia in Intravenous Chemotherapy Chemotherapy

treatment; leuke- remission for ⬎1 chemotherapy provided 3 to 6 given more than
mia in remission but ⬍5 years agent no more times a year 6 times a year
ⱖ5 years frequently than 3
or or
times a year
early-stage CLL patient has not
requiring no responded to
treatment treatment and
has incurable
or
leukemia
disease treated
with oral
chemotherapy
FUNCTIONAL Class 0 Class 1 Class 2 Class 3 Class 4

CLASSIFICATION
a
If patient has incurable disease, use the highest rating for the class (85%).
b
Key factor.
symptoms, infection, anemia, thrombocytopenia, or impairment rating until at least 2 weeks have passed
neutropenia. Acute and chronic leukemias vary in since their last cycle of intravenous treatment. Ratings
their response to therapy and the ability to achieve are based on the nature and frequency of chemother-
complete remission. Even when cure is not possible, apy required on an annual basis (as estimate using the
there is variation in the degree to which treatment overall clinical status of the patient and chemotherapy
is required due to differences in the durability of provided during the prior 6 months as a guide) and the
remission, with patients often able to function nor- degree to which treatment has led to resolution of the
mally during the treatment-free intervals. leukemia, marrow suppression, or deficits in cellular
function. The functional ramifications of either the
Chronic myelogenous leukemia may behave as a rel-
leukemia or the treatment required for the leukemia
atively indolent disease. However, CML may trans-
(see Table 9-2) is also considered. Additional ratings
form into an acute leukemia (referred to as “blast
due to anemia, thrombocytopenia, or neutropenia or
crisis”), at which time treatment needs and overall
the effect of disease on other organ systems should be
debility increase. The availability of imatinib, a tyro-
assessed using the appropriate tables and combined
sine kinase inhibitor, and related drugs can result in
with the hematologic impairment using the Combined
total remission, as it specifically addresses the tyro-
Values Chart in the Appendix. As noted previously,
sine kinase production fostered by the Philadelphia
an additional 10% impairment is given if the patient
chromosomal abnormality that is pathognomonic for
has not responded to bone marrow transplantation
this disease. The required length of imatinib therapy
along with 1% per cycle of chemotherapy for 6 months
is unknown, but current practice is to continue use
up to a total of 6% and 1% per unit of transfused
indefinitely.
blood monthly. The additional impairment that will
When patients are receiving intravenous chemo- be assigned by assessing the effect of the leukemia on
therapy or are undergoing bone marrow transplan- other cell lines and the BOTC is the rationale
tation for the leukemias, they are often completely for using 85% as the top rating for class 4 in the
debilitated, and it is inappropriate to give a permanent leukemia table.
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Chapter 9
CLASS 1 Clinical Studies: Hemoglobin: 70 g/L (7.0 g/dL)
3% to 15% Impairment of the Whole Person before treatment; highest hemoglobin is 110 g/L
(11.0 g/dL); hemoglobin currently is 85 g/L
(8.5 g/dL). Her total white blood cell count is 82.0 ⫻
EXAMPLE 9-12: CHRONIC MYELOGENOUS
109/L (82.0 ⫻ 103/␮L) with 96% lymphocytes before
LEUKEMIA
chemotherapy; reticulocytes: 0.130 proportion of red
Subject: 40-year-old man. blood cells (13% of red blood cells). Positive direct
antiglobulin (Coombs’) test.
History: Pain, tightness in left upper abdominal
quadrant. Initially presented with leukocytosis Diagnosis: Chronic lymphocytic leukemia with
15 ⫻ 109/L (150.0 ⫻ 103/␮L), but since initiation autoimmune hemolytic anemia.
of treatment with daily oral imatinib (Gleevec), his
BOTC: 5% for chemotherapy plus 0% for oral corti-
leukocytosis has normalized. Able to do most ADLs,
costeroids (no overt signs of diffuse toxicity from her
although has difficulty with strenuous work.
steroids and has other systemic symptoms that are
Current Symptoms: None. In remission for 6 already being rated).
months.
Physical Exam: 3.6-kg (8-lb) weight loss. person due to leukemia. She is in class 3, 45%
Splenomegaly before treatment, with spleen extend- impaired due to her leukemia. Her functional status
ing 12 cm below left costal margin. After treatment, and history are also class 3, so she stays at grade C
spleen is no longer palpable. with an impairment rating of 45%, to which 5% is
added for her BOTC. This will be combined with
Clinical Studies: Leukocytes: Normal peripheral
the impairment from her anemia: 25% based on
blood smear and normal cytogenetics.
class 3 symptoms, which place her at 35%, but she
Diagnosis: Chronic granulocytic leukemia. is adjusted to bottom grade (25%) based on her rela-
tively good (class 2) hemoglobin level. The final rat-
BOTC: 0%, no symptoms from imatinib.
ing would be 50% combined with 25%, or 63% WPI.
Comment: Anemia and some of the related symp-
person. Impairment rating assigned is 9%, as disease
toms responded to steroid therapy and may respond
is in remission.
further. The underlying leukemia can generally be
Comment: Remission with daily medication. No controlled with chemotherapy for 3 to 7 years, and
symptoms from imatinib, no additional percentage her functional status may improve with better control
for BOTC added to the rating. of her disease.
CLASS 3 CLASS 4
EXAMPLE 9-13: LEUKEMIA EXAMPLE 9-14: ACUTE LEUKEMIA
Subject: 55-year-old woman. Subject: 55-year-old man.

History: Progressive weakness, easily fatigued, History: Profound weakness, chills, night sweats,
dyspnea on exertion for 6 months. Receiving intra- and fever for 10 months. Has had course of chemo-
venous chemotherapy every 3 weeks for 5 cycles and therapy involving multiagent chemotherapy every 3
then is generally in remission for 1 to 2 years. Last to 4 weeks for a total of 8 cycles during past year,
course of chemotherapy was 1 month ago. Is also although none for the past 6 months. Has required
receiving long-term corticosteroids for her autoim- 2 U of packed red blood cells monthly to maintain
mune hemolytic anemia. hemoglobin level.
Current Symptoms: Decreased appetite; pallor; Current Symptoms: Relatively stable 6 months
fatigue; sleeps often and able to do only basic ADLs later, although only in partial remission. Rests most
(ECOG-PSS class 3). of the day, although can do limited self-care activi-
ties (ECOG-PSS class 3).
Physical Exam: Lymphadenopathy and an enlarged
spleen.
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Chapter 9
Physical Exam: Gingival hypertrophy, nosebleeds. and widely variable degrees of functional impairment.
Splenomegaly; spleen extended 4 cm below costal This virus can directly destroy CD4 T lymphocytes,
margin; ecchymoses. resulting in impairment of the normal immune
response against infection and neoplastic processes.
Clinical Studies: Hematologic values: hemoglobin
The risk of developing opportunistic infection is, in
820 g/L (8.2 g/dL); white blood cell count: 15.0 ⫻
general, inversely related to the absolute CD4 count.7,8
109/L (15. ⫻ 103/␮L) with 80% blast forms; platelets:
18.0 ⫻ 109/L (18 ⫻ 103/␮L). Impairment with HIV infection is caused by single-
or multiple-organ system involvement from primary
Diagnosis: Acute leukemia.
HIV infection or the opportunistic infection or
BOTC: 2% for transfusions. None for chemotherapy neoplastic process from immunologic dysfunction.
at present, as he has not had any chemotherapy Essentially, every organ system can be affected,
within past 6 months. including hematologic, pulmonary, gastrointestinal,
neurologic, dermatologic, and renal. Several systems
Impairment Rating: 67% whole person impairment
are often simultaneously affected, adding to the
due to leukemia. The initial rating is 75% impair-
complexity of impairment determination.
ment of the whole person from leukemia based on
treatment history, but as his functional status is class Acute retroviral syndrome may develop early in HIV
3, he moves to the lowest grade for class 4 of 65%, infection; symptoms include fever, fatigue, pharyngi-
to which is added the 2% BOTC. This will be com- tis, rash, myalgia, and arthralgia. Quantitative HIV
bined with the ratings for his anemia and thrombo- RNA measurements also indicate the extent of HIV
cytopenia to arrive at the final rating. infection. Early stages are characterized by a CD4
count greater than 0.50 ⫻ 109/L (500 cells/␮L); indi-
Comment: Partial response to treatment. Requires
viduals are often asymptomatic but may have lymph-
hospitalization for treatment. Prognosis is poor. Will
adenopathy, leukopenia, thrombocytopenia, and
probably need bone marrow transplant, perhaps after
dermatologic conditions. Intermediate stages have
additional courses of chemotherapy.
CD4 counts of 0.20 ⫻ 109/L to 0.50 ⫻109/L (200 to
500 cells/␮L); antiretroviral therapy is often initi-
9.4d Myelodysplastic Syndromes
ated to prolong this stage of disease. Individuals may
Myelodysplasia of hematopoietic precursors is more
have few or no symptoms or may experience consti-
frequently recognized after age 50 years. It occurs
tutional symptoms, diarrhea, herpes simplex infec-
as a primary (idiopathic) or secondary form, com-
tion, oral or vaginal candidiasis, upper respiratory
monly after exposure to a wide variety of industrial
tract infection, sinusitis, or common bacterial infec-
chemicals or after cytoreductive chemotherapy or
tion. Advanced stages, often defined by CD4 counts
radiation therapy for neoplastic disease. Causative
less than 0.20 ⫻ 109/L (200 cells/␮L), are associated
factors include several drugs, particularly topoisom-
with an increased incidence of opportunistic infec-
erase inhibitors and platinum derivatives. The prin-
tion and meet the Centers for Disease Control and
cipal primary or secondary hematopoietic changes
Prevention (CDC) definition for AIDS. At low CD4
are defective and decreased cellular proliferation
levels, there is increased incidence of complica-
and production. Cell line (red blood cells, white
tions, including Pneumocystis carinii pneumonia;
blood cells, and platelets) involvement and progres-
Toxoplasma gondii encephalitis; tuberculosis; cryp-
sion are variable. (For more information, refer to
tosporidiosis; salmonellosis; esophageal candidiasis;
Tables 9-5, 9-6, and 9-9 for rating impairment due to
neoplasms, including Kaposi’s sarcoma, lymphoma,
anemia, granulocytopenia, and thrombocytopenia.)
and cervical cancer; and neurologic dysfunction,
Eventually, all cell lines become involved; at least
such as mononeuritis multiplex, peripheral neuropa-
one-third of patients progress to a leukemic transfor-
thies, cranial nerve palsies, and myelitis. At CD4
mation. For unknown reasons, patients with myelo-
levels below 0.10 ⫻ 109/L (100 cells/␮L), the follow-
dysplasia have more constitutional symptoms than
ing are more common: HIV-associated dementia,
expected for peripheral hematologic value levels.
wasting syndromes, progressive multifocal leukoen-
Myelodysplasia impairment evaluation is based on
cephalopathy, cytomegalovirus (CMV) retinitis, dis-
the degree of individual component alteration and on
seminated Mycobacterium avium complex (MAC),
its effects on other organ systems.
cryptococcal meningitis, disseminated coccidiomy-
cosis, histoplasmosis, and invasive aspergillosis.
9.4e Impairment from Human
Immunodeficiency Virus Infection The degree of symptomatic involvement and the
Infection with HIV creates a progressive and ulti- course of illness in individuals with the same CD4
mately fatal disease process with a complex course cell-defined stages vary significantly. Functional
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Chapter 9
impairment can also develop from toxicity responses CLASS 1
to antiretroviral treatments, including reverse tran- 3% to 15% Impairment of the Whole Person
scriptase inhibitors; viral protease enzyme inhibi-
tors; and antibacterial, antiviral, antifungal, and
EXAMPLE 9-15: HIV INFECTION
antineoplastic therapies. Determine total impair-
ment only after careful assessment of each of the Subject: 30-year-old man.
potentially affected organ systems. Also consider
History: Tested for HIV infection because of sexual
the nature and severity of the primary or second-
contact with individual with risk factors for HIV.
ary infections or neoplastic processes. Do not rate
HIV disease using any of the standard hematologic Current Symptoms: None.
tables. Instead, use Table 9-8. Objective findings
Physical Exam: Generalized lymphadenopathy.
are key factor. Although the degree of impairment
from HIV approaches 100% in those patients with Clinical Studies: HIV enzyme immunoassay: posi-
end-stage disease, this is due both to the HIV infec- tive. Western blot: positive. HIV RNA: 5000 copies/
tion itself and involvement of other organ systems. mL of plasma. CD4: 0.70 ⫻ 109/L (700/␮L).
Consequently, the top rating for class 4 is 80%, with
Diagnosis: Asymptomatic HIV infection.
the understanding that this will be adjusted upward
once impairment in other organ systems is combined Impairment Rating: 3% of the whole person. His
with that from HIV. initial rating is 9% (class 1 – grade C) based on his
TA B L E 9 - 8 Criteria for Rating Permanent Impairment due to HIV Disease
HIV Disease
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 3%–15% 18%–30% 35%–55% 60%–80%
SEVERITY 3 6 9 12 15 18 21 24 27 30 35 40 45 50 55 60 65 70 75 80
HISTORY Requires no Requires antiret- Requires antiret- Requires con- Requires constant
treatment roviral therapy roviral therapy stant antiretro- medical therapy
to control signs and constant viral therapy and and chronic sup-
and symptoms of medical therapy chronic suppres- pressive therapy
disease to prevent sive therapy with with at least 2
opportunistic at least 1 active active opportu-
infections— opportunistic nistic infections
history of prior infection
and/or
infections
opportunistic
infections require
hospitalization
at least once per
year
OBJECTIVE CD4 count of CD4 count of 500 CD4 count of CD4 count of CD4 count of
FINDINGSb ⬎800 to ⱕ800 ⬎200 but ⬍500 ⬍200 but ⬎100 ⱕ100
or or
HIV by polymerase HIV by PCR
chain reaction ⬎50,000
(PCR) ⬍50

CLASS
a
Initial score based on CD4 count is adjusted upward to 75% if patient meets a history criterion for class and to 80% if also
meets functional criteria.
b
Key factor.
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Chapter 9
CD4 count. This is adjusted downward to 6% due Physical Exam: Thrush; generalized
to his class 0 history (on no medications) and then lymphadenopathy.
again 1 grade lower to 3% given his functional class.
Clinical Studies: CD4: 0.11 ⫻ 109/L (110/␮L ). HIV
If he goes on medications his grade will increase to
RNA: 146,000 copies per milliliter of plasma.
6%, reflecting side effects, etc of the drugs.
Diagnosis: Acquired immunodeficiency syndrome.
Comment: Treatment of an asymptomatic HIV-
infected individual with a low viral load and high Impairment Rating: 40% impairment of the whole
CD4 count is controversial. Current guidelines sug- person. The initial rating assigned is class 3, grade
gest withholding therapy. C (45%) based on his CD4 count. This is adjusted
downward 1 grade to grade B (40%) based on his
overall class 2 functional status. Although he has
thrush, he would not have this disorder if he accepted
CLASS 2 medication. Thus, his impairment level will probably
18% to 30% Impairment of the Whole Person decrease to 35% and perhaps even lower (should his
CD4 count improve) if he receives medications.
EXAMPLE 9-16: HIV INFECTION Comment: Individual should be urged to begin
highly active antiretroviral therapy. In addition, pro-
phylaxis to prevent P carinii pneumonia should be
History: Known to be HIV infected. On multiple initiated.
medications.
Current Symptoms: Asymptomatic; dismayed
about condition and medication regimen; feels well
CLASS 4
generally.
Physical Exam: Diffuse lymphadenopathy.
Clinical Studies: CD4: 0.35 ⫻ 109/L (350/␮L). HIV EXAMPLE 9-18: ACQUIRED
RNA: 45,000 copies/mL of plasma. IMMUNODEFICIENCY SYNDROME
Diagnosis: Asymptomatic, moderately advanced Subject: 30-year-old man.

HIV infection.
History: Has received multiple combinations of anti-
Impairment Rating: 18% of the whole person. retroviral therapy over preceding 4 years.
His initial rating is class 2, grade C (24%), which is
Current Symptoms: Has diarrhea, anorexia, nau-
adjusted downward to class 2, grade B (21%) based
sea, probable AIDS-related dementia, and persistent
on his class 1 functional level and then down again
oral thrush; very weak.
to grade A (18%) based on no history of prior oppor-
tunistic infections. Physical Exam: Has lost more than 10% of normal
body weight; oral thrush; lymphadenopathy.
Comment: All authorities agree that an individual
with CD4 cell counts and viral load in these ranges Clinical Studies: CD4: 0.02 ⫻ 109/L (20/␮L). HIV
should receive antiretroviral therapy. RNA: 1,200,000 copies per milliliter of plasma.
Diagnosis: Acquired immunodeficiency syndrome.
CLASS 3 person due to HIV disease. Meets all criteria for class
35% to 55% Impairment of the Whole Person 4. This would be combined with the impairment for
gastrointestinal tract disease (weight loss) and his neu-
rologic impairment. Final level will be 95% or higher.
EXAMPLE 9-17: ACQUIRED
IMMUNODEFICIENCY SYNDROME Comment: Individual has advanced HIV/AIDS, having
failed to respond to currently available antiretroviral
therapy. Emphasis should be placed on maintain-
History: Known to be HIV infected. Has consis- ing prophylaxis against complicating infections.
tently refused to take antiretroviral therapy. Consideration should be given to entering into a pallia-
tive care program for management of terminal illness.
Current Symptoms: Complains of weight loss,
intermittent temperature elevation, and night sweats.
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Chapter 9
9.4f Monocytes-Macrophages risk of viral infections. If an individual experiences
The monocyte-macrophage family ingests foreign repeated infections after splenectomy, an impairment
proteins, removes cellular debris, particulates mate- rating of 5% should be assigned and added to the
rial, and modulates immune responses. This functional hematologic rating. Otherwise the impairment rating
unit of circulating monocytes and fixed macrophages, is 0. Splenomegaly of greater than 5 cm below costal
“histiocytes,” is structurally associated with endothelial margin is uncomfortable and usually affects ability to
cells and fibroblasts in the reticuloendothelial system. eat by causing early satiety. This leads to assignment
This system is recognized primarily by the phagocytic of an impairment rating of 5%, which is added to the
capacity of monocytes and macrophages. hematologic impairment, if present.
Knowledge about functional defects in the monocyte-
macrophage system is limited. The degree of impair-
ment can be associated with the nature, type, and
CLASS 0
extent of infection. Lipid storage disease is another
abnormality in which macrophages become reposi-
tories for lipids, and cellular and organ hyperplasia
occurs in the spleen, lymph nodes, and bone marrow. EXAMPLE 9-19: SPLENECTOMY
Marrow involvement can produce progressive and
massive bone abnormalities and fractures; impairment
focuses on the degree of orthopedic deficit. History: Ruptured spleen in automobile accident.
Splenectomy; uneventful postoperative course.
Neurologic involvement also occurs in some severe
Returned to all daily activities in 2 months.
forms of lipid storage disease. Enzyme replacement
Evaluation 8 months after hospital discharge. Has
therapy is now available for Gaucher’s disease, one
not had any increased rate of infections.
of the most common types of lipid storage disease.
This therapy is effective at reversing most abnor- Current Symptoms: None.
malities except for neurologic deficit. Impairment
Physical Exam: Well-healed scar on left upper
depends on the nature of the lipid, rate of deposition,
quadrant; otherwise, exam normal.
and primarily affected organs.
Clinical Studies: Slightly elevated white blood cell
Neoplastic transformation occurs primarily as acute
count: 10.0 to 18.0 ⫻ 109/L (10 to 18 ⫻ 103/␮L),
monocytic leukemia, a relatively rare form of leu-
kemia. The exact cell of origin is not clear, but the Diagnosis: Status postsplenectomy for splenic
condition behaves as a form of chronic neoplastic rupture.
transformation. In general, ratings for disease of
monocytes or macrophages are achieved by rating
person.
the effects of disease on other aspects of the hema-
topoietic system and/or on other organ systems com- Comment: Postsplenectomy blood changes are not
bined with use of the table for leukemia (Table 9-7). associated with symptoms or any change in the abil-
ity to perform ADLs. A slight increase in the risk of
9.4g The Spleen and Splenectomy systemic infection for selected organisms does exist
The spleen is a large lymphoid organ that plays for some individuals. If the individual experiences
an important role in innate and adaptive immune repeated infections, the impairment rating should be
responses. As a consequence of splenectomy, some reevaluated.
functional abnormalities may develop. These include
impaired clearance of certain encapsulated bacteria,
such as the pneumococcus. Occasionally, overwhelm-
ing infections develop after splenectomy. This occurs 9.5 Hemorrhagic and Platelet
in fewer than 2% of people from whom the organ Disorders
has been removed and is confined mostly to children
or during the first 2 years after the operation. The
Hemorrhagic disorders include coagulation disorders
incidence has been greatly reduced by prophylactic
and platelet disorders.
administration of the polyvalent pneumococcal vac-
cine. Splenectomy leads to some subtle, albeit clini- Hemorrhagic disorders are either congenital or
cally silent, morphologic abnormalities of red blood acquired. In most hereditary disorders, the basic
cells and a transient elevation of the platelet count. hemostatic defect remains unchanged throughout
Splenectomized individuals are not at an increased the individual’s life. People with hereditary blood
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Chapter 9
coagulation disorders may require prophylactic 9.5a Criteria for Rating Permanent
therapy to help them perform activities they might Impairment due to Platelet Disorders
otherwise avoid because of the threat of trauma. To Thrombocytopenia is not rated for impairment
control bleeding, many patients may require frequent unless it is severe, affects function, and is irrevers-
home treatment, which interferes with daily activity. ible by steroids, splenectomy, or other therapeutic
Impairment ratings vary depending on the frequency regimens. Qualitative platelet defects rarely meet
of treatment and on the extent of interference with criteria for impairment rating unless there is seri-
normal activity. (See Tables 9-1 and 9-2.) ous bleeding, which also may occur in some rare
congenital disorders. There is wide variation in the
Von Willebrand’s disease is frequently mild; bleed-
degree to which individuals with a given platelet
ing occurs only after trauma or surgery. It does not
count will sustain hemorrhagic events.
affect function significantly enough to warrant an
impairment rating. However, some individuals meet Autoimmune thrombocytopenia may require long-
criteria for a significant impairment rating because term immunosuppressive therapy, which can lead
of recurrent bleeding.9-12 to dysfunction of several organ systems and can
hamper daily activities. Complications are evaluated
Severe inherited bleeding disorders may cause com-
according to the criteria of the affected body system
plications such as joint dysfunction from recurrent
or organ and combined with the impairment percent-
hemorrhaging. Impairment due to this complica-
age for the appropriate blood platelet disorder (see
tion is evaluated with criteria found in Chapter 15,
the Combined Values Chart in the Appendix). The
The Upper Extremities, and Chapter 16, The Lower
impairment criteria for platelet disorders are given
Extremities. If several organ systems are impaired,
in Table 9-9. History is key factor. The patient must
the whole person impairment percentages are com-
also be rated for any impairment in other organ sys-
bined (see Combined Values Chart in the Appendix).
tems that has resulted from hemorrhagic events.
TA B L E 9 -9 Criteria for Rating Impairment due to Platelet Disorders
Platelet Disorders
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 7%–15% 25%–35% 45%–65%
SEVERITY 1 3 5 7 11 15 25 30 35 45 55 65
HISTORYb Mild thrombo- Treatment may Thrombocytopenia Severe throm- Profound throm-
cytopenia or be required for requires treat- bocytopenia bocytopenia
clotting disorder acute exacerba- ment subsequent requires intermit- unresponsive to
that requires no tions of thrombo- to trauma or prior tent treatment platelet transfu-
treatment cytopenia to surgery. Easier with transfusion sion and/or 3 or
bruising. but responsive to more hemor-
platelet therapy rhagic events per
and/or occasional year
(ⱕ2 times a year)
hemorrhagic
events
PLATELET Platelet count Platelet count of Platelet count of Platelet count of Platelet count
COUNTc ⬎140.0 ⫻ 10 3 /␮L 100 to ⱕ140 ⫻ ⬎60 ⫻ 10 3 /␮L 20–60 10 3 /␮L ⬍20 ⫻ 10 3 /␮L
10 3 /␮L
a
Use 65% if patient meets both (rather than 1) of the history criteria for class 4 (as well as the platelet count criterion).
b
Key factor (based on average number of events over prior 3 years—if available—otherwise, over past year).
c
Based on “usual” platelet counts.
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Chapter 9
CLASS 2 Physical Exam: Ecchymoses on extremities.
7% to 15% Impairment of the Whole Person Abnormal radii bilaterally; good hand function.
Clinical Studies: Platelets: 8.0 ⫻ 109/L (8.0 ⫻
EXAMPLE 9-20: PLATELET DISORDERS 103/␮L).
Subject: 49-year-old woman. Diagnosis: Amegakaryocytic thrombocytopenic
purpura with absent radii syndrome.
History: 5 years’ chronic idiopathic autoimmune
thrombocytopenia. Splenectomy; corticosteroids and BOTC: 2% for monthly transfusions and 3% for her
other immunosuppressive drugs for 4 years and is prednisone use (has clear signs of side effects from
now stable without therapy. Will require treatment their use) for a total BOTC of 5%.
before surgery.
Current Symptoms: No significant bleeding prob- person due to platelet disorders. Her treatment needs
lem. Chronic low back pain, which interferes with place her in class 3 at a rating of 30%, which is
daily activities. adjusted upward to 35% based on her platelet count.
The BOTC of 5% is added to this for a total impair-
Physical Exam: Minor bruising. Severe osteoporo-
ment rating of 40%.
sis; T12 and L1 compression fractures.
Comment: Requirements for prednisone; limitations
Clinical Studies: Platelets: 30.0 ⫻ 109/L (30.0 ⫻
in performance of vigorous daily activities. Likely
103/␮L).
future problems, as she will probably become resis-
Diagnosis: Chronic idiopathic autoimmune throm- tant to the platelet transfusions.
bocytopenic purpura.
Impairment Rating: 15% impairment for the
Impairment due to Clotting Disorders
bleeding disorder. Her need for treatment before
Congenital deficits in clotting are generally due to
surgery places her in class 2, at grade B (11%). This
factor VIII or XIX deficiencies or von Willebrand’s
is adjusted upward to 15% based on her low platelet
disease. Factor levels determine the degree to which
count and will be combined with appropriate impair-
the former will be symptomatic, whereas the abso-
ment estimate for vertebral fractures and osteoporosis
lute degree of the deficiency is less important in von
(see Combined Values Chart in the Appendix) to
Willebrand’s disease. There are other hemorrhagic
determine whole person impairment.
disorders as well; however, in all of them impairment
Comment: Current platelet counts are not associated is primarily caused by the frequency of hemorrhagic
with symptoms. However, she has a significantly events. Any physiologic abnormalities that develop
increased risk of bleeding with surgical procedures. as a consequence of these events are to be rated
The thrombocytopenia may worsen intermittently separately and combined with the impairment from
(especially with infections) and may require periodic the hemorrhagic disorder.
therapeutic intervention.
Acquired blood-clotting defects are usually second-
ary to severe underlying conditions. For example,
individuals with severe liver disease may have
impaired production of clotting factors leading to a
CLASS 3
hemorrhagic diathesis. Individuals may also develop
antibodies against normal clotting factors as in
acquired hemophilia. Individuals with venous or
EXAMPLE 9-21: PLATELET DISORDERS arterial thromboembolic disease who receive anti-
coagulant therapy with a vitamin K antagonist (eg,
warfarin sodium) need to be monitored chronically
History: Lifelong history of low platelet counts, to ensure a therapeutic degree of anticoagulation. If
congenital; requires 1 to 2 platelet transfusions per these individuals become over anticoagulated, they
month; receiving prednisone last several years to may have a hemorrhagic consequence.
reduce transfusion need. Does not participate in vig-
Hemophilia is typically divided into 3 categories
orous sports for fear of further bruising.
based on the degree of factor deficiency. This cor-
Current Symptoms: Bruises easily; multiple ecchy- relates well with the frequency and risk of hem-
moses on extremities. Heavy and prolonged men- orrhagic complications. Individuals with mild
strual periods. hemophilia (5% to 30% of normal) typically do not
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Chapter 9
bleed spontaneously but do need to be premedicated CLASS 3

before surgery. They may respond to desmopressin 45% to 65% Impairment of the Whole Person
(DDAVP), which will temporarily increase their
factor VIII levels. Those individuals who do not
EXAMPLE 9-22: HEMOPHILIA
respond to this medication and those with lower
clotting factor levels (under 5%) require clotting fac- Subject: 21-year-old man.
tor infusions, usually self-administered. These are
History: Severe factor VIII deficiency (hemophilia
sometimes given on a chronic basis to individuals
A). Frequent spontaneous bleeding into large joints
with clotting factor levels under 1% as prophylaxis
and muscles with 3 to 5 significant hemorrhagic
against bleeding. Individuals with hemophilia may
events per year. Home therapy with intravenous fac-
develop antibodies against exogenously adminis-
tor VIII concentrate 2 times per week. Significant
tered factor. This is a complication of therapy, which
chronic dysfunction of left knee, right ankle, and
complicates the treatment of hemorrhagic events;
both elbows due to past joint bleeding.
these individuals are sometimes given chronic fac-
tor or immunosuppressive therapy. There is also Current Symptoms: Frequent joint, muscle hemor-
variation in the frequency of hemorrhagic events rhages; continuous treatment interferes with perfor-
between individuals with similar levels of factor mance of usual daily activities.
deficiency. Table 9-10 is used to rate impairment due
Physical Exam: Severely restricted range of motion
to the hemophilias. History is key factor. Impairment
in left knee, right ankle, and both elbows. Joint
resulting from hemarthroses is rated separately and
swelling of knee and ankle.
combined with the impairment from the hemophilia.
TA B L E 9 -1 0 Criteria for Rating Impairment due to the Hemophilias
Hemophilias
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3c
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 20%–30% 45%–65%
SEVERITY 1 5 9 20 25 30 45 55 65
HISTORY a, b No treatment required Requires treatment with Prior history of ⱕ2 Prior history of 3 or
vasopressin (DDAVP), bleeding episodes dur- more bleeding epi-
cryoprecipitate, or ing prior year sodes per year
fresh-frozen plasma
after trauma or in prep-
aration for surgery
TREATMENT Mild clotting dis- Clotting factor treat- Long-term clotting fac- Clotting factor
REQUIREMENTS order requiring no ment required after tor treatment required therapy required
treatment bleeds or trauma with development of
antibodies and/or has
required red blood
cell transfusion for
bleeding episodes
FACTOR Normal Mild: ⬎5% to 30% of Moderate: 1% to ⱕ5% Severe: Less than 1%
DEFICIENCY normal clotting factor
a
Based on average number of events over prior 3 years—if available—otherwise over past year.
b
Key factor.
c
Use 65% if meets all criteria for class; 55% if meets 1 criteria other than the key factor.
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Chapter 9
Clinical Studies: Hemoglobin: 120 g/L (9.0 g/dL). joint impairment will be combined with this (see
Factor VIII level: less then 0.001 (p ⬍ 1.0%); anti- Combined Values Chart in the Appendix) for determi-
bodies to factor VIII: not present. Activated partial nation of whole person impairment.
thromboplastin time (aPTT): 120 seconds. X rays
Comment: Control of bleeding episodes with fac-
of joints reveal fluid and hypertrophic changes.
tor VIII replacement will decrease subsequent bony
HIV-negative.
changes. Joint replacement surgery can improve
Diagnosis: Severe hemophilia A with permanent function in specific sites of impairment.
joint dysfunction secondary to recurrent bleeding.
Von Willebrand’s disease is a heterogenous group
BOTC: 9% for factor VIII transfusions (based on 2 of bleeding disorders due to an abnormality of von
transfusions each week and 4 1/2 weeks a month). Willebrand’s factor and can be associated with
easy bruising, excessive menstrual bleeding, and
Impairment Rating: 74% impairment due to hemo-
increased frequency of epistaxis. Individuals
philia A. He is assigned 65% impairment for underly-
with von Willebrand’s disease can experience
ing bleeding disorder, as his history, the frequency of
life-threatening posttraumatic or postoperative
hemorrhagic events and treatment needs and extent
hemorrhage; they may also experience frequent
of factor deficiency, place him in the top of class
hemorrhagic events (key factor) if their disease
3; to this is added 9% for the BOTC. The impair-
is severe. There are a number of other bleeding
ment percentages assigned for anemia and red blood
disorders (Table 9-11); however, as is the case for
cell transfusions (if required) along with that from
von Willebrand’s disease, rating is based on the
TA B L E 9 -11 Criteria for Rating Impairment due to Other Bleeding Disorders
Bleeding Disorders
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 C L A S S 4 a ,c
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 15%–25% 35%–45% 55%–65%
SEVERITY 1 5 9 15 20 25 35 40 45 55 65
GRADE (%) (A B C) (A B C) (A B C) (A B)
FREQUENCY OF No history Chronic mucosal One nonmuco- History of 2 or History of 3 or
HEMORRHAGIC of abnormal oozing and/or sal bleed that more nonmuco- more nonmuco-
EVENTSb bleeding heavy menses resulted in severe sal bleeds that sal bleeds that
and/or nonmuco- restriction of resulted in severe resulted in severe
sal bleed during activity and/or restriction of restriction of
prior year that hospitalization activity and/or activity and/or
did not lead to within past year hospitalization hospitalization
severe restriction within past year during prior
or activity year—at least
one of these
life-threatening
bleeds
TREATMENT No treatment Minor treatment Requires factor Generally Transfusion

REQUIREMENTS required (hemostatis, replacement (if requires transfu- requirements of 2
iron therapy, or applicable) and/ sions of fewer or more U of red
premedication or hemostatic than 2 U of blood cells, with
for procedures) agent packed red blood or without factor
required cells with or replacement
without factor
replacement with
bleeds
a
If there are central nervous system residual impairments, rate according to Chapter 13.
b
Key factor. Based on average number of events over prior 3 years—if available—otherwise over past year.
c
Use 65% if patient meets both criteria for class; 55% if patient meets only key factor.
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Chapter 9
frequency and severity of hemorrhagic events (key 9.6 Thrombotic Disorders

factor) and the need for blood products, which varies
among individuals. The patient must also be rated Thrombotic disorders involve arteries, veins, or
for any impairment in other organ systems that has both. Thrombosis may be either primary due to an
resulted from hemorrhagic events. inherited disorder or secondary due to acquired
conditions. Whereas each risk factor may contribute
to thrombosis, combined factors may lead to a
greater risk.13
CLASS 2
15% to 25% Impairment of the Whole Person 9.6a Inherited Thrombotic Disorders
Known defects include: proteins C, S, and anti-
thrombin III deficiency; gene mutation associated
EXAMPLE 9-23: OTHER BLEEDING DISORDERS
with increased activity of a clotting factor (eg, factor
Subject: 35-year-old woman. V Leiden and prothrombin 20210A); and increased
homocysteine levels due to cystathionine B-syn-
History: History of von Willebrand’s disease gener-
thase deficiency (although homocysteine levels are
ally characterized by occasional heavy menses requir-
also due to deficiencies of vitamin B12 or folate).
ing oral iron supplementation and premedication
Hyperhomocysteinemia is associated with athero-
with antifibrinolytics for dental procedures. Has had
sclerosis and thrombosis of the arteries and some-
episodes of more substantive bleeding throughout her
times of the veins. Forty percent of individuals with
life, although generally no more frequently than once
thrombosis have 1 or more of the aforementioned
a year, as she has modified her activities to decrease
abnormalities. Clinical indications of congenital
her risk of trauma. Nonetheless, she sustained an
thrombotic abnormality include family history;
intramuscular bleed into her buttock and thigh when
occurrence at an early age; recurrence; and occur-
she slipped and fell while at work that required hos-
rence at unusual sites (eg, mesenteric, portal, splenic,
pitalization, 2 U of packed red blood cells, and factor
renal, cerebral, or retinal veins).
replacement, although she had not required transfu-
sions previously. Has recovered without sequelae.
9.6b Acquired Thrombotic Disorders
Current Symptoms: Continues to require treatment Acquired thrombotic conditions associated with
as previously, that is, before dental work and surgery. venous thrombosis include antiphospholipid antibody
Menstrual bleeds are usually heavy and intermit- syndrome (found in some patients with arterial throm-
tently (every 2 to 3 months) very heavy, to the point bosis), malignancy, use of certain estrogen-containing
at which her ability to participate in most daily drugs, obesity, immobility, postoperative phase, multi-
activities is compromised. ple trauma, pregnancy, heart failure, use of indwelling
venous catheters, sickle cell disease, inflamma-
Physical Exam: Unremarkable except for several
tory bowel disease, diabetes, paroxysmal nocturnal
ecchymoses.
hemoglobinuria, and myeloproliferative disorders.
Clinical Studies: Hemoglobin: 125 g/L (9.5 g/dL). The acute phase of venous thrombosis is usually
Von Willebrand’s antigen: 20%; von Willebrand’s treated with unfractionated or low-molecular-weight
functional activity: 22%; factor VIII: 15%. heparin, then oral anticoagulation for 3 to 6 months.
Individuals with a greater risk of thrombosis require
Diagnosis: Von Willebrand’s disease.
anticoagulation, either temporary (postsurgical) or
Impairment Rating: 20% impairment due to von lifelong (as prophylaxis for inherited thrombotic dis-
Willebrand’s disease. Her initial presentation places order and recurrent thrombosis). Arterial thrombosis
her into class 2, grade B (20%), which remains is treated according to the system involved. The length
unchanged, as she does not routinely require transfu- of time patients need to be treated with oral antico-
sions to manage most of her prior bleeding events. agulation depends on a complex set of parameters,
During her prior hospitalization, this can be consid- including the presence of reversible risk factors, his-
ered a proxy for the severity of disease. As she does tory of previous events, type of underlying thrombo-
not require regular transfusions, she does not receive philia (if any), and clinical presentation.
an additional rating for the transfusions themselves.
Thrombotic disorder impairment results from
If there were any sequelae from her bleed, these
systematic complications after thrombosis and
would be rated according to the involved organ
anticoagulation regimen. It depends on the type,
system and the results would be combined with the
site, and extent of the organ involvement, as well
hematologic rating.
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Chapter 9
as the response and complications of anticoagula- use of medications such as warfarin and the limita-
tion. Arterial thrombi may produce ischemic heart tion of activities that results. Those receiving other
disease, stroke, or intermittent claudication. Venous forms of anticoagulation subsequent to surgical pro-
thrombosis often resolves with no aftereffects. If cedures, such as cardiac stenting or neurologic con-
unresolved, postthrombosis syndrome may develop ditions such as transient ischemic attacks or stroke,
due to vein lumen narrowing and/or venous valve can receive up to 3% to reflect the BOTC from the
insufficiency, causing lower extremity edema, use of these medications if there is strong evidence
venous ulceration, venous thrombosis recurrence, that their use has led to modification of significant
and ambulation limitation. ADLs (see Chapters 4, Cardiovascular System and
13, Central and Peripheral Nervous System).
9.6c Criteria for Rating Permanent
If an individual cannot tolerate anticoagulant therapy
Impairment due to Thrombotic Disorders
or does not have severe enough disease to warrant its
Impairment is evaluated based both on the throm-
use, the degree of impairment depends on the likeli-
botic disorder itself and the impact of thromboses
hood of thrombosis. The most objective way to assign
that have occurred on a particular affected body
a severity grade is to use the nature and extent of the
system. With regard to the former, regardless of the
thrombotic disorder as a guide, since there is variation
cause of the thrombotic abnormality, impairment is
in the degree to which individuals with a given throm-
due to restrictions necessitated by the disorder itself
botic disorder will become symptomatic. Impairment
(eg, avoidance of prolonged sitting, high temperatures
from the thrombotic disorder is to be given only if the
with limited access to fluids, or strenuous activities),
affected individual has not been placed on a regimen
anticoagulation given for the disorder, or, rarely,
of anticoagulant therapy. Whole person impairment
from a continued tendency toward thrombosis despite
from thrombotic disorders is listed in Table 9-12.
adequate anticoagulant therapy. The tendency toward
Frequency of thrombotic events is key factor.
thrombosis depends on the nature and extent of the
underlying thrombotic disease, as modulated by the Any additional impairment from the thrombotic disor-
use of oral contraceptives, certain types of estro- der is based on the degree of injury to the end-organ,
gens and other procoagulant medication as well as such as the lungs, heart, brain, kidney, and extremi-
whether the affected individual smokes. There also ties; from thrombosis; and on how the disorder affects
appear to be other factors specific to the individual the individual’s capacity to perform ADLs. Regardless
that have an impact on the risk of thrombosis; these of the system involved, the rating that results due to
have not yet been fully quantified. When a throm- the sequelae of thrombotic disease should be com-
bosis occurs due to a work-related event, the need bined with the impairment from the thrombotic
for lifelong anticoagulation will reflect discovery disease itself (to which is added 5% for the use of anti-
of an underlying congenital problem that was previ- coagulants, if appropriate, before combining) using
ously not identified (eg, a protein C or S deficiency). the Combined Values Chart in the Appendix.
In these situations it is important to differentiate
the impairment due to the congenital thrombotic
abnormality from the impairment resulting from the
effects of a given thrombotic event or events. CLASS 3
Individuals with a hypercoagulable state cannot be
rated (ie, are not at MMI) until those conditions that
warrant the use of anticoagulants have received an EXAMPLE 9-24: THROMBOTIC DISORDER
adequate trial of an appropriate agent. Some indi-
viduals continue to have thrombotic events despite
adequate anticoagulation; others cannot tolerate History: At 40 years of age, 5 left leg deep vein
anticoagulation or refuse it. The rating is therefore thromboses; 2 pulmonary embolisms. Father and
based on the frequency of thrombotic events after brother had multiple venous thromboses. Patient was
MMI has been achieved; this is then adjusted to placed on a lifelong regimen of warfarin (Coumadin)
reflect the nature of the underlying hypercoagulable therapy but after 5 years’ oral anticoagulation had 2
state. If the individual is receiving long-term anti- hemorrhagic episodes: posttrauma knee hematoma
coagulant therapy for the thrombotic disorder with and thigh hematoma; international normalized ratio
warfarin, low-molecular-weight heparin, or heparin, (INR) between 5 and 7. Large hemorrhagic skin
5% is added to the impairment rating. This reflects necrosis twice when INR at 4.
the significant risk of bleeding that results from the
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Chapter 9
TA B L E 9 -12 Criteria for Rating Impairment due to Thrombotic Disorders
Thrombotic Disorders
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 15%–25% 35%–40%
SEVERITY 1 5 9 15 20 25 35 40
GRADE (%) (A B C) (A B C) (A B)
FREQUENCY OF No history of abnor- One prior incident of More than 1 prior One or more throm-
THROMBOTIC mal thrombosis thrombosis thrombotic event— botic events per year
EVENTS b none in prior year
HYPER- Minor abnormalities Heterozygous factor V Protein C or S levels Two of the following:
COAGULABLE not expected to result Leiden deficiency ⬍35% of normal protein C or S level
STATEc in hypercoagulable ⬍35%
or or
state
and/or
lupus anticoagu- antithrombin 3
lant, anticardiolipin deficiency homozygous factor V
or antiphosphlid Leiden abnormality
or
antibodies
and/or
homozygous factor V
or
Leiden deficiency lupus anticoagulant,
other hypercoagulable anticardiolipin or
or
state antiphospholipid
lupus anticoagulant, antibodies
anticardiolipin or
and/or
antiphospholipid
antibodies other hypercoagulable
state
or
other hypercoagulable
state
a
Use 40% if patient meets both criteria for class; 35% if patient meets only key factor.
b
Key factor. Assumes that the “at-risk” individual is receiving adequate anticoagulant therapy, or anticoagulant therapy
could not be tolerated due to significant side effects or anticoagulant therapy has been refused.
c
If clinical information is not available default to mean rating for class.
Current Symptoms: Left leg postthrombotic syn- Impairment Rating: 40% based on frequency of
drome; severe edema with upright position for over 30 thromboses adjusted downward to 35% as only has 1
minutes. Frequent thrombotic episodes despite warfa- identified hypercoagulable state. To this is added 5%
rin use. Therapy-induced hemorrhages and anticoagu- for the use of warfarin, leading to a hematologic system
lation monitoring interfere with work. Lower extremity impairment rating of 40%. This will be combined with
swelling requires intermittent wheelchair use. the rating she receives for her lower extremity condition
using the Combined Values Chart in the Appendix, to
Physical Exam: Edema of left leg to midthigh,
arrive at the whole person impairment rating.
which increases when in upright position; ecchymo-
sis (and resolving ecchymosis) of arms and legs. Comment: Although it is possible that some of the
impairment she experiences results from excessive
Clinical Studies: Platelet count and aPTT: normal.
variability of her INR due to dietary factors, and that
INR: 2.8. Protein C antigen (measured before patient
this may affect her rating in the future, she is effec-
was given warfarin): 26% of normal.
tively at MMI.
Diagnosis: Protein C deficiency with recurrent
venous thrombosis and postthrombosis syndrome.
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Chapter 9
9.7 Criteria for Rating Permanent CLASS 4
Impairment due to Lymphoma 65% to 85% Impairment of the Whole Person
and Metastatic Disease

EXAMPLE 9-25: HODGKIN’S DISEASE
The presence of metastatic disease materially alters the Subject: 28-year-old man.
clinical presentation of a particular form of cancer, both
History: Initial response to 2 cycles of ionizing
through involvement of other organs and the burden
radiation. Disease recurred, and he is now receiving
caused by the systemic effects of the metastatic disease,
6 months of chemotherapy every 2 weeks for a
any chemotherapy that may have been prescribed, and
total of 12 treatments. If the disease goes into
the functional ramifications of disease. Lymphoma is
complete remission, there is consideration of
different pathologically from the leukemias as there
treatment with autologous bone marrow transplant.
can be more systemic signs and symptoms of disease.
Patient gets average of 2 U of red blood cells
This is the rationale for combining these disorders. As
per month.
once the rater has assigned an impairment rating that
reflects local effects, the frequency of chemotherapeu- Current Symptoms: Profound weakness due to
tic intervention and the functional impact of disease are anemia that temporarily responded to drug treatment
the other indexes used to assess impairment, since they and transfusions but has now recurred. Pruritus,
are surrogate markers for the remaining aspects of the chills, and fever. Still able to do basic ADLs.
disease process. No rating is automatically assigned for
Physical Exam: Lymphadenopathy below and above
oral chemotherapy given prophylactically, although the
diaphragm.
examiner can give up to 5% impairment representing
the BOTC on a discretionary basis. Likewise, no rating Clinical Studies: Lymph nodes biopsy showed
is given for a course of chemotherapy provided before Hodgkin’s disease. Hemoglobin 79.0 g/L (7.9 g/dL)
a surgical procedure or until 2 weeks after a course of (as low as 75 g/L, or 7.5 g/dL, before transfusions).
treatment has been provided. Criteria for rating perma-
nent impairment due to lymphoma and metastatic
disease is listed in Table 9-13. History is key factor.
TA B L E 9 -13 Criteria for Rating Impairment due to Lymphoma and Metastatic Disease
Lymphoma and Metastatic Disease

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 3%–15% 20%–30% 35%–55% 65%–85%
SEVERITY 3 9 15 20 25 30 35 45 55 65 75 85
HISTORYa Requires no treat- Disease treated Intravenous che- Chemotherapy Chemotherapy

ment; disease with oral motherapy agent provided 3 to 6 given more than
in remission ⱖ5 chemotherapy chemotherapy for times per year 6 times a year
years management of
or
complications of
disease no more patient has
frequently than “failed” treat-
twice a year ment and has
incurable meta-
static disease or
lymphoma

CLASSIFICATION
a
Key factor.
b
If patient meets both history criteria, use 85%, if otherwise use 75%.
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Chapter 9
Diagnosis: Recurrent, active Hodgkin’s disease. impairment percentage for anemia (35%), for whole
person impairment of 83%.
BOTC: 6% (maximum for chemotherapy) plus 2%
for radiotherapy (1% per cycle) and 2% for transfu- Comment: Prognosis uncertain.
sion needs.
advanced Hodgkin’s disease. His treatment require-
ments place him in class 4 at 75% impairment, which
9.8 Hematologic Impairment
is modified downward to 65% based on his func- Evaluation Summary
tional status. The addition of the BOTC brings this
back up to 75% and will be combined (see Combined Table 9-14 gives an evaluation summary for the
Values Chart in the Appendix) with the appropriate assessment of hematologic impairment.
TA B L E 9 -14
Hematologic Impairment Evaluation Summary
Disorder History, Including Selected Relevant Examination Record Assessment of Hematologic Function
Symptoms
General Symptoms of end-organ impairment, Comprehensive physical Data derived from relevant studies:
eg, cardiovascular (eg, fatigue, palpi- examination with focus on complete blood counts, serology
tations, chest pain); respiratory (eg, affected end-organ testing, biopsies of bone, lymph
shortness of breath); infections; systems assessment nodes
general symptoms
Impact of symptoms on function and
ability to do daily activities
Red Blood Symptoms (eg, shortness of breath on Other organ dysfunction Complete blood count, hemoglobin
Cell exertion, dizziness, throbbing head- (eg, brain, heart, kidneys) electrophoresis, etc
aches, fatigue)
Resulting limitation of physical activ-
ity or complications (eg, angina)
White Fatigue, frequent infections, etc Detailed history (ie, Complete blood count, etc
Blood Cell infections)
HIV
Metastatic
Disease
Platelet Abnormal bleeding from gums, Epistaxis; petechiae; pur- Complete blood count with plate-
mouth, GI tract, urinary tract pura; occult fecal blood; let count; bleeding time; relevant
splenomegaly; evidence of platelet aggregation studies (pro-
Poor hemostasis with trauma
thrombosis thrombin and partial thromboplastin
Family history of abnormal clotting time to rule out other coagulation
disorders)
Bleeding Excessive bruising Hematoma; joint or muscle Complete blood count with platelet
swelling; easy bruisability count; bleeding time; prothrombin
Prolonged spontaneous, traumatic
and partial thromboplastin time;
bleeding
fibrinogen factor levels
From birth or acquired disorder
Family history of bleeding disorder
Muscle or joint pain or swelling
Thrombosis Excessive thrombosis Evidence of thrombosis Proteins C, S and antithrombin
III, factor V Leiden, prothrombin
20210A, homocysteine and CBC with
platelet count
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Chapter 9
End-Organ Damage Diagnosis(es) Degree of Impairment
Include assessment of sequelae, including Record all pertinent diagnosis(es); note Criteria outlined in this chapter
end-organ damage and impairment if they are at maximal medical improve-
ment; if not, discuss under what condi-
tions and when stability is expected
Assess relevant organs (eg, heart, lungs, Anemias; sickle cell; hemolysis; chronic See Table 9-5
kidneys) for congestion or dysfunction disease; polycythemias
Assess relevant organs (eg, heart, lungs, Leukemia; lymphoma See Tables 9-6, 9-7, 9-8 and 9-13
kidneys, lymph nodes)
Metastatic Disease
Due to hemorrhage Immune thrombocytopenic purpura See Tables 9-9, 9-12

(ITP); HIV or drug-associated thrombo-
cytopenia; thrombotic thrombocyto-
penia (TTP); myelodysplasia; leukemia;
platelet functional disorder; essential
thrombocythemia
Due to hemorrhage, hemarthrosis, or Hemophilia; factor deficiency; Von See Tables 9-9, 9-10 and 9-11
nerve impingement Willebrand’s disease; dysfibinogenimia;
disseminated intravascular coagulation
Due to thrombosis Consistent with diagnostic abnormality Table 9-12
Guides6e_09_183-212.indd 211 2/17/09 2:43:02 PM

Chapter 9
12. Hoyer LW. Hemophilia A. N Engl J Med.

References 1994;330:38–47.
1. Doyle D, Hanks GWC, MacDonald N, eds. Oxford Review.
Textbook of Palliative Medicine. New York, NY: 13. Rich S, et al. The hypercoagulable states. Ann Intern
Oxford University Press. 1993:109. Med. 1985;102:814–828.
2. Comis R, Oken MM, Creech RH, et al. Toxicity and Review.
response criteria of the Eastern Cooperative Oncology
Group. Am J Clin Oncol. 1982;5:649–655.
3. Rockey DC. The beta-thalassemias. N Engl J Med.
1999;341:99–109.
Bibliography
Review.
4. Steinberg MH, et al. Management of sickle cell disease. Colman RW, Hirsh J, Marder VJ, Salzman EW. Hemostasis
N Engl J Med. 1999;340:1021–1030. and Thrombosis: Basic Principles and Clinical
Practice. 3rd ed. Philadelphia, Pa: JB Lippincott; 1994.
Review.
Hoffmann R, Benz EJ Jr, Shattil SJ, Furie B, Cohen
5. Goodnough LT, et al. The pathophysiology of acquired HJ, Silberstein LF. Hematology: Basic Principles
aplastic anemia. N Engl J Med. 1997;336:1365–1372. and Practice. 2nd ed. New York, NY: Churchill
Review. Livingstone; 1995.
6. Anaissie EJ, et al. Chronic myelogenous Lichtman M, Beutler E, Kipps T, et al. Williams
leukemia: biology and therapy. Ann Intern Med. Hematology. 6th ed. New York, NY: McGraw-Hill;
1999;131:207–219. 2001.
Review. Hoffman R, Benz E, Shattil S, et al. Hematology: Basic
Principles and Practice. 4th ed. New York, NY:
7. Flexner C. Acute human immunodeficiency virus type Churchill Livingstone; 2005.
1 infection. N Engl J Med. 1998;339:33–39.
Abeloff M, Armitage J, Niederhuber J, et al. Clinical
Review. Oncology. 3rd ed. New York, NY: Churchill
8. Society of General Internal Medicine AIDS Task Force. Livingstone; 2000.
Optimizing care for persons with HIV infection. Ann Kasper D, Braunwald E, Fauci A, et al. Harrison’s
Intern Med. 1999;131:136–143. Principles of Internal Medicine. 16th ed. New York,
Review. NY: McGraw-Hill; 2005.
9. Therapy for adults with refractory chronic immune DeVita V, Hellman S, Rosenberg S. Cancer: Principles
thrombocytopenic purpura. Ann Intern Med. and Practice of Oncology. 7th ed. Philadelphia, Pa:
1997;126:307–314. Lippincott, Williams & Wilkins; 2005.
Review. Goldman L, Ausiello D. Cecil Textbook of Medicine, 22nd
ed. Philadelphia, Pa: WB Saunders Co; 2004.
10. George JN, et al. Chronic idiopathic thrombocytopenic
purpura. N Engl J Med. 1994;331:1207–1211.
Review. No abstract available.
11. Levi M, et al. Disseminated intravascular coagulation.

N Engl J Med. 1999;341:586–592.
Review. No abstract available.
Guides6e_09_183-212.indd 212 2/17/09 2:43:02 PM

CHAPTER 10
The Endocrine System
Chapter 10
10.2 Hypothalamic-Pituitary Axis
10.3 Thyroid
10.4 Parathyroids
10.5 Adrenal Cortex
10.6 Adrenal Medulla
10.7 Pancreas (Islets of Langerhans)

Introduction
This chapter provides criteria for evaluating per-
10.8 Gonads
manent impairment of the endocrine system. The
endocrine system is composed of the hypothalamic-
10.9 Mammary Glands
pituitary complex; thyroid, parathyroid, and adrenals;
islet cell tissue of the pancreas; and gonads. These
10.10 Metabolic Bone Disease
ductless glands secrete hormones that regulate the
activity of organs or tissues of the body. These hor-
10.11 Endocrine System Impairment Evaluation
mones control growth, bone structure, sexual devel-
Summary
opment and function, metabolism, and electrolyte
balance. The various endocrine glands are usually
interdependent, and a disorder of one gland may be
reflected by dysfunction in one or more of the other
endocrine glands, which, in turn, may affect other
body systems. Consider multiple system effects when
an endocrine permanent impairment is identified.
The following revisions have been made for the
Sixth Edition: (1) the descriptions of endocrine gland
function and of disease states have been updated, as
well as the techniques for evaluation of these dis-
eases; (2) the nomenclature of test procedures and of
disease entities, such as diabetes mellitus, has been
updated; and (3) a new method of impairment analy-
sis has been provided along with multiple examples.
213
Guides6e_10_213-246.indd 213 2/17/09 2:47:27 PM

In brief, this new model accomplishes many of the status irrespective of the efficiency of the hormone
goals set forth in Chapter 1. This model strives for replacement or suppression.
internal consistency among the various endocrine
When an endocrine disorder results in decreased
disorders and reflects consensus statements derived
secretion of a hormone, it is usually possible to
from practicing internists and impairment evalu-
replace the hormone by either the oral or the paren-
ators. It also strives for a consistency of ratings
Chapter 10
teral route, resulting in virtual normalization of body

between the various endocrinologic impairments and
physiology. In cases where the replacement hormone
impairments in other organ systems.
does not completely mimic the normal hormonal
Another change in this chapter is the inclusion of state, the individual may be given an impairment
iatrogenic endocrinologic impairment. This change rating to reflect the signs, symptoms, or the changes
allows for the ability to rate the signs, symptoms, that occur in his or her normal daily activities cre-
and physiological effects caused by medical treat- ated by the residual hormonal insufficiency.
ment with hormonal agents. As an example, oral
Disorders resulting in an increased secretion of a
prednisone prescribed to control the signs and symp-
hormone are often amenable to effective treatment.
toms of asthma can result in the individual develop-
In some cases, the treatment may leave the indi-
ing iatrogenic Cushing’s syndrome, which would
vidual with a reduced ability to secrete the hormone,
then be rated as though the Cushing’s syndrome
requiring replacement hormone. This situation is
were a primary ratable disorder. If the prednisone
then similar to that of the patient who presents with
were used to control 2 simultaneous disorders, such
a hormonal deficiency. In other cases, the condi-
as occupational asthma and Crohn’s disease, appor-
tion can only be treated incompletely or not at all.
tionment issues will also be applicable (see Chapter
Impairment then is assessed based on the physiologic
2). Sufficient details need to be supplied in the writ-
consequences of the hormone excess, its effects on
ten report to support the inclusion of a rating for an
other organ systems, and the disturbances in the
iatrogenic endocrinologic disorder.
person’s ADLs created by the signs and symptoms of
the hormone excess.
Endocrine deficiencies may cause or be associ-
10.1 Principles of Assessment ated with impairments of other organ systems.
Impairment ratings in other body systems are evalu-
ated separately and then combined with the impair-
Guides’ user should become familiar with Chapters
ment rating from this chapter, using the Combined
1 and 2 and the Glossary. Chapters 1 and 2 discuss
Values Chart in the Appendix to determine the esti-
the Guides’ purpose, applications, and methods of
mated whole person impairment (WPI).
performing and reporting impairment evaluations.
The Glossary provides definitions of common terms
10.1a Methodology for Determining the
used by many specialties in impairment evaluations.
Grade in an Impairment Class
Dysfunction of an endocrine organ may be the result This chapter employs impairment grids to use in
of an injury to the gland; of disease involving atro- determining the appropriate impairment class (class)
phy, hypertrophy, hyperplasia, or neoplasia; or the and severity grade (grade) within a class for the
result of a partial or total dysfunction of the gland by condition or conditions being rated at Maximum
surgical removal, radiation, or medication. An endo- Medical Improvement (MMI). As was stated in chap-
crine impairment develops from altered hormone ter 1, the decision regarding which factor is the pri-
levels by either oversecretion or undersecretion of mary determinant of impairment (key factor) will be
the hormone or hormones by one or more endocrine clearly stated in each organ system impairment grid.
glands and the effect of such hormonal aberrations For this chapter on the endocrine system, history
on nonendocrine tissue. An endocrine impairment will usually serve as the key factor. The examiner
also develops from altered hormonal levels caused will use this key factor to determine the appropriate
by exogenous administration. An impairment rating class with the middle grade (integer) in that class as
reflects the severity of the medical condition, the the initial (default) rating (see Table 10-1). The exam-
need for medication, the effects of the discontinu- iner will then use non-key factors to assign grades
ation of these medications, and the effects of the for factors other than that considered “key,” with
impairment on the individual’s ability to perform it being impossible to move upward or downward
Activities of Daily Living (ADLs). As stated in between classes based on these non-key factors. The
Chapter 1, even with appropriate medication, some number of potential grades for each impairment
individuals will never regain their previous health class varies based on the number of relevant factors.
Guides6e_10_213-246.indd 214 2/17/09 2:47:28 PM

The Endocrine System 215
TA B L E 1 0 -1 Methodology for Determining the Grade in an Impairment Class
Chapter 10
IMPAIRMENT
SEVERITY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
↑ ↑ ↑ ↑
When there are 2 non-key factors, there are generally than predict response to treatment). For example, in
5 impairment grades per class; the presence of only those individuals with hypothyroidism, infinite levels
one relevant factor other than the key factor reduces of hormone deficiency may exist ranging from com-
the number of possible grades to 3 per class. plete (as in the person with the total thyroidectomy) to
extremely mild, depending on the amount and degree
If the examiner determines that the other factors
of pathology in the diseased gland. Yet all are amena-
affecting the rating are in the same class that had been
ble, in most circumstances, to complete treatment with
used for the key factor rating, the final rating will
a simple medication that will remove all the signs and
generally stay in the middle of that class. On the other
symptoms of the disorder, returning the person to a
hand, if the classes chosen are higher or lower than
completely functional state.
that used for the baseline impairment rating, the level
will be moved to the right or to the left (to a higher or The same rules provided in the tables in this chapter
lower value) to reflect the numerical discrepancy. For apply when rating a pharmacologic hormonal excess
example, if the key factor places the initial rating in due to the administration of a hormonal agent. The
class 3, grade C and there are 2 non-key factors (lead- report must document: (1) the treated impairing dis-
ing to a total of 5 possible grades) that are in class 1 order, (2) the need for this form of treatment, (3) the
and class 4, respectively, the first factor would move (relative) permanency of this form of treatment, (4)
the grade down 2 levels to grade A and the second the relationship between this form of treatment and
would move it back up 1 level to grade B. However, the attainment of MMI, and (5) other issues as clari-
if both non-key factors were class 1, the rating could fied in each of the subsections of this chapter. The
not go any lower than class 3, grade A, the lowest only issue that will not apply to the rating of cases
value for the class. An exception to this rule may of hormonal excess caused by exogenous adminis-
occur when the key factor is in the highest impairment tration is the need to establish the “presence of” an
class for the disorder, as non-key factors falling in the anatomic or physiological causation.
same class can be used to adjust the impairment rat-
ing upward to the highest grade within the class rather 10.1b Interpretation of Symptoms
than keep it at the middle level. Specific tables will and Signs
indicate if a rating schema other than this is used. The endocrine system has a wide array of glands, each
with specific functions. These signs and symptoms
Unless otherwise specified, the history will be the
are discussed in the section pertaining to each gland.
“key factor” used in all the tables in this chapter. In
most circumstances, it is the only factor. The physi-
10.1c Description of Clinical Studies
cal examination is generally of little value when the
Clinical studies for the endocrine system generally
systemic impact of endocrinologic conditions has
assess hyperfunction (increased) or hypofunction
been mitigated by appropriate medical treatment.
(decreased) of a specific gland, and are discussed in
Likewise, objective tests are useful in endocrinologic
detail in each section. Additionally, imaging studies
disorders but are of limited value when used to define
can be used to detect anatomic glandular abnormali-
the degree of severity of a particular condition. Their
ties such as hypertrophy (hyperplasia), nodules, and
primary utility is to help diagnose the disorder and to
tumors, both benign and malignant.
ascertain the completeness of treatment goals (rather
Guides6e_10_213-246.indd 215 2/17/09 2:47:28 PM

10.1d Specific Methodology for considered as having an endocrinologic residual

Impairment Rating in Endocrine Disorders (as used in the tables found in this chapter) and her
For the reasons discussed earlier, the historical por- endocrine impairment rating will primarily reflect
tion of the impairment tables will be the “key fac- her BOTC. If, on the other hand, residual problems
tor” used to determine the impairment rating. The are not encompassed by other chapters, the patient
tables contain, in addition to the history, impairment should be rated as though meeting the definition of
Chapter 10
classes that are based on the “Burden of Treatment having endocrinologic “residuals.” If these problems
Compliance” (BOTC), which include the therapeutic are attributed to and rated by this chapter, the ratio-
procedures necessitated by the endocrine disorder. In nale needs to be adequately explained in the report.
the endocrine chapter, the BOTC is generally used as
the primary discriminator of the level of impairment 10.1e Impairment Based on Burden
within the class to which the patient was assigned of Treatment Compliance
based on his or her clinical history. As introduced in Chapter 1, impairment based on
the BOTC model is a reflection of the impact on
At times, the more severe an endocrine disorder or the
ADLs. Given the degree to which medical and
longer that it is present, the greater are the chances
dietary regimens (which are at times demanding)
that the disorder will affect other organ systems. For
can fully compensate for even a complete loss of
example, the person with long-standing diabetes will
intrinsic endocrine function (and prevent most, if not
have a greater risk of atherosclerotic consequences.
all, systemic sequelae), it would appear reasonable to
These secondary consequences should be rated using
recognize and provide an impairment rating for the
the chapter that corresponds to the appropriate organ
“burden” of patient compliance with these regimens.
system.
This is especially true given that optimal control of
The field of endocrinology encompasses multiglan- diseases such as diabetes often requires patients to
dular disorders. For consistency in this edition of the adhere to a strict regimen of injections, medications,
Guides, all endocrinologic impairment is combined and blood testing, all of which may require adjust-
when addressing the effects of the various glands ment based on the degree to which diet and activity
and/or hormones. For example, say a person has levels remain constant. This chapter consequently
a multihormonal deficiency caused by a pituitary goes into far more detail regarding the BOTC than
problem, the clinical evaluation is completed, and was seen in other chapters.
the person has attained MMI. In this case, each hor-
1. Medications: BOTC points are assessed reflect-
monal deficiency is rated separately using the rules
ing the frequency of use and the route of
found in this chapter for each of the components
administration.
of the endocrine system, and then these values are
combined. 2. Dietary modifications: BOTC points are assessed
when dietary control is needed to control or mod-
The primary function of endocrine glands is to
ify an endocrinologic disorder.
modulate the function of other organ systems. Thus,
any impairment created by a hormonal perturba- 3. Procedure-based impairment (PBI): BOTC points
tion is usually reflected in the impairment of the are assessed reflecting the consequences of bodily
target organ system that the hormone modulates. invasion for maintaining control over the endocri-
As a result, the impairment ratings in the endocrine nologic disorder.
system are generally lower than the ratings found in
4. Surgical intervention: Surgical intervention that
other organ systems.
is necessary to treat and/or control an endocri-
When the individual has attained MMI and has nologic condition is considered as a treatment in
residual symptoms or physical findings, impair- this chapter. Although not necessarily accruing
ment could be assessed by another organ system BOTC points for use in the tables found in this
or systems, by the endocrinologic condition, or by chapter, surgical interventions allow for inclu-
both methods. For example, a woman is slightly sion into appropriate sections of the tables found
hyperthyroid when at MMI. She has a mild resting in this chapter described as “needing treatment.”
tremor, tachycardia, and anxiety. If the Central and Thus, an individual who required surgical treat-
Peripheral Nervous System, Cardiovascular, and ment for an endocrinologic disorder will always
Mental and Behavioral Disorders chapters (Chapters be considered as “having received required treat-
13, 4, and 14, respectively) completely rate each ment”; placing that individual into class 0 would
of these residual problems, then she should not be be inappropriate.
Guides6e_10_213-246.indd 216 2/17/09 2:47:29 PM

10.1f Rules for use of Burden of TA B L E 10 -2 B

Treatment Compliance in this Chapter Parenteral Medications
Medication Use Dosing Frequency Points
Perform the following analysis to determine the Parenteral, once or less per week 2
BOTC score due to medication use: once per week but once per day 3
Chapter 10
1. Determine the route of administration for medica- 1–2 per day 4
tions and select the appropriate table. Use Table 2 per day 5
10-2a for all medications given by the enteral,
intranasal, and topical routes. Use Table 10-2b for
all medications given by the parenteral routes. If
there is more than 1 medication for either route of Rules for determining the total BOTC points:
administration, use the medication with the great-
Points for Medications Points for Dietary
est dosing frequency.
Modification Points for PBI BOTC Total
2. Determine the points for each medication based
Examples of calculating the medication point
on the dosing frequency.
totals:
3. Add the points from Tables 10-2a and 10-2b to get
A person takes 25 mg of cortisone acetate and 0.1
a total score for medications.
mg fludrocortisone acetate for adrenal insufficiency.
Use Tables 10-2a and 10-2b for determining points Both medications are taken once a day by mouth.
for frequency and route of medications.
1. Add points for all the medications.
Dietary Modification Cortisone acetate once a day, orally 2 points
Some endocrinologic conditions require dietary
Fludrocortisone acetate once a day, orally 2 points
modifications. The degree to which the dietary
modifications are necessary varies from patient Total 2 points, as both medications have the
to patient, as does the degree to which patients same route and dosing frequency
comply with these modifications. The BOTC
2. Add the dietary modification points.
points are assessed for dietary modification when
the patient is compliant with these modifications. None 0 points
They are based on the premise that complying
3. Add the PBI points.
with dietary restrictions restricts ADLs in ways
other than those measured by the history and med- None 0 points
ication use alone. (See Table 10-3).
4. Determine the total.
Procedure-Based Impairment (PBI) 2 0 0 2 points
Points in this section are awarded for procedures
For another example, a person with type 1 diabetes
based on the interferences in an individual’s ADLs
takes 10 U of long-acting insulin at bedtime, 10 U
created by the need for monitoring of the endocri-
of intermediate-acting insulin in the morning, and
nologic condition. Currently, this method of impair-
regular insulin 30 minutes before each meal but not
ment assessment is defined only for blood glucose
before his evening snack. He checks his blood glu-
monitoring for the diabetic individual but can be
cose levels 4 times a day. All medications are admin-
used as a model if other types of monitoring for a
istered subcutaneously. He needs to eat 3 meals per
different endocrinologic condition exists. Refer to
day plus an evening snack. His insulin should be
Table 10-4.
TA B L E 10 -2 A TA B L E 10 -3
Enteral, Intranasal, and Topical Medications Points Assigned for Dietary Modification
Dosing Frequency Points Modification Points
Unscheduled (PRN) 1 Dietary modifications—Minimal 2
1–2 per day 2 Dietary modifications—Moderate 5
2 per day 3 Dietary modifications—Severe 10
Guides6e_10_213-246.indd 217 2/17/09 2:47:29 PM

TA B L E 10 - 4 through neural axons and are stored in the posterior

Procedure-Based Points pituitary. The anterior lobe of the pituitary gland,
Procedure Points
with modulation by the hypothalamus, produces tro-
phic hormones that control the activity of the thyroid
Glucose monitoring—1 time per day 1
gland (thyrotropin [TSH]), the adrenal gland (corti-
Glucose monitoring—2 times per day 2 cotrophin [ACTH]), and the gonads (luteinizing hor-
Chapter 10
Glucose monitoring —3 times per day 3 mone [LH] and follicle-stimulating hormone [FSH]).
Glucose monitoring—4 times per day 4 The chemicals produced by the hypothalamic-pitu-
itary axis (HPA) are thus divided into “full” or final
hormones (with full expression of effect), prohor-
mones (that are precursors of the final hormone), or
considered a single medication that he takes 5 times trophic hormones (that produce their final effect by
a day. He will also need to be rated for his dietary inducing the secretion of the final hormone, that can
restrictions and blood glucose checks, since these express the “full” effect of the hormone, from a dif-
also interfere with his ADLs. ferent gland).
1. Add points for all the medications. Hypothalamic substances also modulate the produc-
tion of growth hormone (GH) and prolactin in the
Insulin subcutaneously 5 times a day 5 points
anterior lobe of the pituitary gland. These 2 hor-
2. Add the dietary modification points. mones, however, exert their effects directly on the
tissues of the body rather than through stimulation of
Dietary modifications (minimal by self-
other hormones. Growth hormone is responsible for
assessment) 2 points
growth of the skeleton before epiphyseal closure and,
3. Add the PBI points. in the adult, maintains normal fat, muscle, glucose,
and skeletal metabolism, as well as a sense of well-
Glucose monitoring 4 times a day 4 points
being. For women, prolactin is necessary for lacta-
4. Determine the total. tion following delivery and for milk production in
the suckling process.
5 2 4 11 points
The posterior lobe of the pituitary is an extension
10.1g Rules for the Determination of of hypothalamic neurons. It is the location where
Endocrinologic Whole Person Impairment ADH (vasopressin) and oxytocin are converted from
1. Choose the appropriate class of impairment based their prohormone state and released into the blood.
on the gland involved and clinical history (key Antidiuretic hormone regulates the fluid balance of
factor). Begin with the middle level of impairment the body through its ability to influence the excre-
for the class. tion of water. The actions of oxytocin may have a
role in the process of labor and lactation. Permanent
2. Calculate the points and respective class for
impairments due to altered function of the thyroid
BOTC and use the class in which the BOTC
gland, adrenal glands, gonads, and GH are discussed
points fall to modify the WPI upward or down-
in subsequent sections of this chapter.
ward within the initial impairment class.
3. Use any other key factor that may be present to 10.2a Interpretation of Symptoms
further modify the impairment rating (grade). and Signs
The HPA may be associated with visual field abnor-
4. Combine with any other endocrinologic
malities, which are considered in Chapter 12, The
impairment.
Visual System. Problems with the HPA may also
present with temporal lobe seizures, frontal lobe
abnormalities, obstructive hydrocephalus, and non-
endocrine hypothalamic dysfunction, which are con-
10.2 Hypothalamic-Pituitary Axis sidered in Chapter 13, The Central and Peripheral
Nervous System.
The hypothalamus and the pituitary are regarded as
a unit because of their interdependent function. The Hypersecretion by the anterior lobe hormones is
hypothalamus produces chemical factors that either caused by microadenomas or macroadenomas.
inhibit or enhance production of anterior pituitary Prolactin excess results in hypogonadism. In women,
hormones. The hypothalamus also produces antidi- this may lead to amenorrhea or oligomenorrhea,
uretic hormone (ADH) and oxytocin, which travel infertility, varying degrees of estrogen deficiency
Guides6e_10_213-246.indd 218 2/17/09 2:47:30 PM

with its detrimental effect on the vascular and skel- Inability of the kidneys to secrete a water load leads
etal systems, decreased libido, and galactorrhea. In to hyponatremia if water intake is not restricted.
men, it may result in decreased libido, impotence, Fatigue and lethargy, progressing to confusion,
or infertility. Impairment from prolactin excess is coma, and seizures, may result based on the degree
equivalent to gonadotropic deficiency of the appro- of hyponatremia.
priate end-organ, that is, secondary ovarian failure in
Chapter 10
Hypofunction of the posterior lobe results in ADH
women and testicular failure in men. Gonadal failure
deficiency and diabetes insipidus. Hypofunction usu-
is discussed further in Section 10.8 of this chapter.
ally stems from diseases involving the hypothalamus
Gigantism results when GH hypersecretion occurs or pituitary stalk and, less commonly, from diseases
before epiphyseal closure; when GH hypersecre- of the pituitary gland itself. The hypofunction may
tion occurs in the adult, acromegaly results. The be hereditary, or it may be related to trauma, surgery,
manifestations of acromegaly include enlargement metastatic tumors, craniopharyngioma, Langerhans
of the hands and feet, coarseness of facial features, cell histiocytosis, and sarcoidosis. If the thirst
prognathism, fatigue, and increased perspiration. response is normal, diabetes insipidus is mostly an
Acromegaly of long duration may lead to degenera- inconvenience because of polyuria, polydipsia, and
tive arthritis, peripheral neuropathy, insulin resis- nocturia. Severe dehydration and hypernatremia may
tance and glucose intolerance, and shortened life result if the inability to ingest an adequate amount
expectancy resulting from cardiovascular disease. of fluid ensues or if thirst is impaired because of
Survival in the acromegalic patient is reduced, on concomitant hypothalamic disease. This can lead to
the average, by 10 years due the cardiovascular con- central nervous system changes, for example, mental
sequences. Controversy exists regarding an excess of depression or coma.
colonic neoplasia.
10.2b Description of Clinical Studies
Hyposecretion of a single or of multiple anterior
Structural abnormalities are evaluated by roentgeno-
lobe hormones is known as hypopituitarism, and the
grams of the sella turcica, computed tomography
deficiencies may be either partial or complete. In
(CT), and magnetic resonance imaging (MRI), espe-
the adult years, pituitary tumors, infarction (espe-
cially with gadolinium. Angiography occasionally is
cially postpartum infarction), infiltrative disease,
required. Evaluation of visual fields may be needed;
granulomatous disease, head trauma, and surgical or
vision impairments are discussed in Chapter 12, The
radiotherapeutic interventions are the most common
Visual System.
causes.
Hormonal function must be assessed, and this is
In adults, hypopituitarism most often results in hypo-
often done by stimulation or suppression testing.
gonadism and a deficiency of GH production. The
Growth hormone deficiency is assessed by measur-
most common symptoms of hypogonadism in men
ing GH in the blood after stimulation testing with
are impotence, weakness, decreased motivation, and
GHRH (growth hormone–releasing hormone).
depression. The most common presenting symptom
Corticotropin deficiency is assessed by measuring
of hypogonadism in women is amenorrhea. Growth
serum corticotropin and cortisol levels and by stimu-
hormone deficiency is accompanied most often by
lation testing with insulin or corticotropin-releasing
muscle weakness and reduced exercise capacity, fat
hormone. The diagnosis of secondary hypothyroid-
accumulation (especially intraabdominal), decreased
ism (pituitary and hypothalamic hypothyroidism)
bone density, lack of motivation, a poor sense of
is made by demonstrating low concentrations of
well-being, and social isolation. Postpartum pituitary
thyroid hormones without elevation of the thyrotro-
infarction also results in an inability to lactate due to
pin level. Secondary gonadal insufficiency, that is,
low levels of prolactin. Hypopituitarism in a person
hypogonadotropic hypogonadism, requires the dem-
with diabetes mellitus results in decreasing insulin
onstration of end-organ failure, with low testosterone
requirements with an increased incidence of hypo-
levels in men and low estrogen levels in women, as
glycemic episodes. Effects of dysfunction of TSH
well as low or normal levels of the gonadotropins
and ACTH secretion will be discussed in Sections
LH and FSH. Insufficiency of ADH requires the
10.3 and 10.5, respectively.
documentation of urine hyposmolality in the face of
Hyperfunction of the posterior lobe, which causes a stimulus to concentrate urine, usually water restric-
an excess of vasopressin or the syndrome of inap- tion. Prolactin deficiency is diagnosed by low basal
propriate antidiuretic hormone secretion (SIADH), levels of prolactin and its failure to increase after an
may result from a variety of central nervous system injection of stimulating agents.
disorders; however, SIADH is rarely permanent.
Guides6e_10_213-246.indd 219 2/17/09 2:47:30 PM

Growth hormone excess is documented by elevated causing mental and behavioral disorders (Chapter
insulin-like growth factor (IGF-1), also called 14). The estimated impairments of the various organ
somatomedin-C, and by the failure to suppress GH systems then should be combined by means of the
concentration after a glucose load. Prolactin excess Combined Values Chart in the Appendix.
is documented by measurement of elevated basal
Table 10-5 is to be used in those cases of a hormonal
levels of prolactin. Inappropriate secretion of ADH
Chapter 10
disorder due to an HPA disorder. It is to be used for

is documented by hyponatremia with inappropriately
those hormones or prohormones that are produced
elevated urinary osmolality and sodium levels, in the
by the HPA. It is not to be used for abnormalities of
presence of normal cardiac, renal, adrenal, and thy-
the trophic hormones (TSH, ACTH) produced by
roid function.
the HPA. For the impairment assessment of those
abnormalities, other sections of this chapter should
be used. For example, if a person has an abnormality
Impairment due to HPA Disorders
of the GH (“full” or final hormone) or ADH precur-
The assessment of permanent impairment of the
sor (prohormone), Table 10-5 is to be used to assess
whole person from disorders of the HPA requires
the impairment. However, if a person has an abnor-
evaluation of (l) primary abnormalities related to
mal secretion of their ACTH because of an HPA
GH, prolactin, or ADH; (2) secondary abnormalities
disorder, the endocrinologic impairment is assessed
in other endocrine glands, such as the thyroid, adre-
using the adrenal cortex section of this chapter
nal, and gonads; and (3) structural and functional
(Section 10.5). In those cases in which a trophic
disorders of the central nervous system caused by
hormone is rated by another section of this chapter,
anatomic abnormalities of the pituitary. The exam-
the portions of the appropriate table requiring “the
iner must evaluate each hormonal disorder sepa-
presence of — disorder” is waived based on the
rately, using the guidelines in this chapter for each
“presence of a disorder” of the HPA. Thus, if a per-
of the hormonal abnormalities that exist because of
son has central hypothyroidism (caused by a lack of
an HPA disorder. These values are then combined
thyroid-releasing hormone), the individual is rated by
to produce the final endocrinologic impairment rat-
the thyroid section of this chapter (Section 10.3) as if
ing for the HPA disorder. Following this step, the
his or her primary disorder were based on a disorder
impairment of other abnormalities in close anatomic
of the thyroid gland.
approximation to the hypothalamus and pituitary
gland are evaluated and rated such as those causing Ideally, all impairment ratings are assessed after
impairment in the visual system (Chapter 12), central treatment. When complete hormone replacement
and peripheral nervous system (Chapter 13), or those cannot be successfully accomplished in cases of
TA B L E 10 - 5 Criteria for Rating Impairment due to Disorders of the Hypothalamic-Pituitary Axis
Hypothalamic-Pituitary Axis
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–3% 4%–6% 7%–9% 10%–14%
SEVERITY GRADE 1 2 3 4 5 6 7 8 9 10 11 12 13 14
(%) (A B C) (A B C) (A B C) (A B C D E)
HISTORYa Presence of hypo- Presence of hypo- Presence of Presence of Presence of

thalamic-pituitary thalamic-pituitary hypothalamic- hypothalamic- hypothalamic-
disorder; no treat- disorder; inter- pituitary disorder; pituitary disor- pituitary disor-
ment required mittent treat- daily treatment der; treatment der; treatment
ment required; required; no required; minimal required; signifi-
no residuals residuals residuals cant residuals
BOTC 0 points 1–2 points 3–6 points 7–10 points 11 points
a
Key factor.
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hormone deficiency or when complete hormone Diagnosis: Traumatic diabetes insipidus controlled
suppression cannot be successfully accomplished in by treatment.
cases of hormone excess, then an impairment rating
Treatment: Desmopressin, 0.1 mL (10 g) twice
for that state (hypofunction or hyperfunction) can
daily by nasal spray; no water restriction.
be given. In most instances, however, the effect on
the individual’s health status and ADLs will be the BOTC: Two BOTC points are given for the use of
Chapter 10
result of dysfunction in other organ systems. Note intranasal medication twice a day with no dietary
that these residuals reflect only the residuals that are modification or PBI points.
not addressed by other organ systems (eg, obesity or
Impairment Rating: Based on history, the initial
the cosmetic alterations in a person’s body habitus,
class is 2 at the default level of 5%. The 2 BOTC
as discussed earlier, in Section 10.1c). The BOTC
points place this person in class 1. Therefore, the
is therefore generally the only factor, other than the
rating must be adjusted to the grade in class 2 at 4%
history, that determines the endocrinologic impair-
impairment.
ment in the HPA. Although the history is the key
factor for assigning the impairment class, BOTC will Comment: He was placed in class 2 because daily
allow the evaluator to choose an appropriate impair- treatment was required even though there were no
ment value within that class. other residuals of his disorder (ie, no symptoms or
physical examination abnormalities), and while on
treatment this patient has no interference with his
ADLs.
CLASS 2
4% to 6% Whole Person Impairment
CLASS 4
EXAMPLE 10-1: TRAUMATIC DIABETES
INSIPIDUS

EXAMPLE 10-2: ACROMEGALY
History: Head trauma from a motor vehicle crash 15
months earlier. Fluid intake and output ranged from
4 to 7 L/d. History: After treatment of a growth hormone–
secreting tumor with surgical excision and ionizing
Current Symptoms: Severe thirst; increased fre-
radiation therapy 18 months earlier, symptoms of
quency of urination. Nocturia occurred 3 to 6 times,
fatigue, excess perspiration, and joint discomfort
and thirst during the night is marked. General health
continued. The IGF-1 level remained elevated;
excellent except for fatigue related to interrupted
patient was maintained on a regimen of octreotide
sleep. Symptoms controlled by treatment but recur if
acetate (Sandostatin LAR), 20 mg intramuscularly
a dose of desmopressin is missed. No symptoms of
(IM) every 4 weeks. Testosterone level was low,
other endocrine disease found; able to carry out ordi-
but thyroid and adrenal function remained normal.
nary daily activities.
Libido improved with a testosterone patch; carpal
Physical Exam: Normal. tunnel syndrome required surgical therapy. Blood
pressure was 130/86 mm Hg but required treatment
Clinical Studies: On initial assessment, serum osmo-
with a calcium channel blocker and a diuretic to
lality: 292 mmol/kg H2O (292 mOsm/kg H2O); serum
achieve that level. Further cardiovascular evaluation
sodium concentration: 142 mmol/L (142 mEq/L);
showed that left ventricular ejection fraction was
urine osmolality: 120 mmol/kg H2O (120 mOsm/kg
45% and maximum sustained exercise capability did
H2O); specific gravity: 1.003. No glycosuria. Attempt
not exceed 8.0 METs.
at water deprivation led to severe thirst with a serum
osmolality of 302 mmol/kg H2O (302 mOsm/kg Current Symptoms: Pain in knees and back;
H2O) and urine osmolality of 150 mmol/kg H2O fatigue; decreased libido incompletely treated with a
(150 mOsm/kg H2O). After an initial ADH injec- testosterone patch; hyperhidrosis.
tion, urine osmolality rose to 450 mmol/kg H2O
Physical Exam: Clinical hyperhidrosis; carpal tun-
(450 mOsm/kg H2O) and urine volume diminished.
nel syndrome; enlargement of hands, feet, and nose;
Placed on a regimen of desmopressin, 0.1 mL (10 g)
blood pressure 174/98 mm Hg.
twice daily by nasal spray; on this regimen, feels well
and urine output is well controlled.
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Clinical Studies: Enlarged sella turcica with supra- Hyposecretion (ie, hypothyroidism) is manifested
sellar extension of a pituitary tumor. No visual field by lethargy, mental process slowing, weakness, cold
abnormalities. intolerance, dry skin, constipation, and/or myx-
edema. Late hypothyroid complications include myo-
Diagnoses: Moderately severe acromegaly, inad-
cardial insufficiency, effusions into body cavities,
equately controlled by therapy; hypertensive car-
and coma.
Chapter 10
diovascular disease partially caused by acromegaly,

arthralgias partially caused by acromegaly; central
hypogonadism caused by radiation treatment.
Clinical studies include but are not limited to a
Treatments: Testosterone patch (5 mg) applied once determination of: (1) circulating thyroid hormone
a day; diltiazem, 180 mg once a day; hydrochloro- levels, including total thyroxine, free thyroxine,
thiazide, 12.5 mg once a day; and octreotide acetate, triiodothyronine, and free triiodothyronine; (2) cir-
20 mg every 4 weeks. culating pituitary thyrotropin level; (3) radioiodine
uptake of the thyroid gland; and (4) thyroid antibod-
BOTC: Medications are given by 2 different routes,
ies. The nature of thyroid nodules is often best evalu-
so 2 points are given for the once daily testosterone
ated by needle aspiration followed by surgery in
patch, and 2 points for the octreotide acetate given
appropriate cases.
IM every 4 weeks. There are no points for dietary
modifications or PBI, so a total of 4 points are given.
Impairment Rating: Based on history, class 4, Impairment due to Thyroid Disease
grade C (12%) due to persistent biochemical abnor- In practically all individuals with hyperthyroid-
malities and significant residuals. The initial default ism, the condition can be corrected by treatment
grade is 12%, but the BOTC points are consistent and there is no loss in the ability to perform ADLs.
with class 2, which brings the impairment level 2 However, the ophthalmopathy seen in some patients
grades down to 10%, the lowest value for this class. with hyperthyroidism caused by Graves’ disease
This is combined with other hormonal and/or organ may persist after treatment of the thyrotoxic state
system impairments such as (1) upper extremity and result in permanent cosmetic disfigurement
impairment from carpal tunnel syndrome; (2) der- and/or visual impairment. In severe cases, loss
matologic impairment for the hyperhidrosis; (3) of vision may result. These conditions should be
cardiovascular impairment for hypertension and evaluated as described in the chapter on the visual
diminished exercise capacity caused by dimin- system (Chapter 12). Atrial fibrillation that persists
ished cardiac output; and (4) the impairment for following adequate treatment of hyperthyroidism
headaches. should be evaluated as described in the chapter
on the cardiovascular system (Chapter 4). In most
Comment: Fatigue, diminished libido, arthralgias,
instances, hypothyroidism can be controlled satisfac-
and enlargement of the hands persist. These prob-
torily by the administration of thyroid medication.
lems are addressed as the “significant residuals when
Occasionally, because of associated disease in other
at MMI,” as they are not addressed by other organ
organ systems, full hormone replacement may not
systems. The remainder of the residuals and their
be possible. In those circumstances, the endocrine
treatment of this person’s acromegaly—the hyperhi-
impairment will reflect the incomplete nature of the
drosis, hypertension, headaches, and poor exercise
treatment. History is the key factor. See Table 10-6.
tolerance—are addressed by other organ systems.
CLASS 1
10.3 Thyroid 1% to 5% Impairment of the Whole Person

EXAMPLE 10-3: HASHIMOTO’S THYROIDITIS
and Signs
The thyroid gland hormonally influences the meta- Subject: 45-year-old woman.
bolic rate of many organ systems. Hypersecretion
History: Symptoms of mild hypothyroidism of 2
(ie, hyperthyroidism) is manifested by nervous-
years’ duration. Required daily therapy with 0.20
ness, weight loss, heat intolerance, goiter, tachycar-
mg of levothyroxine to maintain TSH in the normal
dia, palpitation, atrial fibrillation, frequent bowel
range and thyroid slightly enlarged at 1 cm.
movements, tremor, and/or muscle weakness.
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TA B L E 10 - 6 Criteria for Rating Impairment due to Thyroid Abnormalities
Thyroid Abnormalities
Chapter 10
CLASS CLASS 0 CLASS 1 CLASS 2
WHOLE PERSON
IMPAIRMENT RATING (%) 0 1%–5% 6%–10%
SEVERITY 1 2 3 4 5 6 7 8 9 10
GRADE (%) (A B C D E) (A B C D E)
HISTORYa Presence of thyroid disor- Presence of thyroid disor- Presence of thyroid disor-
der; no treatment required; der; treatment required; no der; treatment required;
no residual symptoms residual symptoms residual symptoms
PHYSICAL EXAMINATION Thyroid examination Residual goiter or cosmeti- Residual goiter or cos-
normal cally noticeable nodule metically noticeable nodule
1.5 cm 1.5 cm
BOTC 0 points 1–3 points 4 points

a
Key factor.
Current Symptoms: None. 10.4a Interpretation of Symptoms

and Signs
Physical Exam: Mildly enlarged thyroid. Heart rate
Hypersecretion of PTH, or hyperparathyroidism,
88 beats per minute (BPM) with regular rhythm.
may be due to the hyperfunctioning of 1 gland, as
Clinical Studies: Needle biopsy: indicated lympho- with an adenoma, or of all 4 glands, as with hyper-
epithelial goiter (Hashimoto’s thyroiditis). plasia, or may result from a parathyroid carcinoma.
Manifestations of this condition include lethargy,
Medications: Thyroxine, 0.2 mg once a day orally;
constipation, nausea, vomiting, polyuria, and, in
alprazolam, 0.5 mg 3 times a day.
extreme cases, bone pain, renal calculi, renal failure,
Diagnosis: Hashimoto’s thyroiditis controlled by and coma. Hyposecretion of PTH, or hypopara-
treatment. thyroidism, may be congenital in origin or due to
inadvertent removal of the parathyroid glands dur-
BOTC: Two points for the most frequently used
ing thyroidectomy, surgical excision for the treat-
medications with no dietary modifications or PBI
ment of hyperparathyroidism, or unknown causes.
points given.
Manifestations include chronic fatigue, paresthesia,
Impairment Rating: Class 1, 3% impairment of the tetany, and seizures. Additionally, in cases of chronic
whole person, based on history. The BOTC points hypocalcemia, there may be cataracts, eczema-
and the slightly enlarged thyroid are also consistent tous dermatitis, alopecia, and abnormal dentition.
with class 1, so the impairment level remains at Hypoparathyroidism may also coexist with hypo-
3% WPI. function of other endocrine organs caused by poly-
glandular autoimmune deficiency that might present
with hypothyroidism, diabetes mellitus, adrenal
insufficiency, hypogonadism, and pernicious anemia.
10.4 Parathyroids
The secretion of parathyroid hormone (PTH) from Techniques for evaluating parathyroid gland function
the 4 parathyroid glands regulates the levels of include determinations of serum calcium (including
serum calcium and phosphorus that are essential ionized calcium), phosphorus, albumin, creatinine,
to the proper functioning of the skeletal, digestive, magnesium, PTH levels, 1,25(OH)2 vitamin D,
renal, and nervous systems. The major abnormalities calcium concentration in urine, and urinary calcium
of these glands include hyperfunction, hypofunction, to creatinine 24-hour clearance ratios. Intravenous
and carcinoma. pyelography, skeletal roentgenography, renal
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ultrasound, and bone density studies may be use- system. The physical examination findings that are
ful. Sestamibi scanning with or without iodine 123 included in Table 10-7 refer to those abnormalities
(I123) subtraction as well as ultrasonography, MRI, that can be explained by uncorrected abnormalities
and CT are all useful tools in localizing parathyroid in the serum calcium. If another chapter rates all
adenomas. the residual signs and symptoms, the examiner uses
a lower parathyroid class. Rarely will an adenoma
Chapter 10
10.4c Criteria for Rating Permanent give rise to local symptoms due to a mass effect;
Impairment due to Parathyroid Disease when it does, these symptoms can be considered
In most cases of hyperparathyroidism, surgi- here unless rated by another organ system. The same
cal treatment results in correction of the primary holds true for residuals caused by surgery that was
abnormality, although secondary symptoms and performed for a parathyroid disorder. In these cases,
signs may persist, such as fracture, renal calculi, or the adenoma or surgical residuals must give rise to
renal failure. The latter signs should be evaluated problems that are sufficient to cause alterations in a
according to criteria in the chapters dealing with the person’s ADLs, allowing for inclusion in a class 1 or
musculoskeletal system (Chapters 15 through 17) or 2 parathyroid impairment. The only exception to this
the urinary and reproductive systems (Chapter 7). If rule occurs when the symptoms are so significant
surgery fails, or if the individual cannot undergo sur- that they are ratable by another organ system, for
gery, long-term therapy may be required. The signs example, significant dysphagia that is assessed using
and symptoms of hypoparathyroidism are generally the Digestive System chapter (Chapter 6).
correctable with calcium and vitamin D supplemen-
tation. For those individuals who have persistent
and refractory hypocalcemia, there may be multiple
organ system manifestations, as discussed earlier. CLASS 1
The individual should be rated by those organ sys- 1% to 3% Impairment of the Whole Person
tems, as opposed to a primary rating in this section
unless there are signs and symptoms that are not
EXAMPLE 10- 4: HYPERPARATHYROIDISM
rated by other chapters, such as the person who pres-
ents with residual paresthesia or fatigue. Subject: 28-year-old man.
Note: The “residual signs” of a parathyroid disor- History: Subsequent to an episode of renal colic,
der, as used in other sections of this chapter, refers investigation reveals passing a calcium oxalate stone,
to symptoms that are not rated by a different organ hypercalcemia: 3.1 mmol/L (12.3 mg/dL; normal,
TA B L E 10 -7 Criteria for Rating Impairment due to Disorders of the Parathyroids
Parathyroid Disorders
WHOLE PERSON
SEVERITY 1 2 3 4 5 6 7 8
GRADE (%) (A B C) (A B C D E)
HISTORYa Presence of parathyroid Presence of parathyroid Presence of parathyroid dis-

disorder; no treatment disorder; treatment or sur- order; treatment required;
required; no residual gery required; no residual residual symptoms present
symptoms symptoms
OBJECTIVE FINDINGS b Normal physical exam and Normal physical exam and Residual signs present and/
serum calcium serum calcium or abnormal serum calcium

a
Key factor.
b
Differentiates only between classes 1 and 2.
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8.5 to 10.2 mg/dL), mild hypophosphatemia, elevated BOTC: Two points are given for the most frequent
serum PTH level, and hypercalciuria (452 mg/24 h; medication, calcium, which is consistent with class 1.
normal levels are based on dietary intake; this value
Impairment Rating: Class 1, default level of 2%,
was elevated based on prior diet). These abnormali-
based on history. The normal serum calcium level
ties normalized following surgical treatment of para-
and physical examination are also consistent with
thyroid hyperplasia.
Chapter 10
class 1, so the impairment rating does not change
Current Symptoms: Three months postoperatively, and remains at 2% WPI.
asymptomatic other than periodic episodes of vague
Comment: With continual daily use of safe and
left flank pain.
inexpensive calcium replacement, the woman will
Physical Exam: Normal. remain asymptomatic with no increased likelihood
of morbidity. However, as noted above, this person
Clinical Studies: Serum calcium, phosphorus, and
becomes symptomatic when not taking her medica-
PTH levels, as well as urinary calcium excretion:
tions or taking insufficient dosages.
normal. Renal ultrasound: a large calculus in the left
side of the renal pelvis.
Diagnosis: Primary hyperparathyroidism with ure-
terolithiasis and residual large renal calculus. CLASS 2
Medications: None.
BOTC: BOTC points are 0 (zero).
EXAMPLE 10-6: HYPERPARATHYROIDISM
Impairment Rating: Class 1, 2% WPI, based on the
need for surgery. The BOTC is consistent with class
0 and moves the impairment level down to 1%, the History: Consequent to diagnosis of primary
lowest grade for the class. As the objective findings hyperparathyroidism, 2 neck explorations did not
are consistent with either class 0 or class 1 and he reveal presence of a parathyroid adenoma; treatment
is already at the lowest grade for class 1, his rating eventually consisted of removal of 3½ parathyroid
remains 1% WPI. This should be combined with glands.
other impairments, if applicable.
Current Symptoms: Persistent fatigue, mild nausea,
polyuria, and nocturia.
EXAMPLE 10-5: HYPOPARATHYROIDISM Physical Exam: Normal.
Subject: 62-year-old woman. Clinical Studies: Serum calcium: 3.50 mmol/L (14.0
mg/dL); phosphorus: 0.65 mmol/L (normal 0.74–1.52
History: Surgical treatment for parathyroid hyper-
mmol/L [2.0 mg/dL; normal 2.5–4.5 mg/dL]); PTH
plasia 5 years ago. Due to persistent mild hypocal-
by immunoradiometric assay: 232 ng/L (normal
cemia since surgery, has required daily replacement
10–65 ng/L [220 pg/mL; normal 10–65 pg/mL]);
with 1000 mg of elemental calcium (taken once a
urinary calcium excretion: 190 mg/24 h. Complete
day, 2 tablets of 500 mg each).
blood cell count, serum urea nitrogen (BUN),
Current Symptoms: None until she ran out of and electrolytes: normal other than mild depres-
calcium supplement 5 days ago. Mild perioral and sion of bicarbonate at 19 mmol/L (19 mEq/L).
peripheral paresthesias developed. Ultrasonography, sestamibi, and CT scans failed to
reveal presence of parathyroid tissue in either the neck
Physical Exam: Unremarkable with the exception of
or chest. Bone densitometry values showed T scores
bilateral Chvostek’s sign while “off” treatment.
of 1.8 in the lumbar spine and 1.42 in the hip.
Clinical Studies: Serum calcium: 2.05 mmol/L
Diagnosis: Primary hyperparathyroidism;
(8.2 mg/dL); phosphorus: 1.55 mmol/L (4.8 mg/dL);
osteoporosis.
both returned to normal with resumption of calcium
replacement. Medications: Alendronate, 70 mg once a week orally.
Cinacalcet (Sensipar) was titrated to control serum
Diagnosis: Surgically induced hypoparathyroidism,
calcium at a level of 2.63 mmol/L (10.5 mg/mL); final
mild.
dosage was 30 mg twice a day orally.
Medications: Calcium once a day.
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BOTC: Two points are given for the use of cinacal- the adrenogenital syndrome, and primary aldoste-
cet; however, no other points are given. ronism. Hypersecretion of the adrenal cortex caused
by hyperplasia may be associated with either a tumor
Impairment Rating: Class 2, 6% WPI based on his-
of the anterior pituitary gland or one that arises
tory of symptoms and persistent calcium abnormali-
outside the endocrine system and causes ectopic cor-
ties when at MMI. The BOTC points are consistent
ticotropin secretion. Iatrogenic Cushing’s syndrome
Chapter 10
with class 1; hence, the rating moves down 1 grade

caused by the use of supraphysiologic doses of
to 5% WPI., As there is another non-key factor, the
glucocorticoids administered for systemic diseases,
abnormal serum calcium level is also consistent with
such as bronchial asthma, systemic lupus erythema-
class 2. Because the rating in the highest impairment
tosus, or rheumatoid arthritis, is the most common
class for a system is used to move the rating higher
cause of adrenal hormonal excess. Excess aldoste-
in the class, this moves the impairment grade up
ronism (a mineralocorticoid) may be seen in up to
to 6%.
10% of hypertensive patients.
Comment: The bisphosphonate (alendronate) was
Hyposecretion of adrenocortical hormones may
used to treat the osteoporosis created by his hyper-
be primary, resulting from surgical removal of
parathyroidism. Since it was not used in the treat-
the adrenals or by destruction of the adrenals by
ment of this man’s hyperparathyroidism, it was not
autoimmune disease, infection (human immunode-
included in the BOTC determination. This medica-
ficiency virus [HIV], tuberculosis), or metastatic
tion will generate points when his metabolic bone
cancer. Alternatively, it may be secondary, result-
disease is evaluated (Section 10.10). After his osteo-
ing from decreased production of corticotropin,
porosis has been rated (calculated at 1% WPI; see
or it may be tertiary, resulting from decreased
Example 10-22), that WPI would be combined with
production of corticotropin-releasing hormone by
the 6% WPI created by the hyperparathyroidism
the hypothalamus. States of relative deficiency
derived above.
may be seen in individuals who have been or are
receiving glucocorticoids; in other words, baseline
levels may be normal, but stress levels of cortisol
may be insufficient due to a variable degree of
10.5 Adrenal Cortex adrenal hyposecretion. Therapy is guided by the
number of hormonal deficiencies, which may be
The adrenal cortex synthesizes and secretes adreno-
single, as in hypoaldosteronism, or multiple, as in
cortical hormones. These hormones participate in
adrenocortical destruction. One normal adrenal
the regulation of electrolyte, water, carbohydrate, fat,
gland can compensate for the loss of the other.
and protein metabolism. They also affect the inflam-
Adrenal stimulation studies need to be performed
matory response, cell membrane permeability, and
in all individuals suspected of hyposecretory states
immunologic responses. In addition, these hormones
to identify and pretreat these persons during times
play a role in the development and maintenance of
of stress.
secondary sexual characteristics. Impairment may
result from either hypersecretion or hyposecretion of
the cortical hormones.
Clinical studies include (1) measurement of adreno-
cortical hormones in the urine, such as free cortisol
and aldosterone, and of hormones in the plasma,
and Signs
such as cortisol and aldosterone; (2) measurement of
Hypersecretion of adrenocortical hormones results
corticotropin, serum electrolytes, plasma glucose,
from gland hyperplasia, tumors, or from pituitary
and creatinine; (3) measurement of the effects of
ACTH hypersecretion (central Cushing’s disease).
suppression and stimulation of adrenocortical func-
The symptoms and signs of adrenocortical disease
tion; (4) roentgenography of the adrenal glands,
may arise from hypersecretion of one or more of the
CT, or MRI and (5) venous drainage sampling of
following hormones: (1) glucocorticoids, (2) miner-
both adrenal veins and inferior petrosal sinus vein
alocorticoids, (3) androgens, and (4) estrogens. In
for pituitary drainage. Techniques used to measure
some instances, there may be hypersecretion of hor-
gonadal hormone levels (androgens and estrogens)
mones in one category and hyposecretion in another.
are covered in Section 10.8.
Among the diseases causing hypersecretion of the
adrenocortical hormones are Cushing’s syndrome,
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10.5c Criteria for Rating Permanent Section 10.8 (Gonads). Thus, any medications used
Impairment due to Adrenal Cortex to treat these abnormalities are included in the
Hypoadrenalism is usually a lifelong condition that BOTC point total in this section. The only issue that
requires long-term replacement therapy with glu- can be rated separately is infertility, if this should
cocorticoids and/or mineralocorticoids for proven occur because of the adrenal cortical disorder. This
hormonal deficiencies. Individuals with mildly hypo- impairment should be assessed using Section 10.8,
Chapter 10
functional glands may prove difficult to identify. They with apportionment, to avoid duplication in the
may be fully functional on an everyday basis while impairment rating.
taking medication but not be able to respond properly
Note: Residual symptoms are those that are not
to the physical stress of fever, trauma, infection, or
rated by other organ systems. For example, a person
very warm weather. This impaired ability to respond
with mildly excessive thirst or mild fatigue, when
to stress needs careful consideration. This consider-
at MMI, should be rated using Table 10-8, whereas
ation must also be given to those individuals receiving
the cardiology chapter would be used to rate a
steroid therapy, as dysfunction of the adrenal glands
person with residual hypertension. The biochemi-
may be seen in individuals who take as little as 5 mg
cal abnormalities are due to the adrenal hormones
of prednisone per day. Adrenal dysfunction can occur
but not measurements of the actual hormone levels
within a few days to a few weeks of continuous treat-
themselves.
ment and is caused by creation of a relative state of
adrenal hyporesponsiveness due to suppression of the
HPA axis. While not a primary manifestation of adre-
nal disease, from a physiological standpoint, it mimics CLASS 1
primary adrenal gland failure. Normal responsive- 1% to 3% Impairment of the Whole Person
ness (recovery) is usually seen in these individuals,
although it does not always occur. Recovery may be
EXAMPLE 10-7: HYPOADRENALISM
incomplete and may take as long as 1 year before an
individual’s permanent status can be reliably assessed. Subject: 32-year-old woman.
Gonadal hormone insufficiencies caused by an History: 10-year history of autoimmune thyroiditis;
adrenal cortical disorder are not to be rated using mother has pernicious anemia.
TA B L E 10 - 8 Criteria for Rating Impairment due to Disorders of the Adrenal Cortex
Adrenal Cortex Disorders

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–3% 5%–9% 10%–20%
SEVERITY 1 2 3 5 7 9 10 15 20
HISTORYa Presence of adrenal Presence of adrenal Presence of adre- Presence of adre-

cortex disorder; no cortex disorder; treat- nal cortex disorder; nal cortex disorder;
treatment required; ment required; no treatment required; treatment necessary;
asymptomatic residual signs and/or residual signs and/or residual signs, symp-
symptoms of active symptoms of active toms, and biochemical
disease, no biochemical disease, no biochemical abnormalities
abnormalities present abnormalities
BOTC 0 points 1–4 points 5–7 points 8 points

a
Key factor.
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Current Symptoms: Over the past year progressive EXAMPLE 10-8: HYPERADRENOCORTICISM
fatigue, weakness, and periodic nausea have devel-
oped; weight loss of 6.75 kg (15 lb). Also has peri-
odic postural dizziness and has developed a craving History: Unremarkable other than the delivery of 2
for salt. children, who are now 6 and 4 years old.
Chapter 10
Physical Exam: Thin female weighing 49.5 kg (110 Current Symptoms: Two years of progressive
lb), height 163 cm (5 ft 4 in), body mass index (BMI) weakness, easy bruisability, hirsutism, facial acne,
18; has spotty areas of vitiligo and hyperpigmenta- weight gain, and depression.
tion, most notable in creases of the hands, elbows,
Physical Exam: Blood pressure: 160/95 mm Hg;
knees, neck, and face. Blood pressure: 120/80 mm Hg
pulse rate: 68 BPM. Marked central obesity with mod-
in the supine position; decreased to 100/65 mm Hg in
erate peripheral muscle wasting and notable proximal
the erect position, with a compensatory tachycardia.
muscle weakness. Rounded and acne-covered face.
Axillary and pubic hair sparse.
Red striae present over buttocks, flanks, and lower
Clinical Studies: Serum sodium: 122 mmol/L abdomen, bilaterally. Mildly increased vellus hair
(122 mEq/L); potassium: 6.0 mmol/L (6.0 mEq/L); growth on face and lower arms.
BUN: 10.71 mmol/L (30 mg/dL). Plasma adrenocor-
Clinical Studies: Diurnal variation of cortisol secre-
ticotropin (ACTH) at 10 am: elevated—16 pmol/L
tion was lost, as suggested by plasma cortisol con-
(74 pg/mL; normal, 1 to 13 pmol/L [6 to 60 pg/mL]);
centrations: 690 nmol/L (25 g/dL) and 607 nmol/L
plasma cortisol: low for 10 am: 110 nmol/L (4 g/
(22 g/dL) at 8 am and 10 pm, respectively (normal
dL) rising only to 165 nmol/L (6 g/dL) following
range, 140 to 552 nmol/L [5 to 20 g/dL]). Urinary
intramuscular injection of 250 g of cosyntropin
free cortisol excretion: elevated—350 g/24 h; plasma
(Cortrosyn; normal 18 g/dL). Serum levels of
corticotropin (ACTH): 2 pmol/L (8 pg/mL; normal
dehydroepiandrosterone sulfate (DHEA-S) and free
range, 1 to 13 pmol/L [6 to 60 pg/mL]). Plasma cor-
testosterone: low; thyroid hormone levels: normal.
tisol and urinary free cortisol excretion failed to sup-
Abnormal serum sodium, potassium, and BUN nor-
press during standard 2-day suppression tests, using
malized on treatment.
2 mg of dexamethasone every 6 hours. CT scan of the
Diagnosis: Addison’s disease. abdomen: a 3-cm tumor in left adrenal gland. With
proper preoperative preparation, left adrenal gland was
Medications: 15 mg of hydrocortisone in the morn-
removed laparoscopically. Glucocorticoid replacement,
ing and 10 mg in the evening and 0.1 mg fludrocorti-
followed by tapering doses over 12 months, resulted
sone once a day, both orally.
in complete resolution of the hyperadrenal state. All
Current Symptoms: Total remission of all signs cosmetic abnormalities receded with the exception of
and symptoms except residual inactive dermatologic residual hyperpigmented striae and hirsutism.
abnormalities. The BMI is now 24.
Diagnosis: Cushing’s syndrome due to adrenocorti-
BOTC: Two points are given for the most frequent cal tumor.
medication, hydrocortisone twice a day. There are
Medications: None.
no dietary modifications or PBI points, so the total
BOTC is 2. BOTC: There is no medication use, no dietary mod-
ifications, and no PBI, so her BOTC is 0.
Impairment Rating: Based on history, the WPI is
class 1, default level of 2%, due to of absence of bio- Impairment Rating: Class 1, default level of 2%,
chemical or physical examination abnormalities of based on history and her prior adrenalectomy. Based
active disease, and the lack of symptoms. Since she on the BOTC, the final rating is modified downward
requires treatment, she is not in class 0. The BOTC 1 grade to 1% WPI. This is combined with dermato-
also places her in class 1, so the final WPI remains logic impairment using Chapter 8, The Skin.
unchanged at 2%.
Comment: Since the surgical cure rate for adrenal
Comment: Hypoadrenalism will be permanent, adenoma is virtually 100%, this individual should
with this individual requiring lifelong treatment be considered cured. Her other adrenal gland should
with an adrenal glucocorticoid and mineralocorti- function normally, even during times of stress, obvi-
coid in order to perform usual ADLs. Dermatologic ating the need for replacement treatment under these
changes can be evaluated in the skin chapter circumstances. This is reflected in her lack of rating
(Chapter 8) and combined with the endocrine for this problem, as opposed to other examples pro-
impairment. vided above.
Guides6e_10_213-246.indd 228 2/17/09 2:47:36 PM

CLASS 2 CLASS 3
EXAMPLE 10-9: HYPERADRENOCORTICISM EXAMPLE 10-10: IATROGENIC CUSHING’S

SYNDROME
Chapter 10
History: Unremarkable past medical history.
History: A 10-year history of occupational asthma.
Current Symptoms: Since puberty, at age 13,
Based on diminishing responsiveness to aggressive
persistent acne and progressive hirsutism, with
treatment regimens, she has required 15 to 20 mg
irregular menstrual cyclicity. Feels self-conscious
of prednisone daily for the past 3 years. Attempts to
and depressed regarding physical appearance. Has
reduce the dosage or substitute with other medica-
difficulty socializing.
tions resulted in 2 hospital admissions.
Current Symptoms: Weight gain of 18 kg (45 lb)
pulse rate: 80 BPM. Height: 167.6 cm (5 ft 6 in);
and dependent edema over the past year. Facial acne,
weight: 72 kg (160 lb), which is diffusely distributed.
easy bruising, recurrent vaginal candidiasis, and low
Markedly increased dark terminal hairs on lower
back pain that has been present for the past month.
back and upper chest, including periareolar, upper
Currently, 145 cm (66 in) tall and weighs 86.6 kg
and lower abdomen, and upper thighs; dark vellus
(220 lb).
hairs on face and lower arms. No striae or purpura.
No evidence of muscular weakness. Physical Exam: Cushingoid habitus, several ecchy-
motic areas over distal upper extremities, tinea versi-
Clinical Studies: Abnormally elevated plasma
color on chest, tenderness over the L2 vertebra with
levels of DHEA-S 108.0 mol/L (normal 1.6–12.2
bilateral paralumbar muscle spasm. “Cheesy” vagi-
mol/L [4000 g/dL; normal 50–450 g/dL]), free
nal discharge, suggestive of monilial infection.
testosterone 59.7 nmol/L (normals 10.4–41.6 nmol/L
[1722 ng/dL; normals 300–1200 ng/dL]), and 17- Clinical Studies: Vaginal discharge containing
hydroxyprogesterone 120 ng/ml (normals 50 ng/ml heavy growth of Candida albicans. Lumbar X ray
[3.6 nmol/L; normals 1.5 nmol/L]). Normal levels reveals marked osteoporosis and compression frac-
of estradiol, luteinizing hormone (LH), and cortisol. ture of the L2 vertebra. Cosyntropin (Cortrosyn)
The cortisol suppresses following the administration stimulation test was performed to check for possible
of 1.0 mg of dexamethasone. Had an exaggerated adrenal insufficiency. Found to have a low basal
17-hydroxyprogesterone response to administration cortisol level with partial response to cosyntropin.
of cosyntropin. Administration of 0.5 mg of dexa- On treatment, low potassium level that was corrected
methasone daily has resulted in normalization of by potassium supplementation. Mild peripheral
the biochemical parameters, resolution of the acne, edema requiring a daily diuretic and low salt diet to
and marked diminution of the hirsutism, but not to maintain normal fluid balance. Placed on a regimen
the point of complete remission. Menstrual cyclicity of calcium and a bisphosphonate for treatment of
returned to normal. osteoporosis.
Diagnosis: Adult-onset 21-hydroxylase deficiency. Diagnosis: Iatrogenic Cushing’s syndrome.
Medications: 0.5 mg of dexamethasone orally Medications: Prednisone, 15 to 20 mg orally once
every day. a day; albuterol, 2 puffs 4 times a day; ipratropium,
2 puffs 4 times a day; cromolyn sodium, 2 puffs 4
BOTC: Points are given for use of the most frequent
times a day; beclomethasone, 4 puffs 4 times a day;
medication, dexamethasone 2 points. There are no
theophylline, 150 mg 4 times a day; hydrochloro-
dietary modifications or PBI points assessed, so the
thiazide, 12.5 mg per day; potassium, 10 mEq twice
total number is 2 points.
a day; calcium, 500 mg 3 times a day; and alendro-
Impairment Rating: The initial appropriate class of nate, 10 mg orally once a day.
impairment based on the history would be class 2,
BOTC: Two points are given for the most frequent
default level of 7%, based on history and her need for
medication, prednisone once daily. To this is added
medication and the continued hirsutism. The BOTC
2 dietary modification points for sodium restriction;
is consistent with class 1; therefore, her final rating
there are no PBI points. The total number of points is
will be modified downward to 5%, the lowest value
2 2 4 points.
for class 2.
Guides6e_10_213-246.indd 229 2/17/09 2:47:36 PM

Impairment Rating: Class 3, default level of 15%, there was adequate suppression with high-dose dexa-
based on history and her cushingoid habitus of more methasone. An MRI of the pituitary failed to reveal
than a mild or moderate intensity. The BOTC is the presence of an adenoma, but CT of the abdomen
consistent with class 1 impairment, leading to adjust- demonstrated bilateral adrenal hyperplasia. Treated
ment of her rating downward to the bottom of the with 4500 rad of conventional megavoltage radiation
class to 10%. Her adrenal cortical impairment needs to the pituitary gland, in addition to 4 g of mitotane
Chapter 10
to be combined with her metabolic bone disease rat- daily to suppress the adrenals and prednisone as
ing to produce a final endocrinologic impairment replacement therapy. Despite this treatment, elevated
rating. The final endocrinologic impairment rating serum sodium and low potassium levels persisted,
is combined, using the Combined Values Chart (in although they did not require treatment (potassium,
the Appendix), with her pulmonary impairment rat- 3.4 mmol/L [3.4 mEq/L]).
ing for her asthma, her impairment rating for her
Diagnosis: Recurrent Cushing’s disease.
vertebral collapse, and any permanent gynecologic
impairment to determine her WPI. Her cushingoid Medications: Prednisone, 5 mg per day orally, and
habitus was used in this section to place her in a mitotane, 4 g orally every day. Persistent nausea and
class 3 endocrinologic impairment category since no vomiting while receiving mitotane, requiring the use
other Guides’ chapter, including the dermatologic, of an as-needed antiemetic (average use, 3 doses per
rates this condition. week) given rectally.
Comment: This case is assessed and rated by 2 por- BOTC: He receives 2 points for use of the most
tions of the endocrinology chapter: this section and frequent medication, prednisone, with no additional
the one on metabolic bone disease (Section 10.10). rating for dietary modifications or PBI.
Two points were assessed for the sodium restriction,
Impairment Rating: Class 3, default level of 15%,
a mild dietary modification. In this example, an indi-
based on history and his habitus, persistent bio-
vidual is receiving a hormonal agent (prednisone)
chemical abnormalities, and significant symptoms.
for an organ system other than her endocrinologic
The BOTC is consistent with class 1; his impairment
system. The effects of this hormonal agent, how-
value is reduced to 10% WPI, the lowest level for the
ever, are endocrinologic. The BOTC does not count
class. Combine with other hormonal and/or organ
the medications she takes for her asthma; these are
system impairments.
accounted for separately according to the pulmonary
rating system and subsequently combined. Comment: Radiation therapy was used to spare the
individual a second surgical procedure on the pitu-
itary gland and the possibility of developing Nelson’s
EXAMPLE 10-11: HYPERADRENOCORTICISM syndrome. Mitotane, as an adrenolytic agent, was
used to achieve immediate control of the hypercorti-
solism since it may take years to achieve maximum
History: Transsphenoidal microadenomectomy 2 benefit from the radiation. Common complaints
years ago as treatment of Cushing’s disease. with the use of mitotane are nausea, vomiting, and
anorexia. The antiemetic was in the medication con-
Current Symptoms: In the past 6 months, 9.0-kg
sideration, even though it is not an endocrinologic
(20-lb) weight gain, acne, ankle edema, proximal
medication, as it is used to treat the side effects of
muscle weakness, and generalized fatigue.
the endocrinologic disorder.
pulse rate: 84 BPM. Central obesity with rounded
plethoric facies; red striae on abdomen and flanks;
prominent proximal muscle weakness. 10.6 Adrenal Medulla
Clinical Studies: Serum sodium: 148 mmol/L
(148 mEq/L); potassium: 2.8 mmol/L (2.8 mEq/L; 10.6a Interpretation of Symptoms
BUN: 5.0 mmol/L (14 mg/dL). Plasma corticotropin and Signs
(ACTH): elevated—33 pmol/L (150 pg/mL); urinary The adrenal medulla synthesizes and secretes pri-
free cortisol: elevated—828 nmol/d (300 g/24 h). marily epinephrine, which functions in the regula-
Plasma cortisol at 8 am: 552 nmol/L (20 g/dL); at tion of blood pressure and cardiac output and, to
10 pm: 607 nmol/L (22 g/dL). Whereas there was some extent, affects the intermediary metabolism
no suppression of plasma cortisol and urinary free of the body. The adrenal medulla is usually not
cortisol excretion with low-dose dexamethasone, essential to the maintenance of life or well-being.
Guides6e_10_213-246.indd 230 2/17/09 2:47:37 PM

Its absence may constitute a permanent impair- 10.6c Criteria for Evaluating Permanent
ment rating if an abnormality is detected in the Impairment due to the Adrenal Medulla
individual’s ability to perform ADLs, especially in The usual cause of the impairment due to diseases
the response to stress. Hyperfunction of the adrenal of the adrenal medulla is the effect on various organ
medulla may be caused by pheochromocytomas systems, not the endocrinologic signs or symptoms.
or, rarely, by hyperplasia of the chromaffin cells. When there are signs or symptoms that cannot be
Chapter 10
Pheochromocytomas may arise at any site in the conveniently evaluated and rated by other organ sys-
body that has sympathetic nervous tissue. The pres- tems, a primary endocrinologic impairment may be
ence of a pheochromocytoma is usually associated assessed. The endocrinologic impairment is based on
with paroxysmal or sustained hypertension and may the interferences in an individual’s ADLs caused by
produce manifestations of coronary artery disease. those symptoms and the medications used to control
Pheochromocytomas may be multiple in a patient those signs and/or symptoms. The impairment rating
and may occur in families in association with med- for this section is best done by estimation and extrap-
ullary carcinoma of the thyroid and hyperplasia of olation, with the rationale explained in detail in the
the parathyroids; this constitutes the syndrome of written report. Comparisons with other impairing
multiple endocrine neoplasia. Approximately 10% of processes, to compare the disturbances in ADLs, are
pheochromocytomas are malignant. helpful and are suggested. See Table 10-9.

These techniques include (1) measurement of unme-
tabolized urinary catecholamines, including total CLASS 1
catecholamines, epinephrine, and norepinephrine, 1% to 5% Impairment of the Whole Person
and of their degradation products in urine: vanillyl-
mandelic acid, metanephrine, and normetanephrine;
EXAMPLE 10-12: PHEOCHROMOCYTOMA
(2) measurement of the plasma free metanephrine
and normetanephrine; (3) suppressive response of Subject: 42-year-old man.
catecholamines to oral clonidine; (4) radiography
History: A 1-year history of high blood pressure,
of the adrenals by CT and MRI; and (5) nucleotide
inadequately controlled by various antihypertensive
scanning.
medications.
TA B L E 10 -9 Criteria for Rating Impairment due to Disorders of the Adrenal Medulla
Adrenal Medulla Disorders

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 6%–15% 20%–30% 40%–60%
SEVERITY GRADE 1 3 5 6 10 15 20 25 30 40 50 60
(%) (A B C) (A B C) (A B C) (A B C)
HISTORYa Presence of Presence of adre- Signs and symp- Signs and symp- Signs and symp-
adrenal medul- nal medullary toms of catechol- toms of catechol- toms of catechol-
lary disorder; disorder; treat- amine excess can amine excess can amine excess can
no treatment ment required; be controlled be controlled be controlled
required; no residual with blocking with blocking with blocking
asymptomatic symptoms agents most agents some agents rarely
(75%) of the (50%) of the time (25%) of the
time time
a
Key factor.
Guides6e_10_213-246.indd 231 2/17/09 2:47:37 PM

Current Symptoms: Episodes consisting of head- and (2) the chronic complications resulting from
ache, palpitations, diaphoresis, and a feeling of inadequate control of hyperglycemia and lipid
apprehension, lasting for up to several hours and metabolism over many years.
occurring from 0 to 3 times per day.
The diagnosis and characterization of diabetes has
Physical Exam: Blood pressure: 130/85 mm Hg undergone significant changes over the past decade.
Chapter 10
(170/110 mm Hg during an episode); pulse rate: Diabetes is currently diagnosed by a reproducible

76 BPM (112 BPM during an episode). fasting blood glucose level equal to or greater than
7.0 mmol/L (126 mg/dL) or by abnormal glucose
Clinical Studies: 24-hour urine specimen: con-
tolerance testing (2-hour postprandial glucose levels
tained large amounts of vanillylmandelic acid
greater than 11.1 mmol/L [200 mg/dL]). Prediabetes
(101 ␮mol/d; normal ⬍6 ␮mol/d) and free catechol-
is diagnosed by reproducible fasting blood glucose
amines (350 ␮g/24 h; normal ⬍120 ␮g/24 h). Plasma
levels in the range of 5.6 to 6.9 mmol/L (100 to
concentration of catecholamines and metanephrine:
125 mg/dL; impaired fasting glucose) or by 2-hour
elevated—5000 pg/mL (normal, ⬍500 pg/mL) and
postprandial glucose levels in the range of 7.8 to
1,200 pg/mL (normal, ⬍240 pg/mL), respectively.
11.0 mmol/L (140 to 199 mg/dL; impaired glu-
Did not suppress following oral ingestion of 0.3 mg
cose tolerance). Individuals with this condition are
of clonidine. CT: a 3-cm tumor in left adrenal gland,
prone to the development of overt diabetes (5% to
which, after proper preoperative preparation, was
10% per year) and are at significant risk of the car-
removed successfully.
diovascular complications of diabetes but not the
Diagnosis: Intra-adrenal pheochromocytoma. ocular, neurologic, or renal complications. In 2003,
there were approximately 17 million people in both
Medications: Following recovery, required no
groups in the United States, with approximately
medications.
33% of diabetic individuals being asymptomatic and
Impairment Rating: Class 1, 1% impairment of the undiagnosed. Almost all cases of prediabetes are
whole person. He required treatment for his condi- undiagnosed.
tion (left adrenalectomy) but is now asymptomatic
A lack of insulin due to an autoimmune destruction
and receiving no medications. He is in a class 1
of beta cell characterizes type 1 diabetes, whereas
impairment level. He has no BOTC points. Based
insulin resistance characterizes type 2 diabetes.
on the lack of BOTC points, his impairment rating
Awareness has grown in the last 10 to 20 years of
defaulted to the lowest grade in this class.
another condition associated with insulin resistance,
the metabolic syndrome. This condition is associated
with characteristic abnormalities of serum lipids,
hypercoagulability, and central adiposity. Individuals
10.7 Pancreas (Islets of Langerhans) with this condition are also at an enhanced risk of
cardiovascular complications with its attendant mor-
Insulin and glucagon are among the hormones
bidity and impairment.
secreted by the islets of Langerhans. Both hor-
mones are required for the maintenance of normal If type 1 diabetes is untreated, severe hyperglycemia
metabolism of carbohydrates, lipids, and proteins. and ketonemia will develop, resulting in dehydra-
Permanent impairment may result from a deficiency tion, weight loss, and severe weakness, ultimately
or an excess of either hormone. Removal of normal progressing into stupor, coma, and then death. This
pancreatic tissue during the resection of an islet cell type of diabetes mellitus usually begins in young
neoplasm does not constitute an endocrine impair- persons, but it may occur at any age. People with
ment if, after the operation, the individual’s carbohy- type 2 diabetes have traditionally been thought of as
drate tolerance is normal. over 40 years old and overweight. However, there is a
growing rise in traditional type 2 diabetes in younger
10.7a Interpretation of Symptoms populations. In the early years of this disease, these
and Signs people do not have severe hyperglycemia and,
Abnormalities of islet cell function may be manifest indeed, may not experience any symptoms of the
by high or low plasma glucose levels. Diabetes mel- disease. In later years, when insulin production falls
litus is classified into 2 main groups: type 1 diabetes significantly, the hyperglycemic symptoms become
and type 2 diabetes. The complications of diabetes more evident. However, the severe manifestations of
mellitus fall into 2 general categories: (1) those that hyperglycemia seen in type 1 diabetic patients are
are directly related to the degree of hyperglycemia not usually seen in people with type 2 diabetes. The
Guides6e_10_213-246.indd 232 3/3/09 6:32:31 PM

principle chronic complications of diabetes mellitus person’s ADLs than does taking a pill orally. The
that cause impairment are retinopathy, nephropathy, same holds true for the maintenance and use of intra-
neuropathy, and atherosclerosis. body reservoirs for insulin. These elements are all
addressed in the BOTC analysis.
Hypoglycemia occasionally causes impairment. It
may result from excessive insulin that either is pro- The physical examination of the diabetic patient is
Chapter 10
duced endogenously or administered exogenously. normal except for the long-term consequences of this
Hypoglycemia may be manifest by weakness, sweat- disease. These consequences are usually the effect
ing, tachycardia, headache, confusion, muscular of the vasculopathy found in diabetes, and they cor-
incoordination, blurred vision, loss of conscious- relate with the control that the individual maintains
ness, and convulsions. Prolonged hypoglycemia or over his or her disease over time. These vascular
repeated severe attacks of hypoglycemia may lead to consequences can affect many different organ sys-
mental deterioration and brain damage. tems and are assessed and rated by the appropriate
chapter such as the chapter on cardiovascular dis-
10.7b Description of Clinical Studies ease, renal disease, or ophthomlogic disease.
Clinical studies include but are not limited to: (1)
Thus, the physical examination is not used in the
determination of fasting and postprandial plasma
impairment assessment of the diabetic patient for
glucose levels; (2) determination of glycated hemo-
rating the diabetes itself, although it serves as the
globin, or hemoglobin A1C (HbA1C), level; (3) mea-
basis for rating its complications through the various
surements of levels of triglycerides, low-density
organ systems that the diabetes affects.
lipoprotein (LDL) cholesterol, and other lipids; (4)
electrocardiogram or cardiac stress testing; (5) oph- Objective testing is also a poor method of rating
thalmologic examination; (6) tests of renal function, impairment in the diabetic patient for several rea-
including measurement of serum creatinine and sons. Serum glucose measurements are inadequate to
urinary protein excretion; (7) Doppler testing of the use as an impairment assessment tool. While valu-
peripheral circulation; (8) roentgenograms of the able in the day-to-day treatment of diabetes, they
chest, gastrointestinal tract, pelvis, or extremities, are more a reflection of the adequacy of the type
including arteriograms; and (9) neurologic testing. and dose of medication or medications, compliance
Much of the impairment that results from diabetes is with dietary restrictions, and the effects of lifestyle,
related to its long-term complications. Therefore, the including the amount and regularity of exercise that
examiner determines, in the patient with diabetes, the individual maintains as part of his or her daily
the presence, or absence of vasculopathy, retinopa- routine. Serum insulin and glucagon measurements
thy, nephropathy, and neuropathy and rates those are of some value in the diagnosis of some glycemic
disorders appropriately. Impairments of other organ conditions but are of no value for the impairment
systems would be expressed as WPIs and then com- assessment.
bined with an impairment percent resulting from the
Measurements of the HbA1c, while poor measures
diabetes, by means of the Combined Values Chart in
of the diabetic condition from an impairment rat-
the Appendix.
ing standpoint, can be used to detect the compli-
ance with treatment regimens; significant elevations
10.7c Criteria for Evaluating Permanent
denote poor control. They can also be used to reflect
Impairment due to Diabetes Mellitus
the severity of the diabetes; the more severe the dis-
The endocrinologic impairment created by the dia-
ease, the more likely that a person will not be able
betic condition is best assessed by using the medica-
to make all the adjustments necessary to maintain
tions given to control the condition as a surrogate
“tight” control. Inadequate control over the diabetes,
of the severity of the disease. Impairment is based
as reflected in an elevated HbA1c, can be the result
on the number of medications used to control this
of improper medication use, poor dietary/exercise
condition, the frequency that those medications are
behavior, or inadequate medication prescription.
given, and the consequences of missing doses of the
Elevated levels are used as a discriminatory factor
medication. Impairment also is based on the interfer-
in the historical portion of the impairment assess-
ences in a person’s daily activities by the disruptions
ment of diabetes to provide the impairment evaluator
created by the diabetes. These interferences include
a method of assessing the degree of control that the
the need for dietary controls and the need to check
individual is capable, or willing, of exerting over
blood glucose levels. Higher impairment values
the disease process. The greater the elevation of the
are given for the route of medication administra-
HbA1c, the lower the compliance and/or ability to
tion since injections create more interference in a
Guides6e_10_213-246.indd 233 2/17/09 2:47:39 PM

maintain a “tight control” over the diabetes. Poorer CLASS 1

control of the diabetic condition is associated with 1% to 5% Impairment of the Whole Person
greater cardiovascular, neurologic, and nephrologic
complications and provides a marker of future
EXAMPLE 10-13: TYPE 2 DIABETES MELLITUS
impairment risk.
Chapter 10
Thus, diabetes mellitus, from an endocrinologic

standpoint, is assessed primarily by its interferences History: Diabetes discovered on a routine medical
in a person’s ADLs through the need for medica- examination.
tion, the route of administration of the medication,
Current Symptoms: Feels well, lost 25.4 kg (25 lb)
the need for blood testing, and the need for dietary
in the last year. Able to perform all desired activities.
adjustments. Other factors in the historical assess-
Maintains a lowered energy, or caloric, intake, which
ment that are important to evaluate are the problems
he describes as creating no significant interferences
encountered due to hyperglycemia and hypoglyce-
in life or lifestyle. Weight has been stable over the
mia. Each condition can cause symptoms as well
past 6 months.
as hospitalizations. Not only an indication of the
control that the individual maintains over his or her Physical Exam: Moderately obese. Retinal exami-
diabetes, hyperglycemia and hypoglycemia are used nation showed no diabetic retinopathy. Remainder of
to assess the impairment created by the diabetes as a exam: normal.
major indication of an interference in a person’s nor-
Clinical Studies: Medical examinations during a 2-
mal lifestyle. Lastly, the HbA1c level is used to assess
year period disclosed 1 glycosuria. Fasting plasma
the degree of control, over time, of the diabetes. (See
Table 10-10).
TA B L E 1 0 -1 0 Criteria for Rating Impairment due to Diabetes Mellitus
Diabetes Mellitus
CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 C L A S S 4*
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 6%–10% 11%–15% 16%–28%
SEVERITY GRADE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 19 22 25 28
(%) (A B C D E) (A B C D E) (A B C D E) (A B C D E)
HISTORYa History of Presence of dia- Presence of Presence of Presence of

impaired glucose betes and/or met- diabetes, estab- diabetes, estab- diabetes, estab-
tolerance, estab- abolic syndrome, lished biochemi- lished biochemi- lished biochemi-
lished biochemi- established cally, generally cally, generally cally, that is not
cally, that does biochemically, well controlled well controlled consistently con-
not require treat- treated with a with moder- with complex trolled despite
ment or dietary relatively simple ate intensity medications use of any treat-
modification single oral medi- treatment regi- 4 oral agents ment regimen
cation and/or men of 2–3 oral or use of insu- and adherence
dietary regimen; agents or insulin lin with oral to an aggressive
no insulin used and dietary agents and sig- dietary and medi-
modifications nificant dietary cation regimen;
modifications documented by
abnormal glucose
measurements
OBJECTIVE TEST Normal HbA 1c Normal HbA 1c Normal to ele- Elevated HbA 1c Elevated HbA 1c
RESULTS 0.06 (6%) 0.06–0.065 vated HbA 1c 0.06– 0.081–0.10 0.10 (10%)
(6%–6.5%) 0.08 (6.6%–8%) (8.1%–10%)
a
Key factor.
Guides6e_10_213-246.indd 234 2/17/09 2:47:39 PM

glucose level: 8.9 mmol/L (160 mg/dL) on 2 occa- Impairment Rating: Class 1, default grade of 3%,
sions; no albumin in the urine. After 6 months on a based on a history of diabetes that is controlled with
special diet, weight: normal; fasting plasma glucose a relatively simple diet and medication regimen. The
level: 6.1 mmol/L (110 mg/dL). Twelve months after BOTC is also consistent with class 1, as is the HbA1c.
the patient started his diet, and 6 months after achiev- Therefore, the rating remains at the default grade
ing stable weight, fasting glucose level was 5.0 mmol/ of 3%.
Chapter 10
L (90 mg/dL) with a HbA1c concentration at 0.055
(5.5%). Continued to display no albuminuria.
Diagnosis: Type 2 diabetes mellitus controlled by
diet, without evidence of microangiopathy. Subject: 50-year-old man.
Medications: None; at his current level of weight, History: Type 2 diabetes mellitus for 5 years. At
requires little dietary modifications. onset, had a fasting plasma glucose level of 10.5
mmol/L (190 mg/dL) when on a restricted diet and
BOTC: There are no points for medications or PBI,
taking an oral hypoglycemic agent. Right leg was
but 2 points for dietary modifications.
amputated above the knee because of gangrene of
Impairment Rating: Class 1, default grade of 3%, the foot due to severe peripheral vascular disease 4
based on a history of diabetes requiring adherence years ago.
to diet. The BOTC is consistent with class 1, but the
Current Symptoms: Adheres to prescribed diet and
HbA1c is consistent with class 0. The impairment
takes 16 U of isophane (NPH) insulin twice a day
level is consequently reduced by 1 grade to 2% WPI.
(10 U in the morning and 6 U in the early evening)
administered subcutaneously. No symptoms; no
glycosuria or acetonuria. Checks blood glucose lev-
els only sporadically. Refused to take supplemental
Subject: 55-year-old man. doses of insulin throughout the day.
History: Several-year history of signs and symptoms Physical Exam: Right-knee amputee; decreased
of type 2 diabetes mellitus. sensation in stocking-glove distribution over left
lower extremity.
Current Symptoms: Feels less fatigued when glu-
cose level is lower while following diet and taking Clinical Studies: On this regimen, fasting plasma
medications. Does not check blood glucose levels, glucose level: 6.9 to 7.8 mmol/L (125 to 140 mg/dL);
relying on his doctor to do this for him. HbA1c: 0.08 (8.00%).
Physical Exam: No retinopathy or proteinuria. Diagnosis: Type 2 diabetes with complications,
Although he lost weight on a prescribed diet (he now requiring insulin to control hyperglycemia.
weighs 140 kg; 308 lb), plasma glucose level could
Medications: NPH insulin twice a day,
not be maintained within normal limits on that diet.
subcutaneously.
Clinical Studies: When the patient was on a
BOTC: He is given 4 points for the insulin twice
restricted diet alone, his fasting serum glucose level
daily, 2 points for the minimal dietary modifications,
was 6.7 mmol/L (120 mg/dL) and HbA1c was 0.75
and 0 points for PBI as he checks blood glucose lev-
(7.5%). While he took an oral agent (glyburide, 7.5
els only sporadically. Total BOTC equals 6 points.
mg twice a day), fasting blood glucose levels were
consistently under 5.8 mmol/L (105 mg/dL) and, Impairment Rating: Although his diabetes could be
after 4 months of treatment and continued dietary better controlled (based on the HbA1c), his medical
control, HbA1c level was 0.61 (6.1%). regimen of twice-daily injections of insulin does not
justify more than a class 2 baseline impairment rating.
Diagnosis: Type 2 diabetes mellitus, reasonably well
The BOTC is consistent with class 2, as is the HbA1c.
controlled by diet and oral agent.
Thus, the impairment rating remains at the default
Medications: Glyburide twice a day orally. grade of 8%. This will be combined with other hor-
monal and/or hormonal and/or organ system impair-
BOTC: Two points are given for use of the most
ments: including neurologic abnormalities, peripheral
frequent medication, glyburide, with an additional 2
vascular disease, and amputation. He should also be
points added due to necessary dietary modifications,
assessed for the possibility of other end-organ disease,
for a total of 4 points.
such as retinopathy and nephropathy.
Guides6e_10_213-246.indd 235 2/17/09 2:47:39 PM

EXAMPLE 10-16: TYPE 1 DIABETES MELLITUS include but are not limited to: (1) measurement of
plasma glucose and insulin or C-peptide after overnight
Subject: 35-year-old noncompliant woman.
or longer periods of fasting, on several occasions;
History: Poorly controlled type 1 diabetes mellitus (2) roentgenograms of the skull and chest and CT or
for 15 years. Takes injections of 30 U of isophane MRI of the upper abdomen; (3) tests of liver function;
(NPH) insulin before breakfast and 10 U of isophane and (4) tests of adrenocortical and pituitary gland func-
Chapter 10
insulin before dinner. Checks blood glucose levels tion. Documented hypoglycemia requires a detailed
twice a day, averaging 3 days of 7. Poor diet lacking medical evaluation to determine the specific cause.
both calories (energy) and appropriate balance of
food groups and calories throughout the day. Impairment Assessment
Impairment ratings for hypoglycemia follow the same
Current Symptoms: Severe hypoglycemic reac-
principals as diabetes. As can be seen, there are few
tions occur unpredictably several times each week.
impairing consequences of hypoglycemia per se.
Fatigues easily and complains of burning foot pain
Refer to Table 10-11.
and difficulty walking.
Physical Exam: Malnourished on a 3000-kcal diet.
Vibratory sensation and deep tendon reflexes absent
below the knees. Examination of the fundi disclosed CLASS 1
numerous microaneurysms, but there was no visual 1% to 3% Impairment of the Whole Person
impairment.
Clinical Studies: Fasting plasma glucose level: above EXAMPLE 10-17: POSTPRANDIAL
11.1 mmol/L (200 mg/dL). HbA1c: 0.13 (13%). HYPOGLYCEMIA
Diagnosis: Type 1 (insulin-dependent) diabetes mel- Subject: 23-year-old woman.

litus with complications, not adequately controlled
History: Unremarkable medical history with no
by diet and insulin.
family history of diabetes mellitus; no excessive use
Medications: Insulin, subcutaneously, twice a day. of ethanol.
BOTC: She is given insulin twice a day, which Current Symptoms: For past 2 to 3 months, several
equals 4 points, dietary modification equals 2 points, episodes per week consisting of lightheadedness,
and PBI blood checks 6 times a week equal 1 point. tachycardia, anxiety, hunger, and diaphoresis, which
Total BOTC is 7 points. resolve 10 to 20 minutes after eating; typically occur
3 to 4 hours after a meal.
Impairment Rating: Her rating is class 2 at the
default grade of 8%. She is considered at MMI, even Physical Exam: Unremarkable.
though better control would be theoretically possible;
Clinical Studies: A 5-hour oral glucose tolerance
her history is that she is not amenable to changes in
test with 100 g of glucose: glucose concentration
her diet or insulin regimen. The BOTC is class 2, and
nadir of 2.5 mmol/L (46 mg/dL) at the fourth hour;
there is no change in the default setting. However, the
was associated with the described current symptoms.
HbA1c is very high and therefore moves her grade up 2
Thyrotropin (TSH), sodium, potassium, alanine
points to a final rating of 10% WPI.
aminotransferase (ALT), and alkaline phosphatase:
Comments: Combine with other hormonal and/or normal.
organ system impairments. Combine endocrine
Diagnosis: Postprandial (reactive) hypoglycemia.
impairment with impairment from her neurologic,
Diet consisting of regular meals, limited quantities
ophthalmologic, and vascular disorders. She is at
of refined carbohydrate, and ingestion of snacks
high risk of future end-organ complications.
between meals and at bedtime resulted in abatement
of symptomatic episodes.
10.7d Hypoglycemia
Medications: None.
Description of Clinical Studies
Distinction must be made between the presence of BOTC: 2 BOTC points for dietary modifications.
postprandial and postabsorptive hypoglycemia, since
Impairment Rating: Class 1, 2% impairment rating,
postabsorptive hypoglycemia suggests the possibility
based on both her history and her minimal dietary
of a severe or even fatal disorder, whereas postpran-
adjustments (she had 2 BOTC points for her dietary
dial hypoglycemia is usually self-limited and rarely
modifications).
produces physical impairment. The techniques used
Guides6e_10_213-246.indd 236 2/17/09 2:47:40 PM

TA B L E 1 0 -11 Criteria for Rating Impairment due to Hypoglycemia
Hypoglycemia
Chapter 10
WHOLE PERSON
SEVERITY GRADE (%) 1 2 3 4 5 6

(A B C) (A B C)
HISTORYa History of hypoglycemia, History of hypoglycemia, History of hypoglycemia,

established biochemically, established biochemically, established biochemically,
that does not require any controlled by treatment not controlled by treatment
form of treatment
OBJECTIVE TEST RESULTS Normal HbA1c 0.06 Normal HbA1c 0.06–0.065 Normal to elevated HbA1c
( 6%) (6%–6.5%) 0.06–0.08 (6.6%–8%)

a
Key factor.
Comment: With proper diet, there should be mini- As in boys, precocious puberty in girls results
mal impact on her ADLs. If her symptoms were not in early and rapid somatic development and an
controlled despite diet, she might have been class 2. increased rate of skeletal maturation and height
velocity with, ultimately, a short adult stature. Some
ovarian tumors may cause masculinization. Some
adrenal enzyme defects and neoplasms, as well
10.8 Gonads as some gonadal neoplasms, may produce contra-
sexual precocity. Certain ovarian conditions produce
In addition to producing gender-specific sex hor- irregular menstrual periods with heavy bleeding and
mones that affect physical, sexual, development and anemia. Polycystic ovarian syndrome and several
behavior, the gonads produce either spermatozoa or types of ovarian neoplasms may produce severe
ova. The major hormone of the testes is testosterone, hirsutism and virilization, in addition to anovula-
whereas those of the ovaries are estrogen and pro- tion. Additionally, polycystic ovarian syndrome is
gesterone. In addition to the effects created by the associated with the metabolic syndrome; its systemic
normal aging process, dysfunction of the gonads can effects can be mitigated with oral hypoglycemic
be caused by tumors, trauma, infection, chemother- agents that increase the sensitivity to insulin.
apy, irradiation, autoimmune disease, abnormal XY
Testicular hypofunction that occurs before adoles-
chromatin, and surgical removal. Gonadal function
cence results in eunuchoidism, which is accompa-
may also vary with disorders of the HPA.
nied by diminished sexual function, infertility, and
failure to develop or maintain secondary sexual
characteristics. Growth of the body extends beyond
and Signs
the usual age because of delayed epiphyseal clo-
Precocious puberty in boys is accompanied by early
sure. Individuals with this condition usually lack
and rapid somatic development and an increased
endurance and strength. Testicular hypofunction
rate of skeletal maturation and height velocity, but,
that occurs in adulthood results in varying degrees
paradoxically, it results in short adult height because
of regression of secondary sexual characteristics,
of early closure of the epiphyses of the long bones.
sexual function, strength, and endurance and may be
It may result from various central nervous system
accompanied by infertility.
disorders, adrenal enzyme defects, virilizing tumors,
or occasionally as a familial condition. Precocious Ovarian hypofunction, with onset before adoles-
puberty in girls may also be caused by various cen- cence, may be characterized by primary amenor-
tral nervous system disorders, as well as by ovarian rhea, anovulation, poor development of secondary
and adrenal tumors. Often, a cause is not identified. sexual characteristics, and growth beyond the usual
age because of delayed maturation of the skeleton.
Guides6e_10_213-246.indd 237 2/17/09 2:47:40 PM

Menopause is a natural occurrence in older women, potential of being fertile. These issues, in both men
but it also may follow surgical removal of the ova- and women, are complex and beyond the scope and
ries. It may be accompanied by such symptoms as ability of this chapter.
hot flashes, irritability, fatigue, headaches, mild cog-
Gonadal impairment is also present in those indi-
nitive difficulties, and sexual dysfunction.
viduals who have abnormalities of their body habitus
Chapter 10
(as discussed above) other than those causing repro-

ductive abnormalities. These can be assessed using
Clinical studies include but are not limited to:
this portion of the Endocrinology chapter for these
(1) measurements of plasma gonadotropins, prolac-
types of conditions that might not be otherwise rated
tin, testosterone, estrogen, progesterone, DHEA-S,
or addressed. Impairment due to gonadal hormone
androstenedione, and occasionally 17-ketosteroids
insufficiencies are difficult to assess by using for-
in the urine; (2) radiographic determinations of
mulae similar to those found in other places in this
skeletal age in children and adolescents; (3) CT or
chapter or other chapters in internal medicine. Thus,
MRI to evaluate the pituitary, adrenals, and ova-
the method of placing an individual into a particular
ries; (4) sex chromatin and chromosome studies;
class is based on issues that are not otherwise rated
(5) testicular biopsy; (6) semen analysis; (7) vaginal
by other organ systems and fall into the domain
cytologic examination; (8) colposcopy or laparos-
of hormonal deficiencies such as those caused by
copy; (9) endometrial biopsy; (10) ovarian biopsy;
altered body habitus and infertility. Lack of treat-
and (11) pelvic ultrasound in women.
ment for gonadal impairment rarely results in imme-
diate serious pathology, and many of the long-term
effects can be treated directly, so treatment is virtu-
Impairment due to Disorders of the
ally never “required.” If the abnormality results in
Gonads
mild symptoms that do not affect ADLs or fertility,
Care must be taken when assessing the reproduc-
treatment is considered as “recommended”; if there
tive system of either the male or the female to
are physical findings (such as masculinization or
avoid duplicating impairment, or more importantly,
feminization of body habitus) treatment is classified
misusing this portion of the endocrine chapter and
as “highly recommended.”
the sections of the renal chapter that deal with the
sex organs (Sections 7.7 and 7.8). As can be seen Note:
from a perusal of these sections in the Urinary and
1. Psychological issues, if present, are assessed in
Reproductive Systems chapter, Chapter 7 deals pri-
the Mental and Behavioral Disorders chapter
marily with the anatomic aspects of these organs.
(Chapter 14).
This chapter deals primarily with the hormonal
aspects of the reproductive system. 2. Class 3 impairment is based on factors such as
the patient’s age and desire to remain reproduc-
Infertility, however, has not been covered well in
tive. If this leads to intermittent use of medica-
either Guides’ chapter in the past. It can be caused
tions or surgical procedures to achieve fertility,
by an anatomic abnormality or a hormonal abnor-
these are considered as part of the BOTC. This
mality. Regardless of anatomic or hormonal cause,
value should be combined with other endocrine
it can be a source of impairment for both men
impairments found either in this section or in
and women. When assessing impairment from an
other sections of this chapter. See Table 10-12.
infertility standpoint, 2 primary issues need to be
addressed: the age of the patient and the desire of
that individual to reproduce. Men can be fertile
seemingly forever; however, their desire to repro-
CLASS 3
duce may not be as lasting. This issue needs to be
explained carefully in the impairment evaluation
report before awarding any impairment based on
infertility. Women, on the other hand, have a lim- EXAMPLE 10-18: TURNER SYNDROME
ited expectancy for fertility, although with medical
advancements in recent years, this issue has become
more complex than in the past. With the proper History: Has been one of the shortest among peers
use of exogenous hormones and stored ova, almost since childhood. Primary amenorrhea without breast
any woman, of any age, as long as she has an intact development.
reproductive system, can be thought of as having the
Guides6e_10_213-246.indd 238 2/17/09 2:47:41 PM

TA B L E 1 0 -12 Criteria for Rating Impairment due to Gonadal Disorders
Gonadal Disorders
Chapter 10
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5%a 6%–10% 11%–15%
SEVERITY GRADE (%) 1 3 5 6 7 8 9 10 11 12 13 14 15

(A B C) (A B C D E) (A B C D E)
HISTORYb Gonadal disorder Gonadal disorder Gonadal disorder Gonadal disorder

established biochemi- established biochemi- established bio- established bio-
cally; asymptomatic cally; mild symptoms; chemically; moderate chemically; infertility
treatment recom- symptoms or physical based on hormonal
mended but depen- sequelae, treatment dysfunction
dent on symptoms highly recommended
PHYSICAL FINDINGS No abnormalities due No abnormalities Slightly altered body Abnormal body
to a gonadal disorder habitus weight or stature
due to hormonal
abnormality
BOTC 0 points 1–2 points 3–4 points 5 points c

a
If there are no physical findings, consider them as class 1.
b
Key factor.
c
BOTC includes intermittent use of medications or surgical procedures due to infertility.
Current Symptoms: Failure to grow to anticipated 2 points based on the estrogen use reduces the rating
height; absence of menstrual periods. to class 1, bringing the final WPI back to 12%. This
should be combined with impairment ratings from the
Physical Exam: Height: 142 cm (4 ft 8 in); weight:
Urinary and Reproductive Systems chapter (Chapter
46 kg (101 lb); sparse pubic and axillary hair; Tanner
7) for her lack of functional ovaries and so on.
1 breast development; bilateral short fourth metacar-
pals; short, webbed neck. Comment: Monitor for continued sexual develop-
ment. Note that the estrogen was rated as if it were
Clinical Studies: Follicle-stimulating hormone:
taken once a day instead of 25 days out of 30 based
84 IU/L (elevated; regardless of the time during her
on the close approximation. The medroxyproges-
cycle); 45, XO karyotype; renal ultrasound echocar-
terone was not assigned points since it was taken,
diogram and TSH: normal. Treated with replace-
on the average, less than once a day. The average
ment doses of estrogen and progesterone, after
month, for rating purposes, is 28 days long.
which secondary sexual characteristics developed
and menses occurred.
Diagnosis: Gonadal dysgenesis (Turner syndrome). 10.9 Mammary Glands
Medications: Estradiol, 1 mg orally on days 1 to 25,
The mammary glands are not endocrine organs
and progesterone, 200 mg once a day on days 16 to 25.
but, for convenience sake, they are included in this
BOTC: BOTC of 2 points based on the estrogen use. chapter. The mammary glands make, store, and
secrete milk. Absence of the mammary glands
Impairment Rating: Class 3, 12% impairment of
does not cause impairment of the whole person in
the whole person. Physical findings lead to an initial
males, but in premenopausal females it will prevent
impairment rating of 13%. Short stature is also class
nursing. In some endocrine disorders, there may be
3, increasing the rating to 14%. However, a BOTC of
galactorrhea in females and gynecomastia in males.
Guides6e_10_213-246.indd 239 2/17/09 2:47:42 PM

Gynecomastia in males may be accompanied by With the advent of the various forms of plastic surgi-
galactorrhea. The most significant impairment asso- cal procedures for the breasts, many of the surgical
ciated with disorders of the mammary glands, how- results seen in the past can be mitigated; any impair-
ever, is psychological due to cosmetic abnormalities ment rating should be postponed until the individual
and is rated by the Mental and Behavioral Disorders is at MMI, when the individual is stable and no fur-
chapter (Chapter 14). ther surgical intervention is planned. Impairment rat-
Chapter 10
ings for inadequate lactation are appropriate only for

10.9a Criteria for Rating Permanent individuals who are capable and desirous of a future
Impairment due to Mammary Gland pregnancy. The BOTC is not a significant issue in
Disorders mammary impairment.
Impairment of the individual due to abnormalities of
Cosmetic abnormalities are rated at 1% to 5% WPI
the mammary glands occurs in females of childbear-
and can be assessed for both sexes. The actual
ing age with a reduced or absent ability to lactate, in
number is based on the severity of the cosmetic
an individual with galactorrhea sufficient to require
abnormality, because anything more than a minor
the use of absorbent pads, and in a male with pain-
impairment meets the physical examination criteria
ful gynecomastia that interferes with performance
for class 2 and results in the choice of the highest
of ADLs. Mammary impairment is also seen in an
rating for class 1 (5%). Each breast is rated indepen-
individual who has sustained either a disfigurement
dently. As with all endocrinologic impairment, the
or the removal of part or all of 1 or both breasts. This
impairment for each breast is combined before the
disfigurement can be acquired either on a traumatic or
final mammary impairment. Therefore, a maximum
surgical basis. Cosmetic abnormalities of the breasts
of 9% WPI can be assessed based on disfigurement.
as a source of impairment must be associated with an
alteration of the breast because of these mechanisms. The inability to lactate and the problems associated
Cosmetic abnormalities not attributable to trauma or with galactorrhea apply to both breasts simultane-
the residuals of treatment are not ratable. ously. As opposed to the cosmetic issues, each
TA B L E 10 -13 Criteria for Rating Impairment due to Mammary Disorders
Mammary Disorders
CLASS CLASS 0 CLASS 1 CLASS 2a
WHOLE PERSON
SEVERITY GRADE (%) 1 3 5 10 15

(A B C) (A B)
HISTORYb Asymptomatic; cosmetically History of lactation prob- History of mastectomy not

restored breast lems, galactorrhea, or amenable to cosmetic and/
breast disfigurement; treat- or reconstructive surgery
ment may or may not be
required
Impairment from disfigure-
ment applies to each breast
separately; results are
combined
PHYSICAL FINDINGS None Lactation may or may not Both breasts surgically
be present; minor disfigure- removed
ment of 1 or both breasts
or
severe cosmetic deformity
with no ability to lactate
a
The incremental cosmetic and psychological impact of having 1 vs both breasts removed is relatively small. If 1 breast is
removed the impairment rating is 10%; if both have been removed, it is 15%.
b
Key factor.
Guides6e_10_213-246.indd 240 2/17/09 2:47:42 PM

breast is not rated independently of the other. Comment: While asymptomatic, this woman needs
Therefore, there is a maximum rating of 3% WPI to be followed up to address some potential issues:
for the individual with either of these problems. continued tumor shrinkage/biochemical restoration,
The inability to lactate is an impairing issue only medication changes for anticipated pregnancies, and
for females of reproductive age who are capable of the possible recurrence of her tumor with possible
pregnancy. Galactorrhea applies to either sex. Refer mass effect (such as on her optic chiasm). All of
Chapter 10
to Table 10-13. these would be rated separately and combined.
Mastectomy impairment is reserved for females and
includes the psychological impact of the loss. Any
cosmetic deformity in a male, expressed as a psy-
CLASS 2
chological concern, is assessed using the Mental and
Behavioral Disorders chapter (Chapter 14) and can
only account for an additional 3% impairment. No
PBI points are assessed for the primary breast sur- EXAMPLE 10-20: CANCER OF THE BREAST
gery, as these points are incorporated into the ratings
for the different classes found above.
History: History of breast cancer at age 48 years,
removed by complete left-sided mastectomy and
axillary node dissection. Regional metastases were
CLASS 1 found but no other signs of metastatic disease.
1% to 5% Impairment of the Whole Person Received adjuvant radiotherapy. Now disease free
for 4 years. Takes tamoxifen, 20 mg daily. Declined
option of breast reconstructive surgery.
EXAMPLE 10-19: MICROADENOMA OF
THE PITUITARY Current Symptoms: Swelling of left arm with
dysesthesia.
Physical Exam: Unilateral mastectomy.
History: A 1-year history of galactorrhea; takes no
Lymphedema in left arm. Abnormal light touch sen-
medications.
sation in entire arm.
Current Symptoms: Irregular menstrual cyclicity
Clinical Studies: Normal; positive estrogen recep-
and profuse galactorrhea, sufficient to require the
tors in tumor.
use of absorbent pads. Cabergoline, 0.5 mg taken
orally twice a week, was associated with a normal- Diagnosis: History of cancer of the breast with
ization of prolactin levels and menstrual function. regional nodal metastases. Residual lymphedema
due to axillary node dissection. Dysesthesia due to
Physical Exam: Easily expressible milky breast
lymphedema.
discharge; thyroid normal to palpation. Exam normal
after medication stabilized. Medications: Tamoxifen Impairment Class: class 2,
10% WPI, based on the history of the mastectomy.
Clinical Studies: Serum prolactin: 120 g/L (normal
Postmastectomy lymphedema is addressed sepa-
3.8–23.2 g/L [5217 pmol/L; normal 168–1030 pmol/
rately in the cardiovascular chapter (Chapter 4) and
L]); TSH: 1.2 mIU/L mIU/L; BUN: 5.7 mmol/L (16
combined as appropriate.
mg/dL); alkaline phosphatase: 0.58 kat/L (35 IU/L).
Diagnosis: Prolactin-producing microadenoma of
the pituitary.
Medications: Cabergoline. While receiving 0.5 mg
10.10 Metabolic Bone Disease
twice a week, her serum prolactin level was 5g/L
Metabolic bone disease usually does not result
(222 pmol/L).
in impairment unless there is fracture, pain,
Impairment Rating: The initial rating is class 1 deformity, or peripheral nerve entrapment.
based on history of lactation and the need for treat- Hyperparathyroidism, hypogonadism, glucocorticoid
ment. There is no disfigurement of the breasts; there- excess, hyperthyroidism, nutritional deficiencies,
fore, the physical findings are class 1, leading to a and certain drugs may cause osteoporosis that is
rating of 1%. reversible with treatment, and these are discussed
Guides6e_10_213-246.indd 241 2/17/09 2:47:43 PM

elsewhere, as are multiple myeloma and other malig- varies immensely based on patient preference and
nancies. The treatment of renal osteodystrophy may can be minimal.
be highly successful, but even after renal transplan-
Because of the wide variations in dosing (from once a
tation, bone disease may persist. To prevent progres-
day to once a year), the BOTC points are intrinsically
sive skeletal deterioration, it may be necessary to
incorporated into the scheme found in Table 10-14.
employ continuous treatment for primary osteopo-
Chapter 10
It is consequently included in the rating. Impairment

rosis, hypogonadism, Paget’s disease, and vitamin
from fracture, spinal collapse, or other complications
D-resistant osteomalacia. Permanent deformity may
of metabolic bone disease is discussed in the chapters
result from rickets, osteoporotic fractures, and osteo-
on the musculoskeletal system (Chapters 15 to 17) and
genesis imperfecta.
in Pain-Related Impairment (Chapter 3). In general, the
impairment percents shown in the Guides make allow-
ance for the pain that may accompany the impairing
and Signs
conditions, and, as such, no separate rating is incorpo-
Metabolic bone disease is usually asymptomatic
rated into Table 10-14.
unless complications occur, such as fractures or dis-
orders of calcium metabolism leading to neurologic Any associated loss of motion or function caused by
symptoms or renal disease. the osteoporosis, is rated by the appropriate sections
in the chapters on the musculoskeletal system.
Clinical studies include but are not limited to:
(1) dual-energy X-ray absorptiometry (DEXA);
(2) biochemical markers such as alkaline phospha- CLASS 1
tase, osteocalcin, and collagen cross-links; (3) uri- 1% to 3% Impairment of the Whole Person
nary calcium excretion; (4) radiographs and bone
scans; and (5) bone biopsy.
EXAMPLE 10-21: METABOLIC BONE DISEASE
10.10c Criteria for Rating Permanent Subject: 62-year-old woman.

Impairment due to Metabolic Bone
History: 20 years postmenopausal; never used
Disease
hormone replacement therapy due to strong family
Impairment of the whole person should be consid-
history of breast malignancy. No history of bone
ered based on the clinical history and the objective
fractures in recent years.
findings on diagnostic testing (T score). The BOTC
TA B L E 1 0 -14 Criteria for Rating Impairment due to Metabolic Bone Disease
Metabolic Bone Disease

WHOLE PERSON
0 1%–3% 4%–5%a
IMPAIRMENT RATING (%)
SEVERITY GRADE (%) 1 2 3 4 5

(A B C) (A B)
HISTORY 0 History of osteoporosis; History of osteoporosis; History of osteoporosis;

requires no treatment requires treatment either severe or refractory
to treatment
OBJECTIVE TEST RESULTS Abnormal bone densitom- Abnormal bone densitom- Abnormal bone densitom-
etry in past, current T score etry in past, current T score etry, current T score 2
1 1 but 2
a
If meets both criteria, use 5%; otherwise impairment rating is 4%.
b
Key factor.
Guides6e_10_213-246.indd 242 2/17/09 2:47:44 PM

Physical Exam: Unremarkable. No loss of height. Medications: Bisphosphonate, 70 mg once a week

orally.
Clinical Studies: Bone density by DEXA: lumbar
T score of 2.32 SD; hip 2.64 SD. TSH, PTH, Impairment Rating: Class 1, 2% WPI. Class 1
complete blood cell count, BUN, morning and based on a history of osteoporosis that required
evening cortisol, and urinary excretion of calcium: treatment. However, his case was not refractory to
Chapter 10
normal. Treatment was initiated with 10 mg of alen- treatment, nor was it severe. His T score was greater
dronate daily. than 2 and consistent with class 1 impairment. The
rating consequently remains at the middle grade for
Diagnosis: Osteoporosis secondary to
class 1 and is 2%. This may decrease to 1% with
hypogonadism.
continued treatment. This man’s final endocrinologic
Medications: Alendronate, 10 mg orally once a day. impairment rating will be 2% WPI for the metabolic
bone disease combined with the 8% rating for the
Impairment: Class 1 based on a history of osteo-
parathyroid abnormality, to produce a final endocri-
porosis that requires treatment and has not been
nologic rating of 10%.
shown to be refractory to treatment. Her objective
test scores are consistent with class 2. She is conse-
quently given the highest impairment rating possible
in class 1, 3% WPI. This is combined with other
CLASS 2
hormonal and/or organ system impairments, such as
skeletal impairment that might have resulted from a
vertebral compression fracture.
EXAMPLE 10-23: METABOLIC BONE DISEASE
Comment: Bone density should improve and the
risk of fracture should decrease with continued use Subject: 65-year-old woman.
of alendronate, which will decrease her impairment
History: Premature surgical menopause at age 35
rating further.
years, followed by estrogen therapy for 5 years.
Diagnosed with osteoporosis 5 years ago by a bone
densitometry with T score in the lumbar spine of 3.2.
EXAMPLE 10-22: HYPERPARATHYROIDISM
Started on a regimen of alendronate, 10 mg orally once
(CONTINUATION OF EXAMPLE 10 -6)
a day, and calcium, 1000 mg per day orally.
Current Symptoms: Back pain.
History: Consequent to diagnosis of primary hyper-
Physical Exam: Mild kyphosis, otherwise negative.
parathyroidism, neck exploration did not reveal pres-
ence of a parathyroid adenoma; treatment consisted Clinical Studies: X rays showed new osteoporotic
of removal of 3 1/2 parathyroid glands. compression fractures of T7 and T8. Bone densitom-
etry studies showed lumbar T score of 2.3 SD and
Current Symptoms: Persistent fatigue, mild nausea,
radius T score of 1.9 SD. Serum calcium, alkaline
polyuria, and nocturia.
phosphatase, TSH, 25-hydroxyvitamin D, and serum
Physical Exam: Normal. protein electrophoresis all normal.
Clinical Studies: Serum calcium: 3.50 mmol/L (14.0 Diagnosis: Osteoporosis with development of new
mg/dL); phosphorus: 0.65 mmol/L (2.0 mg/dL); PTH fracture while receiving a bisphosphonate.
by immunoradiometric assay: 232 ng/L (normal
Medications: Alendronate discontinued and treat-
10–65 ng/L [220 pg/mL; normal, 10 to 65 pg/mL]);
ment changed to daily subcutaneous injections of
urinary calcium excretion: 190 mg/24 h. Complete
20 g teriparatide for 2 years. Continued on 1000
blood cell count, BUN, and electrolytes: normal other
mg calcium once a day and vitamin D 400 mg/d,
than mild depression of bicarbonate at 19 mmol/L
both orally.
(19 mEq/L). Ultrasonography and sestamibi and CT
scans failed to reveal presence of parathyroid tissue Impairment Rating: Class 2 based on a history of
in either neck or chest. Bone densitometry values osteoporosis that is refractory and severe. Her test
showed T scores of 1.8 in the lumbar spine and results are also consistent with class 2, leading to
1.42 in the hip. 5%, the highest impairment rating in the class. This
is combined with other hormonal and/or organ sys-
Diagnosis: Primary hyperparathyroidism.
tem impairments, such as skeletal impairment due to
her vertebral compression fractures.
Guides6e_10_213-246.indd 243 2/17/09 2:47:44 PM

10.11Endocrine System
Impairment Evaluation Summary
assessment of endocrine system impairment.
Chapter 10
TA B L E 1 0 -15
Endocrine System Impairment Evaluation Summary
Disorder History, Including Selected Relevant Examination Record Assessment of Endocrine Function
Symptoms
General Change in growth; fatigue; weakness; Height; weight; blood pres- As indicated below
nausea; irritability; etc sure; pulse rate; skin tempera-
ture, texture, and moisture;
general muscle strength and
mass
Hypothalamic- Discuss symptoms such as menstrual cyclic- Note breast discharge Measure prolactin, growth hormone,
Pituitary Axis ity, galactorrhea, polyuria, fatigue, weak- IGF-1, urine specific gravity, serum
Visual field examination and
ness, and headache osmolality, CT or MRI of pituitary, and
assessment of target organs as
function of target organs
described below
Thyroid Fatigue; weakness; slowing of mental pro- Achilles’ deep tendon reflexes; Serum free thyroxine, total triiodothy-
cess; cold or heat intolerance; nervousness; thyroid size and nodularity; ronine, and TSH
weight loss; palpitations; eye changes, presence of tremor; anxiety or
Radioiodine uptake and scan of
such as exophthalmos and diplopia; goiter; generalized slowness; propto-
thyroid; ultrasound of thyroid; fine
change in bowel habits sis of eyes and their movement
needle aspiration of thyroid nodule
Parathyroids Fatigue; weakness; nausea, polyuria; renal Chvostek’s and Trousseau’s Serum calcium; phosphorus; parathy-
calculi; muscular irritability; paresthesias; signs roid hormone
tetany; seizures
Urinary calcium excretion; renal ultra-
sound; bone densitometry; ultrasound;
MRI; sestamibi scan of parathyroid
gland
Adrenal Cortex Weakness; easy bruisability; hirsutism; Blood pressure; weight and its Plasma cortisol and aldosterone; urinary
acne; weight gain; depression; menstrual body distribution; skin; muscle cortisol excretion; suppression and
irregularities; fungal infections strength; edema stimulation tests of cortisol; plasma
ACTH; measurement of other steroid
metabolites; serum electrolytes; urinary
17-KS excretion; bone densitometry; CT
or MRI examination of abdomen
Adrenal Episodes of headache, palpitations, Blood pressure; pulse rate Urinary measurement of catechol-
Medulla diaphoresis, apprehension, and weakness amines and their metabolites; plasma
catecholamines and suppressive
response to clonidine; CT or MRI exam
of the adrenals
Pancreas (Islets Polyuria; polydipsia; weight loss; weakness; Blood pressure; pulse rate; Plasma glucose; insulin or C-peptide;
of Langerhans) diaphoresis; tachycardia; blurred vision; weight; skin; eyes; neurologic; HbAlc; lipids; urinalysis; CT or MRI
confusion; loss of consciousness; convul- heart; presence of pulses exam of pancreas
sions; symptoms relevant to dysfunction of
end organs of diabetes mellitus (eg, eyes,
kidneys, nervous system, heart, and vascu-
lar system)
Gonads Lack of secondary sexual development; Gonads; secondary sexual char- Plasma gonadotropins; testosterone;
irregular menstrual cycles or amenorrhea; acteristics; height estradiol; progesterone; semen analy-
infertility; precocious development of sis; pelvic ultrasound; x-ray for determi-
secondary sexual characteristics; hirsutism nation of skeletal age
and virilization; lack of endurance and
strength
Mammary Inappropriate milk production; growth in Breast Estradiol; testosterone; free thyroxine;
Glands the male; lack of development in the female; liver function tests
medication history
Metabolic Fractures; medications; malignancies; renal Skeletal abnormalities Bone densitometry, such as DEXA;
Bone Disease disease urinary calcium excretion; skeletal meta-
bolic markers
Guides6e_10_213-246.indd 244 2/17/09 2:47:45 PM

Chapter 10
End-Organ Diagnosis(es) Degree of Impairment
Damage
Include assessment of sequelae, including end- Record all pertinent diagnosis(es); note if Criteria outlined in this chapter
organ damage and impairment they are at maximal medical improvement; if
not, discuss under what conditions and when
stability is expected
Dysfunction of relevant organs, such as ovaries, Diabetes insipidus, prolactinoma, acromeg- See Table 10-5
testes, thyroid, adrenal, skeleton, and heart aly, Cushing’s disease, panhypopituitarism,
or deficiency of any one or more pituitary
Is often reversible to varying degrees with
hormones
treatment
Eye muscles and other retro-orbital tissue Hyperthyroidism; hypothyroidism; thyroid See Table 10-6
nodule; goiter; carcinoma
Other end-organ dysfunction usually reversible
with treatment
Renal; skeletal Hypoparathyroidism; hyperparathyroidism See Table 10-7
Skeletal; possible fracture Addison’s disease; Cushing’s syndrome; See Table 10-8
adult-onset adrenal hyperplasia
Other end-organ dysfunction usually reversible
with treatment
Possible cerebrovascular accident from severely Pheochromocytoma See Table 10-9

elevated blood pressure
Eyes; kidneys; nervous system; cardiovascular; Diabetes mellitus; insulinoma; reactive See Tables 10-10 and 10-11
skin hypoglycemia
Gonads; skin; skeletal Gonadal dysgenesis; premature ovarian fail- See Table 10-12 and Chapter 7, The
ure; precocious puberty; polycystic ovarian Urinary and Reproductive Systems
syndrome; seminiferous tubule dysgenesis;
orchitis
Breast Galactorrhea; hypoplasia; gynecomastia SeeTable 10-13
Skeleton Osteoporosis; osteomalacia See Table 10-14
Guides6e_10_213-246.indd 245 2/17/09 2:47:45 PM

Bibliography Henry JB, ed. Henry: Clinical Laboratory Methods. 20th

ed. Philadelphia, Pa: WB Saunders Co; 2001.
Bilezikian, JP, Marcus R, Levine MA, eds. The Kahn CR, Weir GC, King GL, Moses AC, Smith RJ,
Parathyroids: Basic and Clinical Concepts. 2nd ed. Jacobson AM, eds. Joslin’s Diabetes Mellitus. 14th ed.
San Diego, Calif: Academic Press; 2001. Philadelphia, Pa: Lea & Febiger/Lippincott Williams &
Bowker JH, Pfeifer MA, eds. The Diabetic Foot. 6th ed. St Wilkins; 2005.
Chapter 10
Louis, Mo: CV Mosby Co; 2001. Larsen PR, Kronenberg HM, Melmed S, Polonsky KS,
Braverman LE, Utiger RD, Werner SC, Ingbar SH, eds. eds. Williams Textbook of Endocrinology. 10th ed.
Werner and Ingbar’s The Thyroid: A Fundamental Philadelphia, Pa: WB Saunders Co; 2003.
and Clinical Text. 9th ed. Philadelphia, Pa: Lippincott Porte D, Sherwin R, Baron A, eds. Ellenberg & Rifkin’s
Williams & Wilkins; 2005. Diabetes Mellitus. 6th ed. New York, NY: McGraw-
Connell JMC, Davies E. The new biology of aldosterone. Hill; 2002.
J Endocrinol. 2005;186:1-20. Rakel RE, Bode ET, eds. Conn’s Current Therapy. 57th ed.
Davidson JK, ed. Clinical Diabetes Mellitus: A Problem- Philadelphia, Pa: Elsevier; 2005: 661–670, 723–776.
Oriented Approach. 3rd ed. New York, NY: Thieme Schwartz A, Pertsemlidis D, Gagner M, eds. Endocrine
Medical Publishers; 2001. Surgery. New York, NY: Marcell Dekker Inc; 2004.
Felig P, Frohman LA. Endocrinology and Metabolism. 4th
ed. New York, NY: McGraw-Hill; 2001.
Guides6e_10_213-246.indd 246 2/17/09 2:47:46 PM

C H A P T E R 11

Structures
Chapter 11
11.2 Hearing and Tinnitus
11.3 The Face
11.4 The Nose, Throat, and Related Structures
Introduction
nent impairments resulting from principal dysfunc-
tion of the ear, nose, throat, and related structures.
Assess permanent impairment ratings of these
structures by evaluating losses in structure or the
following functions: hearing; equilibrium; facial
motion; respiration; mastication, deglutition, olfac-
tion, taste and smell; speech and voice; and the effect
of these losses on the ability to perform activities of
daily living (ADLs). Impairment criteria, listed in
earlier editions of the Guides, were adapted from the
American Academy of Otolaryngology–Head and
Neck Surgery.1 Abbreviations and their definitions
are listed in the Glossary.
For the Sixth Edition, all sections have been
reviewed and revised. The principles used in the
Sixth Edition table organization are consistent with
other chapters and the philosophy established in
Chapter 1. Some changes have been made in the
impairment percentages to provide clear selection of
a specific number and to accommodate additional
ratings in complex cases, which may be combined
with ratings in other chapters. Ratings have also
been changed slightly to increase the consistency
247
Guides6e_11_247-280.indd 247 2/17/09 2:48:52 PM

of ratings for similar levels of impairment in other 11.2 Hearing and Tinnitus
chapters. Thus, the reader should anticipate that
some ratings are slightly higher or lower than in pre- The ear consists of the auricle, the external auditory
vious editions. canal, the tympanic membrane, the ossicles, the mid-
dle ear, the eustachian tube, the mastoid, the inner
ear, and the internal auditory canal. The auditory
and vestibular systems include the ear and central
11.1 Principles of Assessment nervous system pathways.
The ear provides sensorineural input critical to the
senses of hearing and balance. Hearing enables con-
tact with environmental cues (eg, those that alert)
and enables us to communicate socially. Balance
contributes to maintenance of equilibrium in relation
Chapter 11
to the environment. Balance function is mediated

by dynamically monitoring information about the
position of the head, eyes, trunk, and joints at rest
Hearing sensitivity may be tested with and without and with activity. Hearing and some components of
an assistive device. However, only the measure- balance disturbances can be measured objectively.
ment without the assistive device should be used to Chronic otorrhea and other conditions such as otal-
determine the impairment rating. Assistive devices gia and tinnitus that are subjective2(pp483–524) should be
must not be used during the determination of a hear- noted based on the individual’s self-reports, but they
ing impairment rating because the device will give cannot be measured objectively.
a false impression of a subject’s sensitivity and will
Permanent hearing impairment is a reduced hearing
distort the need to consider hearing conservation or
sensitivity, outside the range of normal for healthy
other indicated measures.
young adults.3 Hearing should be evaluated after
maximum rehabilitation has been achieved and when
the impairment is no longer accelerating beyond an
and Signs
age-appropriate rate. Evaluate hearing impairment
The history of specific symptoms and their severity,
based on the individual’s binaural hearing, deter-
duration, and manner of onset, along with the physi-
mined from the pure tone audiogram.4
cal examination and diagnostic studies, will establish
the diagnosis and will guide the impairment rat-
11.2a Evaluation of Hearing Impairment
ing process. Since the ear, nose, throat, and related
Hearing loss may be sensorineural, conductive,
structures have distinct functions, disorders of each
mixed, and central. Sensorineural hearing impair-
system will be covered separately in this chapter.
ment is caused by pathologic processes taking place
Permanent impairments of each system that have
in the cochlea, the acoustic nerve, or the brain stem.
no overlapping functional losses are evaluated sepa-
There are many causes of sensorineural hearing
rately and then combined.
impairment, including excessive noise exposure,
Some impairment classes refer to limitations in the ototoxic medications, childhood diseases, hereditary
ability to perform daily activities. When this infor- hearing loss (which may begin at any age), presbycu-
mation is subjective and possibly misinterpreted, it sis, meningitis, tumors, infections, and head injuries,
should not serve as the sole criterion on which deci- among others.2,5 Conductive hearing impairment is
sions about impairment are made. Rather, obtain due to abnormalities in the external or middle ear,
objective data about the severity of the findings and including but not limited to otosclerosis, otitis media,
the limitations, and integrate the findings with the congenital deformities, otitis externa, and impacted
subjective data to estimate the degree of permanent cerumen. Mixed hearing impairment occurs when
impairment. there is combined sensorineural and conductive
pathology. Examples include advanced otosclerosis
11.1b Description of Clinical Studies and chronic otitis media. Central “hearing loss”
Multiple and diverse tests are used to investigate involves the inability to process auditory signals; it
the ear, nose, throat, and related structures. Some of may be seen with multiple sclerosis, head trauma,
these tests are discussed in the relevant organ system brain tumors and other conditions. It is different
section. from peripheral (inner ear or eighth nerve) hearing
loss in that it is a form of brain dysfunction, cannot
Guides6e_11_247-280.indd 248 2/17/09 2:48:53 PM

Ear, Nose, Throat, and Related Structures 249
be quantified easily; and is excluded from consider- reaching the ear, the spontaneous nerve discharge
ation for impairment rating in this chapter. may cause the patient to experience a false sensation
of sound. This theory sounds logical, but there is no
The human ear has a frequency range from about 20
scientific proof of its validity.
to 20,000 Hz. It is also extremely sensitive in detect-
ing sounds of low intensity. Pure tone measurements Thus, tinnitus is not a disease but rather is a symp-
are made with an instrument called an audiometer. tom that may be the result of disease or injury.
Earphones are placed over the ears or in the ear However, tinnitus is so common that establishing
canal, and tones are controlled for intensity and fre- causation is frequently difficult. The principal rea-
quency to determine the hearing threshold, which is son for the increasing interest in tinnitus within the
the lowest sound pressure level that can be heard by context of a discussion of impairment is its effect
the individual. Routine audiometry requires a vol- on the daily activities of those individuals who
untary response such as raising a finger or hand or have it. The major problem with evaluating tinni-
pushing a button. Hearing is usually measured with tus is that it is primarily a subjective phenomenon.
Chapter 11
pure tone signals at 250, 500, 1000, 2000, 3000, Consequently, it is frequently difficult to verify
4000, 6000, and 8000 Hz. even the presence of tinnitus, let alone its conse-
quences. Nonetheless, if the tinnitus interferes with
Air conduction tests measure the status of the exter-
ADLs, including sleep, reading (and other tasks
nal, middle, and inner ear, including the cochlea,
requiring concentration), enjoyment of quiet rec-
acoustic nerve, brain stem, and cortex. Bone con-
reation, and emotional well-being, up to 5% may
duction tests measure sensorineural function more
be added to a measurable binaural hearing impair-
directly, bypassing the external and middle ear.
ment. There is currently no way to scientifically
Speech reception and discrimination are tested by
evaluate tinnitus, although validated instruments
using spondee and phonetically balanced words.
such as the Tinnitus Handicap Inventory have been
There are more sophisticated and specialized tests, used.7 Consequently, because physicians are often
such as brain-stem evoked response audiometry, required to rate tinnitus, a variety of individually
also called auditory brain-stem response or auditory devised systems have been created using reason-
evoked potential; electrocochleography; otoacoustic able data sources. However, these are not standard-
emission tests; and middle ear impedance measure- ized or generally accepted by any official medical
ment. These tests, along with other medical evalua- organization, such as the American Academy of
tions (blood tests, imaging studies, and other tests), Otolaryngology–Head and Neck Surgery or the
are used by otologists to help determine the nature American Medical Association. As an example, tin-
and specific cause of hearing impairment in selected nitus may be scaled as slight, mild, mild-moderate,
individuals. moderate, or severe.8 Verification of the presence of
tinnitus through techniques matching loudness and
11.2b Tinnitus pitch is fraught with pitfalls and not recommended.
Tinnitus is a term used to describe perceived
sounds that originate within a person, rather than 11.2c Criteria for Rating Impairment due
in the outside world. Although nearly everyone to Hearing Loss
has mild tinnitus momentarily at some point in Criteria for evaluating hearing impairment are
life, continuous tinnitus is abnormal. The National established through hearing threshold testing, which
Center for Health Statistics has reported that about serves as the most reproducible of the measures of
32% of all adults in the United States acknowledge hearing. Hearing impairment is measured by evalu-
having had tinnitus at some time.6 Approximately ating hearing in each ear separately and both ears
6.4% of the affected individuals characterize their together using audiometry. The binaural hearing
tinnitus as debilitating or severe. The prevalence impairment percentage is based on the severity of
of tinnitus increases up until approximately age 70 the hearing loss, which accounts for changes in the
years and declines thereafter.2(pp411–440) This symptom ability to perform ADLs.
is more common in people with otologic problems,
In the calculation of a hearing impairment rating, no
although tinnitus also can occur in otologically nor-
correction for presbycusis should be made because:
mal patients.
(1) the method in Section 11.2d calculates the degree
It has been speculated that tinnitus may be the result of hearing and assigns a rating regardless of cause
of a continuous stream of discharges along the audi- (eg, age, injury, or noise exposure) and (2) age cor-
tory nerve to the brain caused by abnormal irritation rection would result in a reduced binaural impair-
in the sensorineural pathway. Although no sound is ment score that would thus underestimate the true
Guides6e_11_247-280.indd 249 2/17/09 2:48:54 PM

TA B L E 11 -1
magnitude of the hearing impairment. The estima- Monaural Hearing Loss and Impairmenta
tion of the relative contributions of different causes
DSHL b % DSHL b % DSHL b %
of hearing impairment is an apportionment process,
as described in Chapter 2. 100 0 190 33.8 285 69.3
195 35.6 290 71.2
11.2d Audiometric Measurements to 105 1.9 200 37.5 295 73.1
Determine Hearing Impairment 110 3.8 300 75.0
Hearing levels are determined according to
115 5.6 205 39.4
American National Standards Institute (ANSI)
Standard S3.6-1996.4 In the determination of impair- 120 7.5 210 41.2 305 76.9
ments, the following steps should be taken: 215 43.1 310 78.8
1. Test each ear separately with a pure tone audiom- 125 9.4 220 45.0 315 80.6
eter and record the hearing levels at 500, 1000, 130 11.2 320 82.5
Chapter 11
2000, and 3000 Hz. The following rules apply for 135 13.1 225 46.9
extreme values: 140 15.0 230 48.8 325 84.4
a. If the hearing level at a given frequency is 235 50.6 330 86.2
greater than 100 dB, the level should be taken 145 16.9 240 52.5 335 88.1
as 100 dB. 150 18.8 340 90.0
b. If the hearing level for a given frequency has 155 20.6 245 54.4
a negative value (eg, ⫺5 dB), the level should 160 22.5 250 56.2 345 91.9
be taken as 0 dB. 255 58.1 350 93.8
2. Add the 4 hearing levels (dB) for each ear 165 24.4 260 60.0 355 95.6
separately. 170 26.2 360 97.5
3. For monaural impairment, see Section 11.2a and 175 28.1 265 61.9 365 99.4
consult Table 11-1 to determine the percentages 180 30.0 270 63.8 ≥370 100.0
of monaural hearing impairment for each ear. 275 65.6
4. For binaural impairment, see Section 11.2b and 185 31.9 280 67.5
a
consult Table 11-2 to convert the monaural hear- Audiometers are calibrated to ANSI Standard S3.6-1996
reference levels. 4
ing impairment percentages to a binaural hearing b
Decibel sum of the hearing threshold levels at 500, 1000, 2000,
impairment rating. and 3000 Hz.
5. Consult Table 11-3 to determine the impairment

of the whole person. 11.2e Evaluation of Monaural Hearing
Impairment
This method of evaluating hearing impairment
If the average of the hearing levels at 500, 1000,
should be applied only to adults who have acquired
2000, and 3000 Hz is 25 dB or less, according to the
language skills. Evidence suggests that language
1996 American National Standards Institute (ANSI)
acquisition by children who do not have language
audiometric standards,4 no impairment rating is
skills may be delayed when the average hearing
assigned since there is no change in the ability to
level is in the range of 15 to 25 dB. The Guides’
hear everyday sounds under everyday listening con-
methods for calculating impairment are not
ditions (Table 11-1). The 25-dB “fence” represents
intended to examine an individual’s work disability,
this finding; it is not a compensatory adjustment for
but are meant to account for daily activities that are
presbycusis, the hearing loss that occurs with age.
common in most people. Some persons in occupa-
tions (eg, musician, piano tuner) with specific and At the other extreme, if the average of the hearing
difficult hearing-critical tasks may have significant levels at 500, 1000, 2000, and 3000 Hz is more than
work disability despite 0% binaural hearing impair- 91.7 dB, the binaural hearing impairment rating is
ment. Similarly, the Guides’ impairment estimates 100% since the individual has lost the ability to per-
will not necessarily correlate with difficulties perform an ADL—the ability to hear everyday speech.1
forming unusual nonoccupational hobbies, such as
According to the above standards for monaural hear-
bird watching.
ing impairment, for every decibel that the average
Guides6e_11_247-280.indd 250 3/3/09 6:37:12 PM

hearing level or loss of speech exceeds 25 dB, 1.5% reveals the threshold levels in decibels (dB) given in
of monaural impairment is assigned. Thus, with an Comment.
average hearing level loss of 67 dB above 25 dB,
Diagnosis: Mixed (sensorineural ⫹ conductive)
monaural impairment is 100% (Table 11-1).
hearing impairment, right ear. Mild sensorineural
hearing impairment, left ear.
11.2f Evaluation of Binaural Hearing
Impairment Impairment Rating: 5% impairment of the whole
Hearing impairment of both ears, referred to as person.
binaural impairment, indicates a loss of hearing of
Comment: The decimal sum of hearing threshold
greater than 25 dB in both ears at frequencies of
levels (DSHL) for the right ear is 225 (40 ⫹ 55 ⫹
500, 1000, 2000, and/or 3000 Hz.
60 ⫹ 70), and the DSHL for the left ear is 125
Binaural impairment is determined by the following (25 ⫹ 30 ⫹ 30 ⫹ 40). Combine 225 (worse ear) and
formula: 125 (better ear) using Table 11-2 for a binaural hear-
Chapter 11
ing impairment rating (BI) of 15.6%. Use Table 11-3
Binaural Hearing Impairment (%) ⫽
to obtain the 5% whole person impairment rating.
[5 ⫻ (% hearing impairment better ear)
⫹ (% hearing impairment poorer ear)] ⫼ 6 8% Impairment of the Whole Person
To calculate binaural impairment when only 1 ear

exhibits hearing impairment, use this formula, EXAMPLE 11-2: MIXED HEARING
allowing 0% impairment for the unimpaired ear (the IMPAIRMENT, BILATERALLY
ear with the better hearing).
Alternatively, use Table 11-2, which is derived from
History: Repeated ear infections for many years.
the formula given here, to calculate the value for
Hearing loss in both ears and roaring, pulsing,
binaural hearing impairment. Then apply the value
rushing-water tinnitus in both ears. No history of
for binaural hearing impairment to Table 11-3, which
dizziness. Tympanoplasty, left ear, 4 months ago.
converts binaural hearing impairment to impairment
of the whole person. Current Symptoms: Difficulty hearing in both
ears, but hearing much improved in left ear since
tympanoplasty. Still has tinnitus in both ears, which
despite use of hearing aids and cognitive-behavioral
therapy, continues to cause severe sleep difficulties,
5% Impairment of the Whole Person frequent daytime fatigue, difficulty concentrating on
quiet tasks, and moderately severe depression.
EXAMPLE 11-1: HEARING LOSS Physical Exam: Retracted right tympanic membrane.
Subject: 70-year-old woman. Clinical Studies: Left tympanic membrane shows
well-healed graft. Tympanograms: B pattern for right
History: Retired secretary. Chronic recurrent ear
ear. Tympanometry was not performed for left ear
infections since teens. Occasional drainage from
due to recent otologic surgery. Speech discrimination
right ear. Right ear now dry but feels “like stuffed
scores: 80% for right ear; 85% for left ear. Pure tone
with cotton.” Has occasional tinnitus in right ear; not
audiometry reveals the threshold levels in decibels
bothersome. No dizziness.
(dB) given in Comment.
Current Symptoms: Difficulty hearing, especially
Diagnosis: Mixed (sensorineural ⫹ conductive)
in right ear, with no impact on ADLs.
hearing impairment, bilaterally.
Physical Exam: Scarred, retracted right tympanic
membrane. Left tympanic membrane is thickened
person.
and retracted. Pneumatic otoscopy shows motion of
left tympanic membrane, but no motion on right. Comment: The DSHL for the right ear is 210 (50 ⫹
50 ⫹ 55 ⫹ 55), and the DSHL for the left ear is 135
Clinical Studies: Tympanograms: B pattern for
(25 ⫹ 30 ⫹ 40 ⫹ 40). Combine 210 (worse ear) and
right ear and A pattern for left ear. Speech discrimi-
135 (better ear) using Table 11-2 for a BI of 17.8%.
nation score: 80% for right ear; 95% for left ear.
Add 5% for the presence of tinnitus that severely
Acoustic immitance reveals normal external auditory
affects ADLs giving a BI of 22.8%. Use Table 11-3 to
canal volumes for both ears. Pure tone audiometry
obtain the 8% whole person impairment.
Guides6e_11_247-280.indd 251 2/17/09 2:48:55 PM

TA B L E 11-2
Computation of Binaural Hearing Impairmenta
≤100 0.0
105 0.3 1.9
110 0.6 2.2 3.8
115 0.9 2.5 4.1 5.6
120 1.3 2.8 4.4 5.9 7.5
125 1.6 3.1 4.7 6.3 7.8 9.4

130 1.9 3.4 5.0 6.6 8.1 9.7 11.3
135 2.2 3.8 5.3 6.9 8.4 10.0 11.6 13.1
140 2.5 4.1 5.6 7.2 8.8 10.3 11.9 13.4 15.0
145 2.8 4.4 5.9 7.5 9.1 10.6 12.2 13.8 15.3 16.9
150 3.1 4.7 6.3 7.8 9.4 10.9 12.5 14.1 15.6 17.2 18.8
155 3.4 5.0 6.6 8.1 9.7 11.3 12.8 14.4 15.9 17.5 19.1 20.6
160 3.8 5.3 6.9 8.4 10.0 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5
Chapter 11
165 4.1 5.6 7.2 8.8 10.3 11.9 13.4 15.0 16.6 18.1 19.7 21.3 22.8 24.4
170 4.4 5.9 7.5 9.1 10.6 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3
175 4.7 6.3 7.8 9.4 10.9 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1
180 5.0 6.6 8.1 9.7 11.3 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0
185 5.3 6.9 8.4 10.0 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9
190 5.6 7.2 8.8 10.3 11.9 13.4 15.0 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8
195 5.9 7.5 9.1 10.6 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6
200 6.3 7.8 9.4 10.9 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5
205 6.6 8.1 9.7 11.3 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30 31.6 33.1 34.7 36.3 37.8 39.4
210 6.9 8.4 10.0 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35 36.6 38.1 39.7 41.3
215 7.2 8.8 10.3 11.9 13.4 15 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40 41.6 43.1
220 7.5 9.1 10.6 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45
225 7.8 9.4 10.9 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9
230 8.1 9.7 11.3 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8
235 8.4 10.0 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1
240 8.8 10.3 11.9 13.4 15.0 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40.0 41.6 43.1 44.7 46.3 47.8 49.4
245 9.1 10.6 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45.0 46.6 48.1 49.7
250 9.4 10.9 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9 48.4 50.0
255 9.7 11.3 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8 50.3
260 10.0 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1 50.6
265 10.3 11.9 13.4 15.0 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40.0 41.6 43.1 44.7 46.3 47.8 49.4 50.9
270 10.6 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45.0 46.6 48.1 49.7 51.3
275 10.9 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9 48.4 50.0 51.6
280 11.3 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8 50.3 51.9
285 11.6 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1 50.6 52.2
290 11.9 13.4 15.0 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40.0 41.6 43.1 44.7 46.3 47.8 49.4 50.9 52.5
295 12.2 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45.0 46.6 48.1 49.7 51.3 52.8
300 12.5 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9 48.4 50.0 51.6 53.1
305 12.8 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8 50.3 51.9 53.4
310 13.1 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1 50.6 52.2 53.8
320 13.8 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45.0 46.6 48.1 49.7 51.3 52.8 54.4
325 14.1 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9 48.4 50.0 51.6 53.1 54.7
330 14.4 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8 50.3 51.9 53.4 55.0
335 14.7 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1 50.6 52.2 53.8 55.3
340 15.0 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40.0 41.6 43.1 44.7 46.3 47.8 49.4 50.9 52.5 54.1 55.6
345 15.3 16.9 18.4 20.0 21.6 23.1 24.7 26.3 27.8 29.4 30.9 32.5 34.1 35.6 37.2 38.8 40.3 41.9 43.4 45.0 46.6 48.1 49.7 51.3 52.8 54.4 55.9
350 15.6 17.2 18.8 20.3 21.9 23.4 25.0 26.6 28.1 29.7 31.3 32.8 34.4 35.9 37.5 39.1 40.6 42.2 43.8 45.3 46.9 48.4 50.0 51.6 53.1 54.7 56.3
355 15.9 17.5 19.1 20.6 22.2 23.8 25.3 26.9 28.4 30.0 31.6 33.1 34.7 36.3 37.8 39.4 40.9 42.5 44.1 45.6 47.2 48.8 50.3 51.9 53.4 55.0 56.6
360 16.3 17.8 19.4 20.9 22.5 24.1 25.6 27.2 28.8 30.3 31.9 33.4 35.0 36.6 38.1 39.7 41.3 42.8 44.4 45.9 47.5 49.1 50.6 52.2 53.8 55.3 56.9
365 16.6 18.1 19.7 21.3 22.8 24.4 25.9 27.5 29.1 30.6 32.2 33.8 35.3 36.9 38.4 40.0 41.6 43.1 44.7 46.3 47.8 49.4 50.9 52.5 54.1 55.6 57.2
≥370 16.7 18.2 19.8 21.4 22.9 24.5 26.0 27.6 29.2 30.7 32.3 33.9 35.4 37.0 38.5 40.1 41.7 43.2 44.8 46.4 47.9 49.5 51.0 52.6 54.2 55.7 57.3
ANSI ≥100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230
1969
a
The axes are the sum of hearing levels at 500, 1000, 2000, and 3000 Hz. The sum for the worse ear is read at the side; the sum for the
better ear is read at the bottom. At the intersection of the row for the worse ear and the column.
Guides6e_11_247-280.indd 252 2/17/09 2:48:55 PM

Chapter 11
50.6
50.9 52.5
51.3 52.8 54.4
51.6 53.1 54.7 56.3

51.9 53.4 55.0 56.6 58.1
52.2 53.8 55.3 56.9 58.4 60.0
52.5 54.1 55.6 57.2 58.8 60.3 61.9
52.8 54.4 55.9 57.5 59.1 60.6 62.2 63.8
53.1 54.7 56.3 57.8 59.4 60.9 62.5 64.1 65.6

53.4 55.0 56.6 58.1 59.7 61.3 62.8 64.4 65.9 67.5
53.8 55.3 56.9 58.4 60.0 61.6 63.1 64.7 66.3 67.8 69.4
54.1 55.6 57.2 58.8 60.3 61.9 63.4 65.0 66.6 68.1 69.7 71.3
54.4 55.9 57.5 59.1 60.6 62.2 63.8 65.3 66.9 68.4 70.0 71.6 73.1
54.7 56.3 57.8 59.4 60.9 62.5 64.1 65.6 67.2 68.8 70.3 71.9 73.4 75.0
55.0 56.6 58.1 59.7 61.3 62.8 64.4 65.9 67.5 69.1 70.6 72.2 73.8 75.3 76.9
55.3 56.9 58.4 60.0 61.6 63.1 64.7 66.3 67.8 69.4 70.9 72.5 74.1 75.6 77.2 78.8
55.9 57.5 59.1 60.6 62.2 63.8 65.3 66.9 68.4 70.0 71.6 73.1 74.7 76.3 77.8 79.4 80.9 82.5
56.3 57.8 59.4 60.9 62.5 64.1 65.6 67.2 68.8 70.3 71.9 73.4 75.0 76.6 78.1 79.7 81.3 82.8 84.4
56.6 58.1 59.7 61.3 62.8 64.4 65.9 67.5 69.1 70.6 72.2 73.8 75.3 76.9 78.4 80.0 81.6 83.1 84.7 86.3
56.9 58.4 60.0 61.6 63.1 64.7 66.3 67.8 69.4 70.9 72.5 74.1 75.6 77.2 78.8 80.3 81.9 83.4 85.0 86.6 88.1
57.2 58.8 60.3 61.9 63.4 65.0 66.6 68.1 69.7 71.3 72.8 74.4 75.9 77.5 79.1 80.6 82.2 83.8 85.3 86.9 88.4 90.0
57.5 59.1 60.6 62.2 63.8 65.3 66.9 68.4 70.0 71.6 73.1 74.7 76.3 77.8 79.4 80.9 82.5 84.1 85.6 87.2 88.8 90.3 91.9
57.8 59.4 60.9 62.5 64.1 65.6 67.2 68.8 70.3 71.9 73.4 75.0 76.6 78.1 79.7 81.3 82.8 84.4 85.9 87.5 89.1 90.6 92.2 93.8
58.1 59.7 61.3 62.8 64.4 65.9 67.5 69.1 70.6 72.2 73.8 75.3 76.9 78.4 80.0 81.6 83.1 84.7 86.3 87.8 89.4 90.9 92.5 94.1 95.6
58.4 60.0 61.6 63.1 64.7 66.3 67.8 69.4 70.9 72.5 74.1 75.6 77.2 78.8 80.3 81.9 83.4 85.0 86.6 88.1 89.7 91.3 92.8 94.4 95.9 97.5
58.8 60.3 61.9 63.4 65.0 66.6 68.1 69.7 71.3 72.8 74.4 75.9 77.5 79.1 80.6 82.2 83.8 85.3 86.9 88.4 90.0 91.6 93.1 94.7 96.3 97.6 99.4
58.9 60.4 62.0 63.5 65.1 66.7 68.2 69.8 71.4 73.0 74.5 76.0 77.6 79.2 80.7 82.3 83.9 85.4 87.0 88.5 90.1 91.7 93.2 94.8 96.4 97.9 99.5 100
235 240 245 250 255 260 265 270 275 280 285 290 295 300 305 310 315 320 325 330 335 340 345 350 355 360 365 ≥368
Guides6e_11_247-280.indd 253 2/17/09 2:49:00 PM

TA B L E 11- 3
Relationship of Binaural Hearing Impairment to for a binaural hearing impairment of 23.4%. Use
Impairment of the Whole Person Table 11-3 to obtain the 8% whole person impairment.
% Binaural % Impairment % Binaural % Impairment
Hearing of the Hearing of the 11.2g Equilibrium
Impairment Whole Person Impairment Whole Person
Equilibrium, or orientation in space, is main-
0–1.4 0 50.0–52.8 18
1.5–4.2 1 52.9–55.7 19 tained by the visual, kinesthetic, and vestibular
4.3–7.1 2 55.8–58.5 20 mechanisms. When impairments of equilibrium
7.2–9.9 3 58.6–61.4 21
10.0–12.8 4 61.5–64.2 22
are predominantly due to other organ systems, the
impairment should be evaluated in the relevant organ
12.9–15.7 5 64.3–67.1 23
15.8–18.5 6 67.2–69.9 24
system, for example, disorders of the nervous system
18.6–21.4 7 70.0–72.8 25 (Chapter 13), cardiovascular system (Chapter 4), or
21.5–24.2 8 72.9–75.7 26 visual system (Chapter 12). Permanent impairment
24.3–27.1 9 75.8–78.5 27
may result from any disorder causing vertigo or
27.2–29.9 10 78.6–81.4 28 disorientation in space. Three regulatory systems—
Chapter 11
30.0–32.8 11 81.5–84.2 29
32.9–35.7 12 84.3–87.1 30 vestibular, ocular (visual), and kinesthetic (proprio-
35.8–38.5 13 87.2–89.9 31 ceptive)—are related to the vestibulo-ocular reflex.
38.6–41.4 14 90.0–92.8 32
The evaluation of impairments of equilibrium may
41.5–44.2 15 92.9–95.7 33 include consideration of 1 or more of these mecha-
44.3–47.1 16 95.8–98.5 34
47.2–49.9 17 98.6–100.0 35 nisms.9,10 This chapter addresses only disturbances in
equilibrium due to vestibular disorders.
Dizziness, like deafness and tinnitus, is a subjec-
tive experience and is a symptom, not a disease. Its
EXAMPLE 11-3: SENSORINEURAL HEARING cause must be sought carefully in each case. Patients
IMPAIRMENT, BILATERAL use the term dizziness to describe a variety of sensa-
tions, many of which are not related to the vestibu-
lar system. It is convenient to think of the balance
History: Retired machinist. Progressive hearing loss system as a complex conglomerate of senses that
for 13 years. Worked in several noisy environments; send information to the brain about one’s position
used hearing protectors fairly regularly. Exposure in space. Components of the balance system include
to gunfire during 4 years of service in the Marines. the vestibular labyrinth, the eyes, neck muscles,
General health good. No history of tinnitus or vertigo. proprioceptive nerve endings, and the cerebellum.
If all components of the balance system are provid-
Current Symptoms: Difficulty with communication
ing accurate information, one has no equilibrium
at home, in restaurants, driving a car, and in noisy
problem. However, if we use the example that most
environments.
of the components indicate to the brain that the body
Physical Exam: No abnormalities. is standing still, but 1 component indicates that the
body is turning to one side, the brain becomes con-
Clinical Studies: Audiologic tests: speech reception
fused and a person will experience dizziness. It is
threshold of 20 dB. Pure tone audiometry reveals the
the physician’s responsibility to analyze systemati-
threshold levels in decibels (dB) given in Comment.
cally each component of the balance system to deter-
Diagnosis: Sensorineural hearing impairment, mine which component or components are providing
bilateral. incorrect information, or whether correct informa-
tion is being provided and analyzed in an aberrant
fashion by the brain.
person. Apportionment for the military-related hear-
ing loss can be accomplished only by subtracting Disturbances of equilibrium may be classified as
impairment verified from audiograms reflecting the follows: (1) vertigo, a sensation of rotation of the
individual’s post-Marine hearing status. subject or of objects about the subject in any plane;
(2) giddiness or lightheadedness, distinguished
Comment: The impairment calculated from this
from vertigo by the absence of feelings of move-
audiogram is based on the DSHL. The DSHL for the
ment; and (3) abnormalities of postural stability
right ear is 175 (20 ⫹ 15 ⫹ 60 ⫹ 80), and the DSHL
and/or standing balance with or without vertigo.
for the left ear is 160 (25 ⫹ 15 ⫹ 60 ⫹ 60). Combine
Vertigo may be produced by disorders of the ves-
175 (worse ear) and 160 (better ear) using Table 11-2
tibular mechanism and its central nervous system
Guides6e_11_247-280.indd 254 2/17/09 2:49:02 PM

components, including the cerebral cortex, cerebel- Balance Testing

lum, brain stem, and by eye movements. Vertigo The balance system is extremely complicated, and ideal
may be associated with nausea, vomiting, head- tests have not been developed. Research is currently
ache, fear of movement, ataxia, and nystagmus. under way to develop better tests that will assess accu-
Movement or environmental object movement may rately the entire composite functioning of the balance
worsen these symptoms. system and test each component in isolation. At present,
the most commonly performed tests are ENG and com-
Typically, labyrinthine dysfunction is associated
puterized dynamic posturography (CDP). Vestibular
with a sense of motion. It may be true spinning, a
evoked potential testing is under investigation.
sensation of being on a ship or of falling, or simply
a vague sense of imbalance when moving. In many Electronystagmography
cases, it is episodic. Fainting, body weakness, spots
Electronystagmography is a technique for recording
before the eyes, general lightheadedness, tightness in
eye movements to detect spontaneous and induced
the head, and loss of consciousness are generally not
nystagmus. It allows measurement of eye movements
Chapter 11
of vestibular origin. However, such descriptions are
with eyes open and closed, and permits quantifica-
of only limited diagnostic help. Even some severe
tion of the fast and slow phases, time of onset and
peripheral (vestibular or eighth nerve) lesions may
duration, and other parameters. Although some
produce only mild unsteadiness or no dizziness at
centers use only horizontal electrodes, the use of
all, as observed in many patients having acoustic
both horizontal and vertical electrodes is preferable.
neuromas. Similarly, lesions outside the vestibular
Eye movements also can be tracked using videonys-
system may produce true rotary vertigo, as seen with
tagmography (VNG), a newer technique that uses
trauma or microvascular occlusion in the brain stem.
an infrared camera mounted on goggles instead of
Causes of dizziness are almost as numerous as electrodes. Electronystagmography must be done
causes of hearing loss, and some are medically under controlled conditions with proper prepara-
serious, such as multiple sclerosis, acoustic neuroma, tion, which includes avoidance of drugs (especially
diabetes, migraine, anemia, and cardiac arrhythmia. those that affect the central nervous system). Even a
Consequently, any patient with an equilibrium com- small drug effect may cause alterations in the ENG
plaint needs a thorough examination. For example, tracing. The test is performed in several phases.
although dizziness may be caused by head trauma, These include calibration, which assesses cerebellar
the fact that it is reported for the first time after an function, and tests for gaze nystagmus, sinusoidal
injury is not sufficient to establish causation without tracking, optokinetic nystagmus, spontaneous nys-
investigating other possible causes. tagmus, Dix-Hallpike testing, positional testing, and
caloric irrigations. These tests can give useful infor-
It is important to carry out a systematic inquiry in all
mation about peripheral and central abnormalities
cases of disequilibrium, not only because the condi-
in the vestibular system. Interpretation is complex
tion is caused by serious problems in some cases but
and difficult.11,12 The performance of ENG is espe-
also because many patients with balance disorders
cially helpful when a unilateral reduced vestibular
can be helped. Many people believe incorrectly that
response is identified in conjunction with other signs
sensorineural hearing loss, tinnitus, and dizziness
of dysfunction in the same ear. In such cases, it pro-
are incurable, but many conditions that cause any or
vides strong support for a peripheral (eighth nerve or
all of these symptoms may be treated successfully.
end-organ) cause of balance dysfunction.
It is especially important to separate “peripheral,” or
noncentral, causes, which are almost always treat- Computerized Dynamic Posturography
able, from more central causes, such as brain-stem
For more than 25 years, platforms have been used to
contusion, in which the prognosis is often worse.11
try to assess more complex integrated functioning of
Clinical evaluations include history and physical the balance system. Until recently, most were static
examination, along with possible use of electronys- posture platforms with pressure sensors used to mea-
tagmography (ENG), caloric irrigation, positional sure body sway while patients tried to maintain vari-
and rotary tests, dynamic posturography, Romberg ous challenging positions, such as the Romberg and
and tandem Romberg tests, and brain imaging Tandem Romberg maneuvers. Movement was mea-
studies. The results of these tests should be cor- sured with eyes closed and open. The tests had many
related with validated clinical measures of balance drawbacks, including an inability to separate proprio-
and ambulation to determine the true state of equili- ceptive function and to eliminate visual distortion. In
bratory dysfunction.
Guides6e_11_247-280.indd 255 2/18/09 10:02:45 AM

1971, Nasher13 introduced a widely used CDP system, here as being disturbances of vestibular function,
and other systems also have become available. although such symptoms may occur in some patients
with slowly developing or long-standing vestibular
Dynamic posturography uses a computer-con-
dysfunction.
trolled moveable platform with a sway-referenced
surrounding visual environment. In other words, Vertigo may be accompanied by varying degrees of
both the platform and visual surround move, track- nausea, vomiting, headache, immobility, ataxia, and
ing the anterior-posterior sway of the patient. The nystagmus. Movement may increase the vertigo and
visual surround and platform may operate together the accompanying signs and symptoms. Peripheral
or independently. The system is capable of creating vestibular (labyrinthine) disorders are often asso-
visual distortions or totally eliminating visual cues. ciated with hearing loss and tinnitus. Vestibular
The platform can perform a variety of complex disorders may result in temporary or permanent
motions, and the patient’s body sway is detected impairments. Evaluation of vestibular impairment
through pressure-sensitive strain sensors under the should be performed when the condition is stable
Chapter 11
platform.13 and maximum adjustment has been achieved, which

generally is considered to occur months after resolu-
The typical test protocol evaluates sensory orga-
tion of the disease or injury.9,11
nization through 6 test procedures and movement
coordination through a variety of sudden platform The classification in Table 11-4 has been developed
movements. Balancing strategies and responses are for evaluation of those individuals with permanent
assessed using both the sensory organization and disturbances of the vestibular mechanism. The
movement coordination test batteries. Dynamic impairment ratings reflect the severity of the per-
posturography provides a great deal of information manent impairment and the ability of the individual
about total balance function that cannot be obtained to perform ADLs. Although symptoms may be
from tests such as ENG alone. Dynamic posturogra- intermittent, the examiner needs to gauge function-
phy is also valuable in distinguishing organic from ing during episodes with exacerbations. In many
nonorganic disequilibrium, an asset that is particu- cases, it is possible to document an impairment in
larly valuable in some cases of alleged impairment. the balance system. In others, the subjective com-
plaint of dizziness may be the only abnormality.
Evoked Vestibular Response When present, vertigo and other conditions of dis-
Evoked vestibular response testing is analogous to equilibrium may cause an additional disability that
brain-stem auditory evoked testing. However, ves- is not necessarily reflected in the impairment rating
tibular evoked potentials are not in wide clinical use. because the impairment rating reflects only the
effect on ADLs. Quality of life measures such as
Vestibular System Impairment Rating the Dizziness Handicap Inventory have been used
Permanent impairment can result from defects of the clinically to try to identify and quantify the effects
vestibular (labyrinthine) mechanism and its central of dizziness.14
connections. The defects are evidenced by loss of
The outcome of the symptoms evaluation, the physi-
equilibrium produced by disturbance or loss of ves-
cal signs, and the laboratory test results should be
tibular function.
correlated, with emphasis on the validated symp-
Complete loss of vestibular function may be uni- toms—those confirmed by the history, physical
lateral or bilateral. When the loss is unilateral, findings, and results of laboratory tests—as best
adequate central nervous system compensation may representing the subject’s true state of impairment.
or may not occur. With total bilateral loss of vestibu- The evaluator should consider that while the Guides
lar function, equilibrium is totally dependent on the does not consider occupation in the impairment
kinesthetic and visual systems, which usually are rating, vertigo may cause additional disability for
unable to compensate fully for movement or ambula- people working in hazardous job situations. Persons
tion. Depending on the ability to perform ADLs, the who lose their balance even momentarily may
percentage of permanent impairment of the whole severely injure themselves or others when working
person may range from 0% to 58%. around sharp surfaces, rotating equipment, driving a
forklift, working on ladders or scaffolding, or func-
Disturbances of vestibular function are evidenced by
tioning in other similar circumstances. The evaluator
vertigo (vestibular disequilibrium) as defined earlier
can report any appropriate work restrictions that are
in this chapter. Lightheadedness and abnormalities
medically necessary.
of gait not associated with vertigo are not defined
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To use Table 11-4, follow these steps: lower than or higher than the class originally
1. Place the individual in the appropriate class based
on the key factor, which is history. Begin by select-
history.
ing the middle number in that class. The classes
have discrete numbers. They are not a range. 4. If you begin in class 4, you may move up based
on the number of non-key factors also found in
2. Assess the correct class for the physical exam
class 4.
findings on this patient. If the class selected is
1 class higher than the class selected from step 1, For example, if the patient were found to be in class
move 1 number higher within the class selected 2 originally by history, you would begin at 19% as
using the history. If the physical examination is the middle number in class 2. If the physical exam
2 levels higher than the history class, move up were in class 4, you would move up to 27%, staying
2 levels within the history selected class. If the within the class 2 but moving up 2 grades. If the
class from the physical exam is in a lower class diagnostic test were in class 3, it is 1 class higher
Chapter 11
than that selected from the history, move lower than the original class but it would not change your
within the class selected from step 1. rating since you cannot exceed 27% in class 2.
However, if the diagnostic tests were in a class 1,
3. Assess the class of the patient using the diagnos-
you would move down 1 grade and the final rating
tic findings. Using the number you established
would be 23%.
in step 2, move again up or down if the class is
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TA B L E 11- 4 Criteria for Rating Impairments due to Vestibular Disorders a
Vestibular Disorders
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 11%–27% 30%–42% 45%–58%
SEVERITY 1 3 5 7 9 11 15 19 23 27 30 33 36 39 42 45 48 51 54 58
GRADE (%)
HISTORYb Symptoms Symptoms or signs of Symptoms or Symptoms or Symptoms or signs of

Chapter 11
or signs of vestibular disequilib- signs of vestibular signs of vestibu- vestibular disequilib-

vestibular rium consistent with disequilibrium lar disequilibrium consistent with
disequilib- objective findings consistent with rium consistent objective findings
rium objective findings with objective
Activities of daily Activities of daily
present findings
living: requires assis- Activities of daily living cannot be
without
tance for complex living cannot be Activities of performed without
objective
activities, eg, riding a performed with- daily living assistance except for
findings
bike or certain types out assistance cannot be self-care not requir-
of demanding activi- except for simple performed ing ambulation
ties related to the activities, eg, without assis-
and
individual’s work, self-care, some tance except for
eg, working on gird- household duties, self-care home confinement is
ers or scaffolds walking, and rid- necessary
ing in a motor
vehicle operated
by another person
PHYSICAL No con- No confirmable find- Unsteady gait; Difficulty walk- Difficulty standing
EXAM firmable ings or mildly abnor- abnormal ing without or walking without
findings mal gait, Romberg, Romberg assistance assistance
or other findings
DIAGNOSTIC No con- Abnormal findings Abnormal find- Moderately Severely abnormal

OR OTHER firmable on ENG or VNG, ings on ENG or abnormal find- findings on ENG or
OBJECTIVE diagnostic such as positional VNG, such as ings on ENG or VNG, such as posi-
FINDINGS findings nystagmus or positional nystag- VNG, such as tional nystagmus,
abnormal caloric mus, abnormal positional nys- abnormal caloric
response, may be caloric response, tagmus, abnor- response, or abnor-
present or abnormal mal caloric mal central nervous
central nervous response, or system signs
Electrocochleography
system signs, or abnormal cen-
may be abnormal and
abnormal sway or tral nervous
abnormal sensory system signs abnormal sway and
tests may be pres- severe abnormalities
and
ent on dynamic on all 6 conditions
posturography abnormal sway tested with the sen-
or abnormal sory organization
sensory tests portion of dynamic
may be pres- posturography
ent on dynamic
Brain MRI abnormali-
posturography
ties may be present
Brain MRI
abnormalities
may be present
a
ENG indicates electronystagmography; VNG, videonystagmography; and MRI, magnetic resonance imaging.
b
Key factor.
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CLASS 0 Physical Exam: Abnormal Romberg but gait and

0% Impairment of the Whole Person tandem gait are normal. No residual nystagmus.
Clinical Studies: ENG and caloric studies: no ves-
EXAMPLE 11- 4: BENIGN PAROXYSMAL tibular function of right ear. Other neuro-otologic
POSITIONAL VERTIGO findings: within normal limits. Audiogram: normal
hearing bilaterally.
Diagnosis: Vestibular neuronitis, probably viral,
History: Retired physician. Three-week history of
with total loss of vestibular function, right ear.
vertigo that occurs whenever he rolls over to his right
side when lying in bed. He describes the feeling as a Impairment Rating: 5% impairment of the whole
spinning sensation that lasts a few seconds. He also person.
experiences vertigo when he turns to the right when
Comment: Class 1 impairment, with mild loss of
shopping at the grocery store. No nausea or vomiting.
function. History places this individual in class 1.
Chapter 11
His physician did a Dix-Hallpike t est, which showed
The rating begins at 5%. The mildly abnormal physi-
rotary nystagmus with right ear down; he was treated
cal exam findings leave the rating number unchanged.
with the Epley maneuver to reposition otoconia.
The objective findings on ENG testing are in class 1.
Currently he is asymptomatic with no disruption of
(If the physical exam findings were in class 3, these
ADLs.
findings would have moved the rating up the scale to
Current Symptoms: Asymptomatic; the dizziness 9%—the highest rating in class 1—but would not have
has not recurred; no disruption of ADLs. moved the patient to class 2 or 3, because once you
have chosen the class level using the history as your
guide, you cannot move out of that class into another.)
Clinical Studies: Dix-Hallpike test: no rotary
nystagmus at the present time.
Diagnosis: Benign paroxysmal positional vertigo.
CLASS 2
Impairment Rating: 0% impairment of the whole 11% to 27% Impairment of the Whole Person
person.
Comment: Treatment to be repeated as necessary. EXAMPLE 11-6: VESTIBULAR DISORDERS

History: Nurse; 3-month history of progressive
CLASS 1 hearing loss in left ear, increased difficulty with
1% to 9% Impairment of the Whole Person gait, some loss of balance with falling to the left, and
slurred speech when fatigued. History of hyperten-
sion, controlled with ß-blockers. Audiogram showed
EXAMPLE 11-5: VESTIBULAR NEURONITIS
normal hearing in right ear, 80-dB sensorineural
Subject: 50-year-old-woman. hearing loss in left ear. Tympanograms were type
A bilaterally. Auditory brain-stem response showed
History: Sudden onset of severe vertigo, nausea,
absence of wave V in left ear. The ENG showed
and vomiting. No history of upper respiratory tract
absent caloric response in left ear. A magnetic reso-
infection, fever, cough, or chills. Confined to bed
nance image (MRI) with gadolinium showed large
for 3 days. Hearing normal; no tinnitus. Treated
left cerebellopontine angle (CPA) mass involving
with vestibular suppressors. Gradual, slow recovery
the left internal auditory canal. A 4-cm acoustic
of ability to ambulate. Able to return to work as a
neuroma with secondary brain-stem compression
secretary in 2 weeks but unable to walk in the dark
was removed via the translabyrinthine approach.
since onset of her spell of vertigo 6 months ago.
Postoperative ophthalmologic exam reveals exposure
Current Symptoms: Can perform ADLs without keratopathy of the left eye. Left lateral canthoplasty
assistance. Slightly unsteady when fatigued. Does with insertion of gold weights in left upper eyelid
not tolerate rocking motion (sailboat) without visual was performed, plus a cross-face sural nerve graft to
fixation of horizon. Unable to ride bicycle, but can the left side of the face.
drive automobile at night.
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Current Symptoms: Preoperatively active. Now rehabilitation exercises did not provide any benefit.
walks with some difficulty with a broad-based gait. Underwent labyrinthectomy and vestibular nerve
Has fallen twice since surgery. Can perform self-care section on left side without relief of symptoms.
and limited household activities; unable to drive a car.
Current Symptoms: Unable to walk without assis-
Physical Exam: Left-sided facial paralysis. Total tance. Minimal nausea as long as he uses vestibular
hearing loss in left ear. Cerebellar tremor worse suppressants. Riding in a car causes severe dizziness
in the left upper extremity than in the left lower with nausea.
extremity. Somewhat unsteady gait with moderately
Physical Exam: Very unsteady, broad-based gait.
abnormal Romberg.
Thin legs with poor muscle tone.
Clinical Studies: Total loss of hearing and of
Clinical Studies: The ENG shows absent caloric
vestibular function, left ear. No residual tumor,
response in left ear. Profound sensorineural hearing
but changes in brain-stem area noted on MRI.
loss in left ear. Severe abnormalities in all 6 posi-
Electroencephalogram: no evidence of epileptiform
Chapter 11
tions tested with sensory organization portion of

activity. Gait and balance scores abnormal for age.
dynamic posturography. Normal MRI.
Diagnosis: Large left acoustic neuroma with post-
Diagnosis: Severe, uncompensated unilateral
operative total left auditory and vestibular impair-
vestibular injury.
ments, left-sided facial nerve paralysis and mild to
moderate unsteadiness. Impairment Rating: 39% impairment of the whole
person.
Impairment Rating: 23% impairment due to ves-
tibular disorders; combine with appropriate ratings for Comment: History places this individual in class 3.
other impairments to determine whole person impair- The rating begins at 36%. The class 3 physical exam
ment (see Combined Values Chart in the Appendix). findings leave the rating number unchanged. The objec-
tive findings regarding dynamic posturography, which
Comment: The history places this individual in
are in class 4, move the rating up 1 number to 39%.
class 2. The rating begins at 19%. The class 2
physical exam findings leave the rating number
unchanged. The objective findings, which are in
class 3, move the rating toward the top of category
2 or 23%. Additional ratings would be combined for
11.3 The Face
facial nerve, loss of hearing, and tremor in the upper
The face, its parts, and its structural components
extremities. Care must be taken not to rate the same
serve multiple functions: protection of underlying
impairment of ADLs twice when combining multiple
structures and organs (such as the eyes), portals of
impairments.
entry for deglutition and respiration, and communi-
cation through expression and speech.
The portal for deglutition is the mouth and lips.
CLASS 3 Disturbances in function can result in drooling or
30% to 42% of Whole Person Impairment inability to keep food or liquid in the mouth while
eating. The lips and mouth also serve in vocal articu-
lation, adding intelligibility to speech. The nose
EXAMPLE 11-7: UNILATERAL VESTIBULAR
and mouth are the portals of entry for respiration.
INJURY
Impairment may be a result of neurologic disorders,
Subject: 48-year-old man. such as partial or complete paralysis of the lips;
scar formation and contracture of the lips; or loss of
History: Victim of a mine explosion 3 years ago,
tissue.
with complete loss of hearing and vestibular function
in left ear. Chronic dizziness with nausea and weight The face plays a unique role in communication. No
loss developed from severe vestibular injury. Very other part of the body serves as specific a func-
unsteady gait. Needs a cane or walker to ambulate. tion for personal identity and for the expression
Uses high-dose vestibular suppressants to counteract of thought and emotion. Facial expressions are an
nausea and maintain his body weight. Vestibular integral part of normal living postures. A degree of
Guides6e_11_247-280.indd 260 2/17/09 2:49:05 PM

normalcy is needed for effective verbal and nonver- medical evaluation. However, unless the cause of
bal communication. Facial anatomy contributes to facial paralysis has been established clearly (eg,
identity, expression, normal functioning, and appear- transaction of the nerve associated with a facial
ance of the forehead, cheeks, eyes, eyelids, eyebrows, laceration), medical evaluation is required to deter-
lips, mouth, nose, chin, and neck. The face is such mine the cause of facial paralysis. There are many
a prominent feature that it plays a critical role in the conditions that can result in facial paralysis, includ-
individual’s physical, psychological, and emotional ing benign and malignant tumors, Lyme disease,
makeup. Facial disfigurement can affect all of these multiple sclerosis, and lead poisoning. The diagnosis
components and can result in social, vocational, and of Bell’s palsy (idiopathic facial paralysis) can be
even psychiatric harm. made only when all known potential causes have
been eliminated. Blood tests, electrophysiologic
11.3a Criteria for Rating Impairment due studies such as electromyography and electroneurog-
to Facial Disorders and/or Disfigurement raphy, and imaging studies may be appropriate in the
To evaluate permanent impairment due to a disorder assessment of facial paralysis.
Chapter 11
or disfigurement of the face, consider changes in
To use Table 11-5, follow these steps:
anatomy, function, and the effect of the impairment
on the ability to perform ADLs. This section deals 1. Place the individual in the appropriate class
with permanent impairment as it relates mainly to based on the key factor (history). Begin by
the face’s structural integrity. For loss of function selecting the middle number in that class.
involving other aspects of the functioning of the The classes have discrete numbers. They are
face, refer to the specific organ system involved and not a range.
combine the structural integrity loss with the rel-
evant loss of function. For example, loss of structural
findings on this patient. If the class selected
integrity can result from cutaneous disfigurement,
by physical examination is 1 class higher than
such as that due to abnormal pigmentation or scars,
the class selected from step 1, move 1 number
or from loss of supporting structures, such as soft
higher within the history-based class previously
tissue, bone, or cartilage of the facial skeleton, or
selected in step 1. If it is 2 grades higher, move
from loss of neurologic function.
up 2 grades within the history-based class. If the
Disfigurement of the face can result from many class from the physical exam is in a lower class
causes, particularly burns, traumatic injury, than that selected from the history, move lower
surgery, infections, or dysplasia. Effects on indi- within the class selected from step 1.
viduals can vary tremendously, as can remaining
3. Assess the class of the patient using the diagnos-
function. The patient’s history is important in
tic findings. Using the number you established
elucidating not only the cause and nature of the
in step 2, move again up or down if the class is
impairment but also its impact on the patient.
lower than or higher than the class originally
Total disfigurement of the face after treatment
should be deemed a 25% to 45% impairment of
the whole person, dependent also on the degree of
history.
functional loss. Facial disfigurement may be con-
sidered total if it is severe and grossly deforming For example, if the patient were found to be in
of the face and features. Such disfigurement must class 2 originally by history, you would begin at
involve at least the entire area between the brow 8% as the middle number in class 2. If the physi-
line and the upper lip on both sides. Severe dis- cal exam were in class 4, you would move up to
figurement above the brow line should be deemed 10%, staying within the class 2 but moving up
to be, at a maximum, 1% impairment of the whole 2 grades. If the diagnostic test were in class 3
person. If disfigurement is severe below the upper (1 class higher than the original class), it would
lip, it may be deemed to be 8% impairment of the not change your rating since you cannot exceed
whole person. Specific, prominent facial disfig- 10% within class 2. However, if the diagnostic
urements are estimated as shown in Table 11-5. tests were in a class 1 you would move down
1 grade and the final rating would be 9%.
Substantial facial disfigurement resulting from
trauma does not necessarily require an extensive
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TA B L E 11- 5 Criteria for Rating Impairment due to Facial Disorders and/or Disfigurementa
Facial Disorder/Disfigurement
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–5% 6%–10% 11%–23% 25%–45%
SEVERITY 1 3 5 6 7 8 9 10 11 14 17 20 23 25 30 35 40 45
GRADE (%)
HISTORYb Limited cutane- Facial abnormal- Facial abnormal- Facial abnor- Massive or total
Chapter 11
ous scarring with ity involving ity with some loss mality involves distortion of nor-
no direct physi- only cutaneous of supporting absence of normal facial anat-
ologic effects structures with structure mal anatomic omy with severe
highly visible scar part or area of disfigurement
May have mild
and/or abnormal the face, such as
obstruction of Significant
pigmentation loss of the eye
the nasal passage interruption of
or loss of part
No activities but no social activities
of the nose with
of daily living, shortness of due to lack of
resulting cos-
including breath or other social acceptance
metic deformity
breathing or clear impairment
eating, are other than with The patient may
affecteda social interaction have some con-
cerns regarding
his or her appear-
ance affecting
the extent of
social activities
PHYSICAL EXAM Scar is either Significantly Loss of Exam consistent Findings of the
small or slightly visible scar and/ supporting with above or above or severe
larger with or abnormal structure of part severe unilat- bilateral total
minimum width, pigmentation of the face with eral total facial facial paralysis
maybe in obvious or without paralysis or mild with loss of major
or
location, and has cutaneous bilateral total portion of or the
no physiologic mild unilateral disorder, such as facial paralysis entire nose
defects total facial depressed cheek
or Move the
paralysis or nasal or
impairment
frontal bones loss of support
or number up
tissue affecting
nasal distortion depending on
multiple facial
that affects phys- the severity
regions
ical appearance of the facial
appearance
DIAGNOSTIC None No evidence of May have X rays Consistent Findings

OR OTHER involvement of consistent with with the above consistent with
OBJECTIVE any bony struc- changes as noted findings the noted deficit
FINDINGS ture or cartilage in history
a
Any vision loss or losses should be rated in those chapters. Breathing and eating disorders should be rated separately in this
chapter and combined. The rater must use caution not to assess the activities of daily living (ADL) impairment in more than
1 section.
b
Key factor.
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CLASS 0 Clinical Studies: None.

Diagnosis: Stable scar on right cheek with loss of
normal skin color and residual skin texture changes.
EXAMPLE 11-8: COMPOUND NASAL BONE Healed fracture.
FRACTURE
Subject: 25-year-old woman. person. Patient begins in class 1 at 3%. No change up
or down from this number, as the zygomatic arch has
History: Struck in nose with baseball bat 1 year pre-
been repaired.
viously; sustained 2-cm laceration across dorsum of
nose with minimally displaced nasal bone fractures. Comment: No permanent loss of structural integrity
Underwent closed reduction of fractures of nasal of arch. Injured skin area has lost some structural
bones and repair of laceration. Returned to normal integrity, but healed without surgery. Area has
activities after normal recovery. abnormal pigmentation and appearance compared to
Chapter 11
surrounding skin.
Current Symptoms: Small scar on top of nose.
Physical Exam: Normal nasal region except for
well-healed, stable, 1.5-cm scar across glabellar
region. Scar falls in skin-fold lines. CLASS 2
Diagnosis: Residual scar on dorsum of nose from
EXAMPLE 11-10: HEALED COMPOUND BONE
compound nasal bone fracture.
FRACTURE
person.
History: Struck across nasal region 19 months
Comment: No loss of nasal function or nasal bone
previously by a box that had fallen off a shelf in a
structural integrity. Appearance of nose did not change.
store. Sustained crush injury to face with compound
Scar falls in skin-fold line and is barely visible.
fracture of nasal bones and compound fracture of
frontal bone that goes into frontal sinus. Fractures
and wounds were surgically repaired. Wounds and
CLASS 1
bones healed well. Frontal sinus and nasal respira-
tory function returned to normal. No additional
surgery. Returned to normal activities.
EXAMPLE 11-9: HEALED FRACTURE
Current Symptoms: Affected area is darker than
Subject: 36-year-old man. surrounding skin; hollow area over nasofrontal
region.
History: Fell off tractor at work 18 months previ-
ously and sustained deep abrasion over right cheek Physical Exam: Slightly brown discoloration of skin
and fracture of right zygomatic arch. Surgery was over superior dorsal nasal and glabellar regions. A
performed with closed reduction of zygomatic arch 3-cm depression 3 to 4 mm deep over frontal sinus
fracture and debridement of right cheek wound. region.
Fracture healed well and maintained its normal
anatomic position. Deep abrasion healed well with
additional topical wound care. Returned to normal Diagnosis: Healed compound nasal and frontal bone
activities shortly after injury. fractures. Residual skin pigmentation changes. Loss
of structural integrity of frontal bone.
Current Symptoms: Injured skin area on right
cheek is lighter than normal surrounding skin, espe- Impairment Rating: 8% impairment of the whole
cially after sun exposure, but does not require medi- person. This individual is in class 2, and the physical
cal care, even with prolonged sun exposure. exam and objective findings are also class 2, so the
number does not change.
Physical Exam: A 3- to 4-cm area of skin on right
cheek is lighter than uninjured skin. Injured skin has Comment: Although initial injury required exten-
irregular, rough “cobblestone” appearance in some sive surgery, permanent loss of structural integrity of
areas. Right zygomatic arch has normal appearance skin and frontal bone involves relatively small area,
and projection compared to left side. with no anticipated problems with function of nose
or nasal passages.
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EXAMPLE 11-11: CRUSH INJURY TO Current Symptoms: Scar on left cheek. Missing tip
RIGHT-SIDED FACIAL REGION of nose on left side. She is uncomfortable with her
appearance.
Physical Exam: Significant depression on left tip
History: Struck on right side of face with a heavy
of nose due to loss of left lateral cartilage and nasal
pipe 14 months previously. Sustained crush injury to
tissue. Alar region on left has significant shortening
right-sided facial region; deep laceration along infe-
compared with right side and partially consists of
rior orbital rim; and fractures of malar (“tripod”),
grafted tissue, which has whiter, thicker appearance
orbital floor, and nasal bones. Refused additional
than skin on right side. Left cheek has a stable, soft
surgery. Quickly recovered and returned to normal
scar approximately 4 cm long by 2 mm wide running
activities after surgical repair of injuries.
from left nasolabial fold to left lateral orbital region.
Current Symptoms: Scars on right lower eyelid and
lateral orbital regions. Sunken appearance of right
Chapter 11
eye and right cheekbone. Nose is wider and flatter Diagnosis: Loss of skin and cartilage on left tip of
than it was before injury. Individual is embarrassed nose and scar on left cheek.
by his appearance but has no complaints of loss of
vision or nasal function.
person. Begins in class 3, the physical exam and
Physical Exam: Well-healed, stable, 1- to 2-cm objective findings remain in class 3; thus, the final
scars over right inferior and lateral orbital rim percentage is 17%.
regions, with palpable metal plates beneath scars. A
Comment: Reconstructive surgery was able to
1-cm depression of right malar eminence (compared
somewhat correct cosmetic defect. But loss of an
with left side). Mild to moderate enophthalmos of
anatomic part and a significant scar on left cheek
right orbit. Nasal bones have smooth, flat depression
have affected self-image.
in nasofrontal region.
Diagnosis: Depression of right malar bone and nasal
CLASS 4
bones; enophthalmos of right orbit; scars on right
lower eyelid and lateral orbital skin.
EXAMPLE 11-13: LOSS OF STRUCTURAL
person. History places the patient at 8%. Involvement
INTEGRITY OF RIGHT SIDE OF FACE, LOSS
of nose and orbital region is a class 3 for physical exam
OF NORMAL SPEECH FUNCTION, AND
and objective findings. Therefore, the final number is
MASTICATION
10%, 2 numbers higher than the middle number of 8%.
Comment: Structural integrity of right orbital and
nasal regions was lost, leaving permanent, measur- History: Thrown and kicked in face by a bull
able depressions and enophthalmos. 26 months previously. Sustained crush injury to right
side of face and compound fractures of mandible,
nasal bones, and orbital bones. Subsequently, severe
infection developed in the face, which required
CLASS 3 multiple surgical procedures. Operations resulted in
11% to 20% Impairment of the Whole Person loss of most of the normal skin and muscle on right
side of nose, right cheek, and right side of upper lip.
Nasal septum cartilage and tip were lost. Bones of
EXAMPLE 11-12: DISFIGUREMENT OF NOSE
right side of nose, right half of mandible, and right
Subject: 35-year-old woman. anterior maxillary region were lost. Underwent no
further reconstructive procedures but has been fitted
History: Sustained gunshot wound to face 9 months
with facial prostheses. Condition is stable. Required
previously. Bullet blew off portion of left side of
speech therapy due to loss of articulatory function.
nose and created open, deep wound on left cheek.
Required help in management of diet because of per-
Returned to most normal activities after undergoing
manent dietary restriction to semisolid or soft foods.
several operations.
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Current Symptoms: Altered speech with loss of oral region includes the mouth and lips, teeth, tem-
ability to speak well. Loss of skin and bones on right poromandibular joint (TMJ), tongue, hard and soft
side of face. Loss of ability to eat normal food. palate, region of the palatine tonsil, and oropharynx.
The neck and chest region includes the hypophar-
Physical Exam: Loss of normal skin, muscles, bone
ynx, larynx, trachea, esophagus, and bronchi.
structures on right side of nose, and in right man-
dibular and right anterior maxillary regions. Speech The functions of these structures, and the order
is poorly articulated and has low intensity due to loss in which they will be discussed, are as follows:
of skin and muscle on right side of mouth. (1) respiration, (2) mastication and deglutition,
(3) olfaction and taste, and (4) speech and voice.
Permanent impairment may result from a devia-
Diagnosis: Massive loss of normal structural integ- tion from normal in any of these functions, and,
rity of right side of face and loss of normal speech because of their close relationship, more than
function and mastication. 1 structure may be involved.
Chapter 11
11.4a Respiration
person. This rating begins in class 4 with 35%
Respiration may be defined as the act or function of
impairment. Physical exam and objective tests are in
breathing, that is, the act by which air is inspired and
class 3; thus, the rating is decreased to 25%.
expired from the lungs. The respiratory mechanism
Comment: Combine with other impairments for loss of includes the lungs and the air passages; the latter
speech (Section 11.4d) and mastication (Section 11.4b). includes the nares, nasal cavities, mouth, pharynx,
larynx, trachea, and bronchi.
In this chapter, discussion of permanent impairments
EXAMPLE 11-14: LOST LEFT SIDE OF FACE
related to respiration is limited to defects of the
Subject: 45-year-old woman. upper air passages. Refer to Chapter 5 on the pulmo-
nary system for a discussion of impairments of the
History: Sustained severe electrical injury to face
lower airways and lung parenchyma.
26 months previously with loss of left orbital struc-
tures, skin on left cheek, and anterior maxillary The most commonly encountered defect of the upper
sinus bones. air passages is obstruction, which may be partial,
as with congestion or stenosis, or complete, as
Current Symptoms: Lost vision in left eye and is
with occlusion. Obstructions and other air passage
missing left side of face. She says she looks like a freak.
defects are evidenced primarily by dyspnea, or dif-
Physical Exam: Loss of left orbital structures with ficulty breathing. Sleep apnea, which is covered in
open orbital region. No bones remain on orbital floor Chapter 5, may be related to functional upper-airway
or inferior orbital rim. Left anterior maxillary sinus obstruction.
regions and overlying skin and muscles are gone, leav-
Rhinitis, rhinorrhea, allergic and “sinus” conditions,
ing large, residual, open orbital and maxillary cavity.
and related maladies are so common that establish-
Clinical Studies: None. ing a cause is often difficult. Nevertheless, exposure
to occupational irritants or allergens can produce
Diagnosis: Massive loss of normal facial structural
such symptoms, and it is possible for these symp-
integrity.
toms to persist even after a worker has been removed
Impairment Rating: 40% impairment of the whole from the causal environment. Allergic rhinitis may
person. Begin in class 4 at 35% and move up 1 due to be work related in veterinarians, animal handlers,
the severity of the physical examination findings. health care workers, grain handlers, farmers, out-
door workers, workers in dusty or moldy factory
Comment: Combine with other impairments from
environments, and other people exposed to airborne
the vision chapter (Chapter 12).
allergens. In most cases, mild nasal congestion and
rhinorrhea are not serious health problems. However,
in the case of occupational allergens, rhinitis fre-
quently precedes the development of asthma or may
11.4 The Nose, Throat, and occur concurrently with asthma. The new onset or
Related Structures worsening of rhinitis in workers exposed to occupa-
tional allergens should also include consideration of
The nasal region includes the external part of the and evaluation for asthma (see Example 11-18 and
nose, the nasal cavity, and the nasopharynx. The
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Chapter 5). In addition, exposure to some products, of other contributing factors is also necessary, such
including sawdust, radium, nickel, and chromium as acid reflux, post-nasal drainage, and asthma.
may be associated with the development of cancers Paradoxical vocal fold motion also may occur as a
in the nose and sinuses. These may cause serious manifestation of a focal dystonia known as respira-
permanent impairment and even loss of life. No cri- tory dystonia. The etiology is usually unknown. Like
teria have been established to measure impairment other laryngeal dystonias (eg, spasmodic dysphonia),
associated with rhinorrhea, and this condition is respiratory dystonia is treated with botulinum toxin
usually not a serious disability or handicap for most injection. Mild cases may be controlled through
individuals. Measurement of nasal airflow remains nasal breathing or other voice therapy techniques
controversial. Rhinomanometry may provide an that are used routinely for patients with laryngo-
objective measure of nasal resistance at a specific spasm caused by conditions other than dystonia.
point in time, but rhinomanometry has many limita-
Individuals with air passage defects may be evalu-
tions and cannot provide a diagnosis or establish
ated in accordance with the classification in Table
causation.15,16 When used, it must be interpreted
Chapter 11
11-6. Permanent impairments involving obstructive

expertly, with full understanding of the limitations
sleep apnea should be evaluated with the pulmonary
and variably of the technique. When nasal abnor-
system criteria described in Chapter 5.
malities are also associated with loss of olfaction or
taste, more important consequences may ensue as To use Table 11-6, follow these steps:
discussed in Section 11.4c.
1. Place the individual in the appropriate class
Dyspnea is a cardinal factor that contributes to an based on the key factor (history). Begin by select-
individual’s diminished capacity to carry out ADLs ing the middle number in that class. The classes
and also contributes to permanent impairment. This have discrete numbers. They are not a range.
subjective complaint or symptom, which indicates
an awareness of respiratory distress, usually is noted
findings on this patient. If the class selected by
first and is most severe during exercise. When dys-
physical examination is 1 class higher than the
pnea occurs at rest, respiratory dysfunction probably
class selected from step 1, move 1 number higher
is severe. Dyspnea may or may not be accompanied
within the history class previously selected in
by related signs or symptoms.
step 1. If it is 2 grades higher move up 2 grades
Dyspnea is usually not related to nasal obstruction, within the history selected class. If the class from
since adults with nasal obstruction learn quickly to the physical exam is in a lower class than that
breathe through the mouth. This symptom may be selected from the history, move lower within the
produced by pharyngeal stenosis, vocal fold paralysis class selected from step 1.
or fixation, laryngeal stenosis, or tracheal stenosis.
3. Assess the class of the patient using the diagnostic
Dyspnea with lower airway problems is discussed in
findings. Using the number you have established in
Chapter 5, The Pulmonary System. Other symptoms
step 2, move again up or down if the class is lower
associated with rhinitis include nasal congestion,
than or higher than the class originally selected by
rhinorrhea, itching, sneezing, headache, and fatigue.
the history. You may not move out of the class you
Evaluation for upper airway causes of dyspnea typically
have originally selected from your history.
includes transnasal pharyngolaryngoscopy, tracheos-
copy, imaging studies, and pulmonary function tests. 4. If you begin in class 4, you may move up based
on the number of non-key factors also found in
Laryngeal hyperirritability with laryngospasm may
class 4.
cause intermittent airway obstruction that can be
severe. It is a condition in which the vocal folds For example, if the patient were found to be in class 2
adduct during inspiration, rather than abduct. This originally by history, you would begin at 19% as the
is called paradoxical vocal fold motion or vocal cord middle number in class 2. If the physical exam were
dysfunction (VCD) and may result in stridor, airway in class 4, you would move up to 27%, staying within
obstruction, and a feeling of panic. Cases of VCD the class 2 but moving up 2 grades. If the diagnostic
are commonly caused by laryngopharyngeal reflux. tests were in class 3, it is 1 class higher than the origi-
Environmental irritants and allergens may also play nal class but it would not change your rating since you
a role in VCD formation. Control of episodic para- cannot exceed 27% within class 2. However, if the
doxical vocal fold motion is best achieved by speech diagnostic tests were in class 1, you would move down
therapy with an experienced practitioner. Treatment 1 grade and the final rating would be 23%.
Guides6e_11_247-280.indd 266 2/17/09 2:49:08 PM

TA B L E 11- 6 Criteria for Rating Impairment due to Air Passage Deficits
Air Passage Deficits

CLASS CLASS 0 CLASS 1 CLASS 2a CLASS 3 CLASS 4b
WHOLE PERSON
IMPAIRMENT
RATING (%) 0 1%–9% 11%–27% 30%–42% 45%–58%
SEVERITY 1 3 5 7 9 11 15 19 23 27 30 33 36 39 42 45 48 51 54 58
GRADE (%)
HISTORYC There are no There are no There are no There are no Dyspnea occurs
Chapter 11
complaints of complaints of complaints of complaints of at rest, although
dyspnea at rest dyspnea at rest dyspnea at rest dyspnea at rest individual is
not necessarily
and Activities requir- and and
bedridden
ing intensive
minimal or no dyspnea is pro- dyspnea is pro-
effort may be and
interference with duced by stress, duced by walking
interfered with
any activities prolonged exer- more than 1 or dyspnea is aggra-
or require pro-
tion, hurrying, 2 level blocks, vated by the
phylactic restric-
hill climbing, or climbing 1 flight performance of
tion of activity or
recreational or of stairs even any of the usual
require medica-
similar activities with periods of activities of daily
tion to maintain
except sedentary rest, or perfor- living beyond
optimal function
forms mance of other personal cleans-
usual activities of ing, dressing, or
daily living grooming
For ventilator
dependence, refer
to the pulmonary
chapter ratings
PHYSICAL EXAM Minimal changes Mild changes to Moderate Severe changes Severe changes
to the orophar- the oropharynx, changes to the to the orophar- to the orophar-
ynx, laryngo- laryngopharynx, oropharynx, ynx, laryngo- ynx, laryngo-
pharynx, larynx, larynx, upper laryngopharynx, pharynx, larynx, pharynx, larynx,
upper trachea, or trachea, or lower larynx, upper upper trachea, upper trachea, or
lower trachea, or trachea, or trachea, or lower or lower trachea, lower trachea, or
incomplete and incomplete and trachea, or revers- or obstruction complete, nonre-
episodic obstruc- episodic obstruc- ible complete or of the nose or versible obstruc-
tion of the nose tion of the nose permanent incom- nasopharynx that tion of the nose
or nasopharynx or nasopharynx plete obstruction is only partially or nasopharynx
of the nose or reversible
nasopharynx
DIAGNOSTIC There are no Sinus CTd shows Sinus CT shows Sinus CT shows Sinus CT shows
OR OTHER tests showing mild mucosal moderate muco- moderately diffuse severe
OBJECTIVE obstruction of thickening, mild sal thickening severe mucosal mucosal thick-
FINDINGS the nose, sinuses, obstruction of or moderate thickening or ening or severe
nasopharynx, nasopharynx or turbinate swell- turbinate swell- turbinate swell-
oropharynx, or oropharynx, or ing, moderate ing, or mod- ing, or severe
larynx laryngoscopy obstruction of erately severe obstruction of
may show mild nasopharynx or obstruction of nasopharynx or
alteration in oropharynx, or nasopharynx or oropharynx, or
vocal fold (cord) laryngoscopy oropharynx, or laryngoscopy
function may show moder- laryngoscopy may may show severe
ate alteration in show moderately alteration in
vocal fold (cord) severe altera- vocal fold (cord)
function tion in vocal fold function such as
(cord) function bilateral paralysis
a
Individuals with successful tracheotomy or stoma should be rated as having 25% impairment of the whole person.
b
Move up in class 4 based on the severity and number of findings in physical exam and objective findings.
c
Key factor.
d
CT indicates computed tomography.
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CLASS 1 CLASS 4
EXAMPLE 11-15: CHRONIC RHINOSINUSITIS EXAMPLE 11-16: VOCAL FOLD PARALYSIS
Subject: 35-year old woman. Subject: 29-year-old man.

History: Worked as an operating room (OR) nurse History: Tracheotomy performed 10 years ago
for 12 years. Has had persistent sneezing and runny after traumatic tracheal intubation. Diagnosed with
nose with congestion, cough, and dyspnea at work Arnold-Chiari syndrome and underwent successful
for the past 4 years. Symptoms so severe, had to give neurosurgical decompression. Developed meningitis
up nursing. Past history includes seasonal allergic of unknown etiology, hemiparesis, and other neu-
rhinitis. rologic sequelae. Past history reveals hearing loss,
hypertension, and diabetes. Has 20-year history of
Current Symptoms: Continues to have chronic
Chapter 11
cigarette use.
sinusitis, with acute sinusitis 3 to 4 times a year,
without seasonal variation. Cough and dyspnea Current Symptoms: Wheelchair dependent. Metal
persist, and she has stopped exercising due to symp- tracheotomy tube in place. With tube occluded, has
toms. Notes the occasional onset of acute shortness good voice but poor airway.
of breath and hoarseness that does not respond to
Physical Exam: Right-sided hemiparesis and right-
bronchodilator.
sided hearing loss.
Physical Exam: Nasal mucosa is pale and boggy,
Clinical Studies: Fiberoptic laryngoscopy: both
with near obstruction of both nares and clear dis-
vocal folds in midline position with very poor
charge. Audible inspiratory wheezes are heard
abduction.
over the larynx. Chest exam shows faint expiratory
wheeze and prolonged expiratory phase. Diagnosis: Bilateral vocal fold paralysis with poor
airway. Permanent tracheotomy.
Clinical Studies: Sinus computed tomography (CT)
shows chronic maxillary and ethmoid sinusitis. Impairment Rating: 58% impairment due to vocal
Fiberoptic laryngoscopy at rest shows normal vocal fold paralysis and tracheotomy dependence. Class
fold function. Fiberoptic laryngoscopy after metha- 4. Combine with appropriate ratings for musculosk-
choline administration shows paradoxical closure of eletal and hearing impairments to determine whole
the vocal folds with posterior chink formation dur- person impairment (see Combined Values Chart in
ing inspiration (consistent with vocal fold dysfunc- the Appendix).
tion). Latex IgE radioallergosorbent test (RAST) is
positive. Skin testing to local aeroallergens shows 11.4b Mastication and Deglutition
positive reactions to grasses only. The act of eating includes mastication and degluti-
tion. Numerous conditions of nongastrointestinal
Diagnosis: Chronic rhinosinusitis from occupation-
origin, singly or in combination, may interfere with
ally acquired latex allergy. Vocal fold paradoxi-
these functions.
cal adduction. Seasonal allergic rhinitis to spring
aeroallergens. Dysfunction of the TMJ may impede mastication,
affect speech, cause lower facial deformity, and pro-
Impairment Rating: 7% impairment. Partial inter-
duce pain.17,18 In this section, the effect of TMJ dys-
mittent obstruction of the laryngeal airway due to
function on eating is considered. Evaluation of TMJ
paradoxical vocal fold adduction.
function and mastication includes assessment of
Comment: Class 1 due to shortness of breath from dentition and occlusion. History, physical examina-
vocal fold dysfunction. The rating begins at 5%. tion, dental X rays, TMJ imaging, and TMJ arthros-
The physical exam findings are also in class 1 due copy may be appropriate. Examination commonly
to intermittent findings, so there is no change in includes an evaluation for trismus, and a measure
the number. The objective test results are moderate, of maximal mouth opening distance. Restriction of
and rating moves 1 number; the final rating is 7%. mouth opening or closing, malocclusion, and/or loss
Combine with appropriate rating for occupational of dentition may impair mastication. These limita-
asthma to determine whole person impairment tions may be worsened if pain is present when the
(see Combined Values Chart in the Appendix). individual attempts to chew.
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Dysphagia (difficulty swallowing) and odynopha- (eg, milk shake), puree (eg, yogurt), soft (eg, banana),
gia (pain upon swallowing) may interfere with an semisolid (eg, hamburger), and solid (eg, steak). The
individual’s ability to consume sufficient nutrition, relationship of the restrictions to impairments of
as well as with the enjoyment of eating. The oral, mastication and deglutition is shown in Table 11-7.
pharyngeal, and esophageal phases of swallow-
ing should be evaluated in patients with swallow-
ing complaints. In addition to history and physical
examination, appropriate tests may include modified
barium swallow with videofluoroscopy, esophagram 10% Impairment of the Whole Person
(barium swallow), fiberoptic endoscopic evalua-
tion of swallowing (FEES), capsule endoscopy and
EXAMPLE 11-17: INFLAMMATION AND
esophagoscopy (transoral or transnasal). Swallowing
SCARRING OF LEFT TMJ
problems may also be associated with respiratory
problems and impairment of airway protection, par- Subject: 58-year-old woman.
Chapter 11
ticularly if the swallowing dysfunction is associated
History: After removal of an impacted upper left
with penetration and aspiration of food into the
third molar, individual developed a left oro-antral
larynx. Such conditions are particularly problematic
fistula and acute left maxillary sinusitis, confirmed by
if laryngeal sensation is impaired. Flexible endo-
X ray. Dental films confirmed a tooth remnant in the
scopic evaluation of swallowing with sensory testing
maxillary area. Despite use of antibiotics, persistent
may be used to assess laryngeal sensation by stimu-
drainage from the fistula developed, as did pain in the
lating the external branch of the superior laryngeal
left maxillary area of the face. Severe pain was noted
nerve to trigger a laryngeal adductor reflex. If this
in the left TMJ, and she experienced progressive loss
brain stem–mediated, airway protection reflex is
of mobility of the mandible, with the ability to open
absent in a patient with aspiration and ineffective
the jaws limited to a 1-cm excursion. The left oro-
cough, oral feeding may be unsafe.
antral fistula was explored surgically 6 weeks later,
In accordance with the philosophy of the Guides, and the residual tooth fragment was removed. A left
when mastication and deglutition are evaluated, the naso-antral window was placed in the inferior meatus
ability to eat should be stable and maximal rehabili- for drainage of the maxillary sinus. Extensive scarring
tation should have been achieved. When mastica- in and about the left TMJ was found. The scars were
tion or deglutition is impaired, the imposition of released, but full mobility of the mandible was not
dietary restrictions usually results. Such restrictions obtained until the left coronoid process was released
are the most objective criteria by which to evaluate from the surrounding tissues. She received postopera-
permanent impairment of these functions.19–24 Thus, tive steroid therapy; physical therapy exercises main-
the key factor for this section remains history, with tained mandibular mobility. A stent to keep the jaws
modification of the rating in a class by the specific apart was created and used for several months while
history of the patient. Definitions of mechanical food individual was sleeping.
classifications vary somewhat among experts but
Current Symptoms: Discomfort in the left TMJ
usually include clear liquid (eg, water), full liquid
(on a soft diet) with occasional consumption of
hamburger.
TA B L E 11-7
Physical Exam: Maxillary mobility limited to about
Impairments of Mastication and Deglutition: 60% of mobility noted at surgery, with a well-healed
Relationship of Dietary Restrictions to
Permanent Impairment oral fistula area.
Impairment of Clinical Studies: Paranasal sinus X rays: normal.
the Whole
Type of Restriction Person (%) Diagnosis: Inflammation and scarring of the left
Diet is limited to semisolid or soft TMJ; reduced mandibular mobility.
5, 10, 15
foods a
Diet is limited to liquid foods a 20, 25, 30 person.
Ingestion of food requires tube
feeding or gastrostomy 50 Comment: Individual is able to talk satisfacto-
rily, but dietary choices are limited. Speech is not
a
The choice of these discrete numbers depends on the range affected. No facial deformity, but she may need to
of foods that can be consumed by the individual within the
category.
continue exercises to maintain maxillary mobility.
No problem in maintaining body weight.
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11.4c Olfaction and Taste Numerous conditions can result in voice or speech
Impairment of smell and taste may be caused by disturbances, and information on these conditions is
viruses, tumor, trauma, or exposure to pollutants. readily available in the literature.27–30 Briefly, voice
Bilateral complete loss of either sense results in and speech afflictions may be due to injury of or
potentially disturbing impairment, especially when trauma to the brain, face, neck, or chest; exposure
there is loss of olfaction, causing an inability to to irritants;31–33 cerebrovascular events; voice misuse;
detect toxic fumes and other hazards. In the past, cancer; psychogenic factors; and other causes.
taste and smell assessments have depended entirely
In this chapter, speech is defined as the capacity to
on subjective response. However, more sophisticated
produce vocal signals that can be heard, understood,
taste and smell testing is now available and is capa-
and sustained over a useful time period. Speech ought
ble of identifying typical organic and nonorganic
to allow effective communication in the ADLs.
responses.25,26
This chapter does not consider primarily the causes
Only rarely does complete loss of the closely related
and characteristics of abnormal speech. Rather, it
Chapter 11
senses of olfaction and taste seriously affect an

considers how an impairment relates to the individ-
individual’s performance of the usual ADLs. For
ual’s ability or efficiency in using speech to make
this reason, a value of 1% to 5% impairment of the
himself or herself understood in ADLs. It is assumed
whole person is suggested for use in cases involving
that speech evaluation pertains to the production of
partial or complete bilateral loss of either sense due
voice and articulate speech and not to the language
to peripheral lesions.
content or structure of the individual’s communica-
Partial loss or distortion of taste and smell may be a tion. On the basis of these assumptions, the primary
more serious disability for persons in certain indus- problem is estimating proficiency in the use of
tries, such as those involving food and fragrance. oral language or measuring the utility of speech as
However, these factors will not be reflected in the defined earlier. This section also considers esopha-
impairment rating focused on ADLs. geal speech.
At this time, there is no single, acceptable, proven test
11.4d Voice and Speech
that will measure objectively the degrees of impair-
For many years, “voice” and “speech” were treated
ment due to the many varieties of speech disorders.
as 1 subject under the heading “speech.” Since the
Therefore, it is recommended that speech impairment
late 1970s, voice and voice science have evolved as
be evaluated by examining the (1) audibility, (2) intel-
subspecialties in the field of otolaryngology–head
ligibility, and (3) functional efficiency of speech, as
and neck surgery and speech-language pathology.
defined below in the section on suggested criteria for
Technology and standards of practice now permit
determining voice and/or speech impairment.
appropriate consideration of both aspects of verbal
communication. Voice refers to production of sound Other definable attributes of speech, such as voice
of a given quality, ordinarily using the true vocal quality, pitch, and melodic variation, are evaluated in
folds. Speech refers to the shaping of sounds into the context of their effect on 1 of the 3 primary char-
intelligible words. The severity from impairment acteristics noted above.
of speech is intuitively obvious: if a person can-
Voice, as the term is used in this section, refers to the
not speak intelligibly, verbal communication in the
production of audible sounds by the vibration of the
home, workplace, and social settings is extremely
true vocal folds of the larynx. Voice, or phonation,
difficulty or impossible. However, voice disorders
is therefore the generator of speech—the shaping
have been underappreciated for so long that their
of sounds into intelligible words. Alternative physi-
significance may not be as immediately apparent.
ologic sound generators, such as the false vocal folds
Nevertheless, if a voice disorder results in hoarse-
or the esophagus, are not considered specifically
ness, breathiness, voice fatigue, decreased vocal
here, but they may function in lieu of normal vocal
volume, or other similar voice disturbances, an
fold oscillation, and this situation does not preclude
individual may be unable to be heard in the pres-
the use of the methods for determining impairment
ence of even moderate background noise or to carry
set forth in this chapter.
on telephone conversations for prolonged periods of
time. Communication with hard-of-hearing family This section does not consider primarily the causes
members and friends may be particularly difficult of voice disorders. Rather, it recognizes that voice
and frustrating for everyone involved.
Guides6e_11_247-280.indd 270 2/17/09 2:49:10 PM

disorders may present such definable symptoms as universally accepted measure to quantify voice or
abnormal volume (voice fatigue, weakness, or low speech function. Therefore, the standard of practice
sound intensity), abnormal control (pitch and/or requires the use of a battery of tests.
melodic variation), and/or abnormal quality (hoarse-
Various tests and objective measures of voice have
ness, harshness, and/or breathiness). These symp-
been available clinically at least since the late 1970s
toms indicate abnormal physiologic functioning of
and 1980s. Tests such as strobovideolaryngoscopy,
the phonatory mechanism and may contribute to
acoustic analysis, phonatory function assessment,
impairment of speech.
and laryngeal electromyography (EMG) are recog-
At this time, there is no single, acceptable, proven test nized as appropriate and useful in the evaluation of
that will measure objectively the degrees of impair- speech and voice disorders.28,30,31,36,37 Selected blood
ment associated with the many varieties of voice dis- tests and imaging studies also may be appropri-
orders. Tests such as laryngoscopy, acoustical analysis ate. Some or all of these tests may be necessary in
of voice, strobovideolaryngoscopy, analysis of phona- selected cases to determine the cause and severity
Chapter 11
tory function, laryngeal electromyography and oth- of a voice or speech disorder and to establish the
ers are recognized as appropriate and useful.28 The presence of organic versus nonorganic voice and/or
significance of current normative data is unclear when speech impairment. Evaluation by a certified speech-
confined to consideration of impairment. language pathologist and other voice team profes-
sionals is required in many cases.
Evaluation
Evaluation of voice requires visualization of the
Evaluation of a person with speech or voice com-
larynx by a physician trained in laryngoscopy
plaints begins with a thorough history. Inquiry
(usually an otolaryngologist) and determination
should include questions regarding the patient’s
of a specific medical cause for the voice dysfunc-
professional and avocational vocal needs and habits,
tion. Assessment of voice quality, frequency range,
voice use patterns, problems before the onset of the
intensity range and endurance, pulmonary function,
current complaint, the time and apparent cause of
and function of the larynx as a valve (airflow regu-
the onset of voice and speech dysfunction, and any
latory) can be performed easily and inexpensively.
evaluations and interventions that have been tried
Normative values for these assessments have been
to improve voice function. It is also essential to
established in the literature and are discussed else-
obtain information about irritants that may impact
where.28,34,35 More sophisticated techniques to quan-
the voice greatly. Not only mucosal irritants and
tify voice function (spectrography, inverse filtering,
inhalant toxicity may impair the voice but also any
etc) may be helpful in selected cases. Slow-motion
substances that decrease lung function or neurologic
assessment of vocal fold vibration using strobovide-
function (including neurotoxins such as heavy met-
olaryngoscopy (an established procedure that was
als). A thorough history must include information
first described more than 100 years ago), high-speed
about virtually all body systems, because maladies
video, or videokymography is often medically neces-
almost anywhere in the body (endocrine, rheumato-
sary to establish an accurate diagnosis.
logic, gastroenterologic, orthopedic, psychiatric, and
others) may be causally related to voice complaints. Imaging studies such as MRI, CT, or positron emis-
The details of a comprehensive voice and speech his- sion tomography (PET); blood tests, neurologic
tory and physical examination are beyond the scope testing, and speech-language evaluation may be
of this brief chapter and may be found in other litera- used to determine the cause and severity of a speech
ture.28,34,35 The physical examination should include disorder. Many approaches are available for speech
thorough evaluation of the structures in the head and assessment, most of which are described in standard
neck, and evaluation of other parts of the body, as speech-language pathology textbooks.28 However, for
appropriate, based on history and physical assess- the purposes of determining impairment, the assess-
ment of the patient. A thorough evaluation of voice ment protocol that has been employed most com-
and speech is also mandatory. monly uses “The Smith House” reading paragraph,
which reads as follows.
For the purposes of this chapter, it should be
assumed that the evaluation of voice and speech Larry and Ruth Smith have been married nearly
involves an assessment of a person’s ability to pro- 14 years. They have a small place near Long Lake.
duce phonation and articulate speech and does not Both of them think there’s nothing like the country for
involve assessment of content, language, or linguistic health. Their 2 boys would rather live here than any
structure. At the present time, there is no single,
Guides6e_11_247-280.indd 271 2/17/09 2:49:11 PM

other place. Larry likes to keep some saddle horses you plainly. Be sure to speak so I can understand
close to the house. These make it easy to keep his sons you.” Then ask him or her to read aloud the short
amused. If they wish, the boys can go fishing along paragraph, “The Smith House.”
the shore. When it rains, they usually want to watch
4. If additional reading procedures are required,
television. Ruth has a cherry tree on each side of the
simple prose paragraphs from a magazine may
kitchen door. In June they enjoy the juice and jelly.
be used. A person who cannot read may be
The examiner should have normal hearing as defined requested to give his or her name and address and
in the earlier section in this chapter on hearing. The name all the days of the week and months of the
setting of the examination should be a reasonably year. Additional evidence regarding the person’s
quiet room that approximates the noise levels of rate of speech and ability to sustain it may be
everyday living. obtained by noting the time required to count
to 100 by ones. Completion of this task in 60 to
The examiner should base judgments of impairment
75 seconds is accepted as normal.
on 2 kinds of evidence: (1) attention to and observa-
Chapter 11
tion of the individual’s speech in the office—for 5. Record judgment of the individual’s speech
example, during conversation, during the interview, capacity with regard to each of the 3 rows of the
and while reading and counting aloud—and (2) classification chart (Table 11-8), as discussed
reports pertaining to the individual’s performance in below. The class of speech impairment is deter-
everyday living situations. Reliable observers who mined by the highest voice performance deficit
know the person well should supply the reports or identified on the classification chart.
the evidence. The general standard of evaluation is
6. The percentage impairment to be assigned within
an average speaker’s performance in average situa-
the class identified is determined by further con-
tions of everyday living. It is assumed in this context
sideration of objective test results and the remain-
that an average speaker can usually perform accord-
ing voice performance measures. Follow the
ing to the following criteria:
instructions below for Table 11-8.
• Talk in a loud voice when the occasion demands it.
The advantages of this system are simplicity, and
• Sustain phonation for at least 10 seconds after wide application for impairment determination.
1 breath. However, this approach does not take advantage of
many standardized speech evaluation tests, of tech-
• Complete at least a 10-word sentence in 1 breath.
nology for better quantification, or of techniques
• Form all of the phonetic units of American available to help identify psychogenic and intentional
speech and join them intelligibly, or those of the voice and speech dysfunction. These advanced meth-
individual’s primary language. ods should be used at least when the results of simple
confrontation testing are unconvincing or equivocal;
• Maintain a speech rate of at least 75 to 100 words
ideally, they should be used in all cases.
per minute and sustain a flow of speech for a rea-
sonable length of time. A speech rate of 125 words In addition, this approach does not address the issue
per minute enables a speaker to read approxi- of people whose native language is not English. No
mately one 8½ ⫻ 11-inch page of double-spaced specific passages have been assigned for various lan-
text in 2 minutes. guages. However, appropriate passages may be drawn
from the phoniatric or speech-language pathology lit-
Specific Instructions erature of appropriate countries and used by a medical
1. Place the individual approximately 8 ft from the examiner whose command of the specific language is
examiner. sufficient to permit valid and reliable interpretation of
the patient’s responses. Reading other material, count-
2. Interview the individual. This will permit obser-
ing in the patient’s native language, or naming days of
vation of his or her speech in ordinary conver-
the week and months of the year may be utilized for
sation while pertinent historical information is
non-English assessment.
obtained.
Physicians performing impairment evaluations are
3. Have the individual’s back toward the examiner
often expected to make additional comments regard-
and keep a separation of 8 ft between the exam-
ing the impairment’s effect on the individual’s occu-
iner and the examinee. Instruct the person as fol-
pational requirements. This disability is frequently not
lows: “You are to read this passage so I can hear
Guides6e_11_247-280.indd 272 2/17/09 2:49:11 PM

reflected in the AMA impairment rating but should Table 11-8 summarizes suggested voice and speech
be addressed in a separate discussion. Physicians impairment criteria. In the evaluation of functional
performing the additional task of discussing disabil- efficiency, everyday speech communication should
ity must be certain that they understand thoroughly be interpreted as including ADLs. A judgment is
the occupational needs and demands of the patient. made regarding the patient’s speech and voice capac-
One schoolteacher’s professional vocal needs may be ity with regard to each of the columns of the classi-
very different from those of another schoolteacher, fication chart (Table 11-8). Note that the impairment
even in the same school district. Similar differences ratings for speech and/or voice impairments are
occur among all voice professionals, including sing- not evaluated separately. The degree of impairment
ers, telephone operators, and others whose occupa- of voice and/or speech is equivalent to the greatest
tions depend on voice and speech (eg, shop foremen percentage of impairment recorded in any 1 of the
who must be heard over noise). Understanding the 3 columns of the classification chart.
individual circumstances is essential in formulating
For example, a particular patient’s voice/speech
an accurate, rational, and defensible opinion regard-
Chapter 11
impairment is judged to be the following: audibil-
ing the occupational consequences of a voice and/or
ity (class 1); intelligibility (class 3), and functional
speech problem. All such disability information must
efficiency (class 2). A patient’s voice/speech impair-
be documented thoroughly and separately from the
ment class is judged to be equivalent to the greatest
impairment rating discussion, which focuses, in con-
impairment (class 3). The exact number in that class
trast, on impairment of ADLs.
is found using Table 11-8.
Criteria for Determining Voice and/or Speech To use Table 11-8, follow these steps:
Impairment
1. The key factor is voice/speech performance
For the purposes of classifying voice and/or speech
measures. To determine the class of impairment,
impairment, the patient’s audibility, intelligibility,
choose the class corresponding to the highest of
and functional efficiency must be taken into account.
the 3 speech performance measures: audibility,
Audibility permits the patient to be heard over back-
intelligibility, or functional efficiency.
ground noise. It generally reflects the condition of the
voice. Intelligibility is based on the ability to articu- 2. Using the middle number from the class deter-
late and to link phonetic units of speech with accuracy mined in step 1, move up or down 1 number if
sufficient to be understood. Functional efficiency is the objective tests are in a class above or below
based on the ability to produce a satisfactorily rapid the class initially chosen.
rate of speaking and to sustain this rate over a time
3. If, after step 2, you have not reached the highest
period sufficient to permit useful communication.
number in the originally selected class and 1 of
Impairment determination should be based on the other factors under speech performance is in
subjective and objective assessments of voice and the same class as initially chosen in step 1, move
speech, on reports pertaining to the patient’s perfor- up within the same class.
mance in everyday living and, in some cases, on val-
For example, if the patient were found to be in class
idated instruments such as the Voice Handicap Index
2 by the highest of the 3 speech performance lev-
(VHI),36 and on the results of the “Smith House”
els, in this example audibility, the individual would
reading passage test. Reliable observers should sup-
qualify for class 2 and you would begin at 15% as
ply the reports or evidence. The standard of evalua-
the middle number in class 2. If the diagnostic test
tion should be the normal speaker’s performance in
were in class 3 or 4, you would move up to 18%.
average situations for everyday living. Judgments as
Since 18% is the highest rating in class 2, you have
to the amount of impairment should be made with
completed the rating. If, however, the diagnostic test-
reference to the classes, percentages, and examples
ing were in class 1, you would move from 15% to
provided in the classification chart. The categories in
12%. In this case you would evaluate the remaining
the chart suggest activities or situations with differ-
factors of intelligibility and functional efficiency. If
ent levels of impairment. Data gathered from direct
1 of these were in class 2 you would increase the rat-
observation of the individual or from interviews
ing to 15%. If both factors were in class 2, you would
should be compared with these categories, and val-
increase the rating to 18%.
ues should be assigned on the basis of the specific
impairments that are present.
Guides6e_11_247-280.indd 273 2/17/09 2:49:11 PM

T A B L E 1 1 - 8 Criteria for Rating Voice and Speech Impairmenta
Voice and Speech Impairment

WHOLE PERSON
IMPAIRMENT
RATING (%) 0 2%–10% 12%–18% 20%–28% 30%–35%
SEVERITY 2 6 10 12 15 18 20 24 28 30 33 35
GRADE (%)
VOICE/SPEECH Audibility: Can Audibility: Can Audibility: Can pro- Audibility: Can pro- Audibility: Can not
Chapter 11
PERFORMANCE produce voice produce voice of an duce voice of an duce speech of an produce speech of
MEASURESb,c of an intensity intensity sufficient intensity sufficient intensity sufficient an intensity suf-
sufficient for for many needs of for some needs of for a few needs of ficient for everyday
most needs of everyday speech everyday speech such everyday speech, speech needs
everyday speech, and is usually heard as close conversation; but can barely be
Intelligibility: Can
although this under average con- however, has consid- heard by a close
perform no articula-
sometimes may ditions; however, erable difficulty at a listener or over the
tory acts necessary
require effort may have difficulty distance or in noisy telephone and may
for everyday speech
and occasionally being heard in noisy places—such as cars, be able to whisper
may be beyond places—such as buses, trains, train sta- audibly but with no Functional
individual’s cars, buses, trains, tions, or restaurants— louder voice Efficiency: Can meet
capacity train stations, or because the voice no demands of
Intelligibility:
restaurants tires easily and tends articulation and pho-
Intelligibility: Can perform a
to become inaudible nation for everyday
Can perform Intelligibility: Can few articulatory
after a few seconds needs with adequate
most articu- perform many artic- acts necessary for
speed and ease
latory acts ulatory acts neces- Intelligibility: Can everyday speech,
necessary for sary for everyday perform some articu- can produce some
everyday speech, voice and be under- latory acts necessary phonetic units, and
but may occa- stood by a stranger, for everyday speech may have approxi-
sionally be asked but may have and can usually con- mations for a few
to repeat and numerous inaccura- verse with family words such as
may find it dif- cies and sometimes and friends, but may names of own fam-
ficult or impos- appears to have dif- be understood by ily members, but is
sible to produce ficulty articulating strangers only with unintelligible out
some phonetic difficulty and often of context
Functional
units may be asked to
Efficiency: Can meet Functional
repeat
Functional many demands of Efficiency: Can
Efficiency: Can articulation and Functional Efficiency: meet a few
meet most phonation for every- Can meet some demands of articu-
demands of day speech with demands of articula- lation and phona-
articulation and adequate speed and tion and phonation tion for everyday
phonation for ease, but sometimes for everyday speech speech with ade-
everyday speech speaks with dif- with adequate speed quate speed and
with adequate ficulty and speech and ease, but can ease (such as single
speed and ease, may be discontinu- sustain consecutive words or short
but occasionally ous, interrupted, speech only for brief phrases), but can-
may hesitate or hesitant, or slow periods and may give not maintain unin-
speak slowly the impression of terrupted speech
being easily fatigued flow; speech is
labored, and rate is
impractically slow
OBJECTIVE TESTS None required Strobovideo- Strobovideo- Strobovideo- Strobovideo-

laryngoscopy, laryngoscopy, objec- laryngoscopy, laryngoscopy, objec-
Strobovideo-
objective voice and tive voice and speech objective voice and tive voice and speech
laryngoscopy,
speech measures, measures, and VHI speech measures, measures, and VHI
objective voice
and VHI are mildly are mildly to moder- and VHI are mod- are moderately to
and speech
abnormal ately abnormal erately to severely severely abnormal
measures, and
abnormal
VHIa should be
normal or nearly
normal
a
VHI indicates Voice Handicap Index. See reference 36.
b
Key factor.
c
Physical examination of the voice and speech, and confrontational testing, should be consistent with the activity descriptions for
each classification listed above under history
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CLASS 1 EXAMPLE 11-19: VOCAL DIFFICULTIES

History: Rock-and-roll singer and songwriter; devel-
EXAMPLE 11-18: RECURRENT VOCAL FOLD
oped new onset of vocal difficulties while recording
HEMORRHAGE SCAR
album 1 year previously. Had been singing and per-
Subject: 47-year-old woman. forming for 10 years with no prior vocal difficulties.
Loss of midrange, decreased volume, breathiness, and
History: Professional operatic soprano and voice
hoarseness while singing. Diagnosed with left vocal
teacher; had sudden onset of dysphonia 1 year
fold polyp 3 months later. Underwent surgical excision
previously; diagnosis was vocal fold hemorrhage.
of lesion 1 month after that. Treated for laryngopha-
Developed vocal fold mass secondary to hemor-
ryngeal reflux with usual medical therapy.
rhage. Gastroesophageal reflux. Five vocal fold
surgeries for repeated vocal fold masses. Had opera- Current Symptoms: Breathiness; hoarseness; loss
Chapter 11
tions to attempt to reduce vocal fold scar. Advised of vocal stamina; loss of volume; loss of lower range.
to undergo another surgical procedure that would Voice is worse in morning, with frequent throat-
implant fat into vocal fold. clearing and sensation of lump in throat.
Current Symptoms: Husky speaking voice; lowered Physical Exam: Right vocal fold mass, left vocal
pitch; oral dryness; postnasal drip. Unable to sing fold scar, reflux laryngitis, and neurolaryngologic
or perform professionally since vocal fold hemor- asymmetries on strobovideolaryngoscopy. Excess
rhage. Audibility is sometimes a problem in noisy tension in jaw and tongue, hoarseness, and decreased
environments. range while singing.
Physical Exam: Voice is mildly hoarse, mildly soft, Clinical Studies: Laryngeal EMG: 20%
and slightly breathy. Audibility is sometimes a prob- decreased function of left superior laryngeal nerve.
lem in noisy environments. Left vocal fold posthem- Abnormalities in electroglottogram (EGG), quasi-
orrhagic cyst, right vocal fold mass, left vocal fold open quotient, air-conduction flow, minimal flow,
scar, possible mild superior laryngeal nerve paresis, maximum flow rate, S/Z ratio, maximum phonation
muscular tension dysphonia, and gastroesophageal time, and acoustic measurements.
reflux disease on laryngeal examination by strobo-
Diagnosis: Persistent vocal fold mass and vocal fold
videolaryngoscopy. Singing technique was very good
scar after recent vocal fold surgery; superior laryn-
and was able to correct minor technical deficiencies.
geal nerve paresis; laryngopharyngeal reflux disease.
Clinical Studies: Mild decrease in maximum
phonation time and air-conduction flow.
person. The individual is a class 1 based on audibil-
Diagnosis: Recurrent vocal fold hemorrhage and ity results, particularly in the morning. The rating
vocal fold scar. Intermittently uncontrolled gas- begins at 6%. Objective tests are in the severe cat-
troesophageal reflux disease. Obesity. Inability to egory, class 4, so, the final rating is 10%, since this is
regain singing voice she had before the vocal fold the highest one can rate in class 1.
injury. Altered and diminished self-image.
Comment: He is unhappy with his vocal prog-
Impairment Rating: 6% impairment of the whole ress and is totally disabled as a professional singer
person. The individual is a class 1 based on audibil- because of this work-related injury; however, his
ity results. The rating begins at 6%. Objective tests disability is separate from his impairment rating.
are also in class 1. Intelligibility and functional
efficiency are class 0, however, they cannot be used
to increase the rating. The final rating is class 1, 6%
impairment of the whole person. CLASS 2
12% to 18% Percent Impairment of the Whole Person
Comment: Afraid her career is over. Traumatic
change in self-image. Unable to resume her living as
an internationally known opera star. Resigned her EXAMPLE 11-20: VOCAL FOLD SCAR
teaching position in Europe and moved to the United AND LEUKOPLAKIA
States to receive necessary voice care. Voice is now
of a sufficient intensity for most everyday speech
needs. History: Has a 22-year history of working in auto-
mobile reconstruction. Recurrent sinusitis and
Guides6e_11_247-280.indd 275 2/17/09 2:49:12 PM

progressive hoarseness for 2 years. Voice worse Became aphonic after 3 days back at work. Required
after vocal fold “polypectomy” for leukoplakia. Had 2 vocal fold surgeries since initial injury. Undergoing
septoplasty and functional endoscopic sinus surgery. psychological counseling for stress-related problems
No complaint of nasal or sinus disease. Speaks about secondary to voice problems. Quit smoking.
14 hours a day over loud noise. Must talk loudly or
Current Symptoms: Voice deterioration after using
yell frequently. Is regularly exposed to car fumes,
voice and after any exposure to fumes, perfume,
asbestos, and aerosols. Does not smoke. Rarely
smoke, or gasoline; hoarseness associated with short-
drinks alcohol.
ness of breath; chronic sensation of lump in throat.
Current Symptoms: Constant hoarseness. Difficulty
Physical Exam: Voice is harsh, hoarse, slightly
speaking and pain by afternoon. Frequently clears
breathy, and strained. Bilateral vocal fold scarring,
throat. Complains of lump in throat.
decreased mucosal wave, hypervascularity, and
Physical Exam: Leukoplakia on left vocal fold and mucosal irregularities on strobovideolaryngoscopy.
stiffness of vibratory margin secondary to scar on Voice fatigues rapidly and becomes hard to hear if
Chapter 11
strobovideolaryngoscopy. Erythema and edema of there is any background noise.

glottis consistent with gastroesophageal reflux
Clinical Studies: Marked abnormalities in harmonic
disease. Improper speaking technique and signifi-
to noise ratio, shimmer, and maximum flow rate.
cant muscle-tension dysphonia.
Diagnosis: Mucosal vocal fold injury secondary to
Clinical Studies: Laryngeal EMG: left superior
inhalation of noxious fumes, initially vinyl chloride.
laryngeal nerve paresis and muscle-tension dyspho-
Airway hyperactivity that causes dysphonia and
nia. No evidence of neuromuscular junction abnor-
dyspnea.
malities. Severely abnormal harmonic to noise ratios,
decreased intensity, decreased frequency range, and Impairment Rating: 18% impairment of the whole
decreased phonation time. person. The individual is a class 2 based on audibil-
ity results. The rating begins at 15%. Objective tests
Diagnosis: Vocal fold scar, leukoplakia (hyperkerato-
are moderately severe (class 3), and both intelligibil-
sis), muscle-tension dysphonia, and gastroesophageal
ity and functional efficiency are in class 2; therefore,
reflux disease.
the final rating is 18%.
person.
CLASS 3
Comment: Leukoplakia requires biopsy. Hoarseness
caused by scarring from previous injury and from
surgery is permanent. The individual is a class 2
based on audibility results. The rating begins at 15%. EXAMPLE 11-22: BILATERAL VOCAL FOLD
Objective tests are moderately severe class 3, and PARALYSIS
both intelligibility and functional efficiency are in
class 2; therefore, the final rating is 18%.
History: Involved in motor vehicle collision 20 years
previously. Sustained massive brain-stem trauma
EXAMPLE 11-21: VOCAL FOLD SCAR and multiple injuries, including fractured clavicle,
shoulder, and hands. Was comatose for 8 weeks.
Underwent tracheotomy and gastrostomy 3 days
History: Worked with rubber, plastics, and chemi- after collision. Left hemiparesis, cognitive deficits,
cals for 20 years (described as responsible for memory loss, and “personality change.” Completed
“everything that blows up”). Suffered inhalation occupational therapy, physical therapy, and speech
injury from heavy exposure to vinyl chloride fumes and cognitive rehabilitation.
due to reactor malfunction. Had microlaryngoscopy
Current Symptoms: Unable to be heard on tele-
and excision of bilateral vocal fold polyps 1 year
phone; cannot carry on sustained conversation;
after inhalation injury. Voice improved after sur-
cannot raise voice above soft whisper.
gery; remained off work for 6 weeks after operation.
Exposed to ammonia fumes 1 month after return- Physical Exam: Extremely breathy, soft voice.
ing to work. Experienced immediate dyspnea and Halting speech pattern. Short phrasing. Can count
sudden and severe hoarseness. Required a second only up to 8 on 1 breath. Has left-sided facial weak-
microlaryngoscopy and vocal fold polypectomy. ness, dysphagia, and chronic cough. Bilateral vocal
Guides6e_11_247-280.indd 276 2/17/09 2:49:13 PM

fold immobility, with patent but narrow airway on Current Symptoms: Unable to speak. Unable to
strobovideolaryngoscopy. develop esophageal speech or use electrolarynx.
Remains totally aphonic.
Clinical Studies: Laryngeal EMG: bilateral vocal
fold paralysis. Severely short phonation times. All Physical Exam: No evidence of cancer. Has very
acoustic measures: highly abnormal. dense and deep scarring of neck musculature. Stoma
appears epithelialized and open.
Diagnosis: Bilateral vocal fold paralysis.
Clinical Studies: Four esophageal dilatations.
Impairment Rating: 28%. The individual is a class
Stoma remains open, but he has not been able to
3 based on audibility results. The rating begins at
accommodate Singer-Blom prosthesis.
24%. Objective tests are in the severe category (class
4), so the final rating is 28%. This is the highest one Diagnosis: Laryngeal cancer; laryngectomy.
can rate in class 3.
Comment: Underwent voice therapy. Conservative, person. The individual is a class 4 based on audibil-
Chapter 11
anterior vocal fold medializations. Cannot be heard ity results. The rating begins at 33%. Objective tests
in office setting or anywhere with background noise. are in the severe category, class 4, which does not
Is dysfluent and has halting speech (often interpreted change the rating. The intelligibility and functional
by others as intellectual deficits). Unable to use the efficiency are in class 4, thus increasing the rating to
telephone. Unable to carry on sustained conversa- 35%.
tion. Unlikely to ever regain voice he had before
Comment: Altered self-image secondary to dis-
motor vehicle collision. Requires ongoing medical
figurement from cancer, radical neck surgery, and
care (not only for voice) and will require multiple
tracheostomy. Unable to achieve speech with Singer-
laryngeal surgical procedures for voice improve-
Blom assistive device or by alternative means. Lacks
ment. Is prone to aspiration pneumonia secondary to
motivation and dexterity for use of assistive voicing
vocal fold paralysis. Requires ongoing voice therapy
devices due to chronic alcohol abuse.
and voice-assistive devices. Combine with appropri-
ate ratings due to other impairments to determine
whole person impairment (see Combined Values
References
1. American Academy of Otolaryngology Committee on
CLASS 4 Hearing and Equilibrium and American Council of
30% to 35% Impairment of the Whole Person Otolaryngology Committee on the Medical Aspects of
Noise. Guide for the evaluation of hearing handicap.
JAMA. 1979;241:2055–2059.
EXAMPLE 11-23: LARYNGEAL CANCER
2. Sataloff RT, Sataloff J. Occupational Hearing Loss.
AND LARYNGECTOMY 3rd ed. New York, NY: Taylor & Francis; 2006.
Subject: 50-year-old man. 3. Glorig A, Roberts J. Hearing Levels of Adults by Age
and Sex: United States, 1960–1962. Washington,
History: Had large endolaryngeal tumor without DC: National Center for Health Services Research
airway obstruction. Hoarseness for 1 year. Enlarging and Development, US Dept of Health, Education, and
anterior neck mass for 2 weeks. Dysphagia and 4.5-kg Welfare; 1965. DHEW-PUB-1000-SER-11-11.
(10-lb) weight loss over 2 months. A 40 to 50 pack a 4. American National Standards Institute. American
year history of smoking. Moderately heavy alcohol National Standards Specification for Audiometers.
user. Underwent total laryngectomy with radical neck ANSI Standard S3.6-1996. New York, NY: American
National Standards Institute; 1996.
dissection and excision of malignant laryngeal cutane-
ous fistula. Surgery was followed by radiation therapy. 5. Mandel S, Sataloff RT, Schapiro S. Minor Head
Underwent 4 esophageal dilatations and stomal revi- Trauma: Assessment, Management and Rehabilitation.
New York, NY: Springer-Verlag; 1993.
sions in preparation for Singer-Blom prosthesis after
laryngectomy and radiation therapy. Had submental 6. National Center for Health Statistics. Hearing Status
and Ear Examinations: Findings Among Adults.
swelling that required full-mouth dental extraction United States, 1960–1962. Vital and Health Statistics,
and alveoloplasty. Smokes through tracheostomy. Eats Series 11, No. 32. Washington, DC, US Dept of Health,
well; weight is stable. Has virtually no family to assist Education, and Welfare; 1968.
him in his care.
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7. Newman CW, Jacobson GP, Spitzer JB. Development 20. Carlsson GE, deBoever JA. Epidemiology. In: Zarb GA,
of the Tinnitus Handicap Inventory. Arch Otolaryngol ed. Temporomandibular Joint Function and Dysfunction.
Head Neck Surg. 1996;122:143–148. Copenhagen, Denmark: Munksgaard; 1994.
8. Physician’s Guide to Medical Practice in California Presents the need for better definition of principles of
Workers’ Compensation System. Industrial Medical diagnosis and treatment of TMJ disorders.
Council, State of California, 1994;3:37.
21. Okeson JP. Current terminology and diagnostic
9. Shepard NT, Telian SA. Practical Management of the classification schema. deBont LGM. Epidemiology
Balance Disorder Patient. San Diego, Calif: Singular and natural progression of temporomandibular joint
Publishing Group; 1996:33–168. intracapsular and arthritic conditions. Stohler CS.
Epidemiology and natural progression of muscular
Presents the basics of vestibular system function, clinical
temporomandibular disorder conditions. In: NIH
diagnosis, treatment planning, and rehabilitation of vestibular
Technology Assessment Conference on Management
disorders. The discussion of normative data is helpful.
of Temporomandibular Disorders. Bethesda, Md:
10. Barbarh O, Stockwell GW. Manual of National Institutes of Dental Research and the NIH
Electronystagmography. St Louis, Mo: CV Mosby; 1976. Office of Medical Applications of Research,.National
Institutes of Health; 1996:21–26, 33–39.
11. Herdman SJ. Vestibular Rehabilitation. Philadelphia,
Chapter 11
Pa: FA Davis; 1994:47–180, 206–242. Stresses the need for reliable diagnostic instrumentation
compatible with both diagnostic and therapeutic purposes.
A presentation of vestibular function, adaptation, assessment,
and medical management of vestibular disorders. A chapter on 22. Norman JE, Bramley P, Painter DM. Medico-legal
the assessment and treatment of vestibular deficits in children implications: post-traumatic disorders. In: Norman
with developmental disorders is included. JE, Bramley P, eds. Textbook and Color Atlas of the
Temporomandibular Joint. Chicago, Ill: Year Book
12. Goebel JA, Satalofff RT, Hanson JM, et al.
Medical Publishers Inc; 1990:134–135.
Posturographic evidence of non-organic sway pattern
in normal subjects, patients and suspected malingers. A brief commentary on some medicolegal aspects of
Otolaryngol Head Neck Surg. 1997;117:293–302. posttraumatic TMJ disorders.
13. Nasher LN. A model describing vestibular detection 23. Widmer CG. Evaluation of diagnostic tests for TMD.
of body sway motion. Acta Otolaryngol Scand. In: Clinics in Physical Therapy: Temporomandibular
1971;72:429–436. Disorders. London, England: Churchill Livingstone; 1994.
14. Jacobson GP, Newman CW. The development of the An overview of the reliability and validity of diagnostic tests
Dizziness Handicap Inventory. Arch Otolaryngol Head for TMD.
Neck Surg. 1990;116:424–427.
24. Kaplan AS, Assael LA. Temporomandibular Disorders:
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obstruction: a study of 1000 patients. Arch Otolaryngol. Saunders Co; 1991:106–117.
1979;105:542–545.
25. Serby MJ, Chobor KL. Science of olfaction. New York,
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nasal resistance. Otolaryngol Head Neck Surg.
26. Spielman AI, Brand JG, eds. Experimental Cell Biology
1985;93:778–785.
of Taste and Olfaction: Current Techniques and
17. Dworkin SF, Kimberly KH, LeResche L, et Protocol. Boca Raton, Fla: CRC Press; 1995:15–430.
al. Epidemiology of signs and symptoms in
27. Spiegel JR, Frattali M. Olfactory consequences
temporomandibular disorders: clinical signs in cases
of minor head trauma. In: Mandel S, Sataloff RT,
and controls. J Am Dent Assoc. 1990;120:273–281.
Schapiro SR, eds. Minor Head Trauma: Assessment,
An epidemiologic study of signs and symptoms of Management and Rehabilitation. New York, NY:
temporomandibular disorders (TMD) in a probability sample of Springer-Verlag; 1993:225–234.
adults enrolled in a major health maintenance organization.
28. Sataloff RT. Professional Voice: The Science and
18. McNeil C. Epidemiology. In: McNeil C, ed. Art of Clinical Care. 3rd ed. San Diego, Calif: Plural
Temporomandibular Disorders: Guidelines for Publishing Inc; 2005.
Classification, Assessment, and Management. 2nd ed.
An extensive review of the current information on diagnosis
Chicago, Ill: Quintessence Books; 1993.
and treatment of voice disorders. Data on normative values are
Discusses prevalence of TMD in nonpatient populations and limited.
the need to assess chronic pain and headache related to
29. Colton RH, Casper JK. Understanding Voice Problems:
temporomandibular joint (TMJ) dysfunction.
A Physiological Perspective for Diagnosis and
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eds. Temporomandibular Disorders: Diagnosis and
30. Aronson A. Clinical Voice Disorders. 3rd ed. New
Treatment. Philadelphia, Pa: WB Saunders Co; 1991.
York, NY: Thieme Medical Publishers; 1990:117–145.
Presents the need for long-term studies of TMJ disorders.
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32. Sataloff RT. Vocal tract response to toxic injury: 35. Baken RJ. Clinical Measurement of Speech and Voice.
clinical issues. J Voice. 1994;8:63–64. Boston, Mass: College-Hill Press; 1987:518.
33. Gould WJ, Sataloff RT, Spiegel JR. Voice Surgery. St Methods of measurement are emphasized.
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36. Jacobson BH, Johnson A, Grywalski C, et al. The Voice
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Overview of standard methods for clinical examination of the 37. Sataloff RT, Mandel S, Manon-Espaillat R, Heman-
voice. Ackah YD, Abaza M. Laryngeal Electromyography.
2nd ed. San Diego, Calif: Plural Publishing Inc; 2006.
Chapter 11
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280
CHAPTER 12
The Visual System
12.2 Impairment of Visual Acuity
Chapter 12
12.3 Impairment of the Visual Field
12.4 Impairment of the Visual System
12.5 Visual Acuity Measurement at Near

(Reading Acuity)
12.6 Reporting Aids

Introduction
nent impairment of the visual system as it affects
an individual’s ability to perform vision-related
Activities of Daily Living (ADLs). The visual sys-
tem includes the eyes and supporting structures, the
neural pathways, and the visual cortex of the brain.
Changes to the visual cortex are also discussed in
Chapter 13, The Central and Peripheral Nervous
System. For vision loss, that chapter follows the
calculations presented here.
In accordance with the mandates of Chapters 1
and 2 of the Guides and with the principles of
the International Classification of Impairments,
Disabilities, and Handicaps (ICIDH)1 and the
International Classification of Functioning,
Disability and Health (ICF),2 this chapter focuses
on vision, that is, on the functional impairment
of the visual system as a whole. That system is
unique in that it combines the input from 2 sepa-
rate eyes into a single visual perception. The cal-
culations in this chapter therefore do not consider
anatomic changes to any component of the visual
system by themselves, but only their functional
consequences. For instance: they do not consider
281
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the disfiguring aspect that may accompany an eye Since the FVS scale is different from the earlier
injury (see Section 11.3a and Table 11-5), nor do VES scale, visual impairment ratings based on
they consider the loss of vision in 1 eye without the Fourth or earlier editions cannot be compared
considering the remaining vision in the other eye directly to impairment ratings based on the
(see Section 12.4b). The impairment ratings in current edition.
this chapter estimate the severity of the effects of
2. The FVS is based primarily on an assessment of
vision loss on the ability to perform vision-related
visual acuity and visual field, yet allows individ-
ADLs. As explained in Chapters 1 and 2 (see
ual adjustments for other functional deficits, such
Section 2.1), the assessment of impairment is only
as contrast and glare sensitivity, color vision, bin-
a first step toward disability assessment and deter-
ocularity, stereopsis, suppression, and diplopia if
mination of monetary compensation; the ratings
these deficits cause a significant ability loss that
therefore do not consider the effect on specific
is not reflected in the rating of the visual acuity
job-related functions or on employability. Those
or visual field loss. The previous system allowed
aspects involve many factors that are beyond the
corrections only for diplopia and aphakia; these
scope of the Guides. One should remember that
separate scales are no longer needed.
there are totally blind individuals who are gain-
fully employed; there also are fully sighted indi- 3. Near-vision measurements, which are often
viduals who are unemployed. inaccurate and were often omitted, are now
optional; Section 12.5 contains a discussion on
In the Fifth Edition of the Guides this chapter
how to make the assessment of reading acuity
was significantly revised from earlier editions.
more accurate.
The revision was based on a consensus within the
Chapter 12
international community of experts in low vision.

The visual acuity and visual field ranges on which
the ratings are based were introduced in the 1970s
and 1980s in the International Classification of
Diseases, 9th Revision (ICD-9; 1977),3 the ICD-9
Before using the information in this chapter of
Clinical Modification (ICD-9-CM; 1978),4 and
the Guides, the user should become familiar with
ICIDH (1980),1 and were later confirmed in ICD-10
Chapters 1 and 2 and with the Glossary. Chapters 1
(1994)3 and in reports for the International Society
and 2 discuss the Guides’ purpose, applications, and
for Low Vision Research and Rehabilitation (1999),5
methods for performing and reporting impairment
the International Council of Ophthalmology (2002),6
evaluations. The Glossary provides definitions of
and the World Health Organization (WHO; 2003)7.
common terms used by many specialties in impair-
The Functional Vision Score (FVS) has been shown
ment evaluation.
to correlate well with measures of Quality of Life.8–10
Additional background information is provided in Ophthalmology is able to precisely measure organ
companion publications to the Guides.11,12 functions such as visual acuity and visual field.
Therefore, this chapter uses visual acuity and visual
Some important aspects of the differences between
field as the key factors (see Section 1.8c) on which
the current system and the system used in the Fourth
the impairment evaluation is based. The resulting
Edition and earlier editions are:
impairment ratings are statistical estimates of the
1. The FVS, used now, estimates the ability to ability loss that may result from a given impairment.
perform vision-related ADLs. The Visual Individual performance of certain tasks may be
Efficiency Scale (VES), used through the Fourth better or worse than the statistical average and may
Edition, was based on employability estimates in be further influenced by rehabilitative measures.
1925.13–16 That vision-specific scale predated by The use of a statistical average is justified,
several decades the development of the Guides, because we do not want to disadvantage those who
but through various revisions had developed have made good adaptations by reducing their
internal inconsistencies and was no longer based impairment rating. The case of Helen Keller may
on current measurement standards. Like the be quoted as an example of someone who made
VES, the FVS is an ability scale on which 0 extraordinary adaptations despite very severe
indicates “no ability” and 100 indicates “normal limitations. These adaptations should not have
ability.” The impairment rating for the visual reduced her impairment rating.
system is calculated as: 100 FVS.
Guides6e_12_281-320.indd 282 2/17/09 2:49:37 PM

The approach to impairment ratings in this chapter Section 2.7). Section 12.6 contains a template that
differs from that advocated in Section 1.8c, in which lists essential elements of any report. These include:
an impairment range (class) is determined first,
based mainly on history and physical findings (see Current Visual Symptoms
Table 1-5), and a percentage rating is assigned later. List the current symptoms and complaints. Consider
In this chapter, calculations based on visual acuity whether they explain the claimed ability loss.
and visual field yield a percentage rating, from
which the class or range follows. The number of Pertinent Visual History
ranges in this chapter (see Table 12-1 and following Consider whether the history is consistent with the
tables) is 1 more than in Table 1-3. This is because current complaints. Include:
the Functional Vision Score can also be used for
• Causes of the current vision loss and other factors
vision rehabilitation, where differentiation between
that may affect the individual’s ability to perform
severe and profound loss is needed and where
vision-related ADLs.
combining all losses from 50% to 95% into 1 group
is not meaningful. The internationally accepted FVS • Preexisting conditions and treatments and reasons
ranges are more similar to the detailed ranges of the for apportionment, if applicable (see Section 2.5c).
Karnofsky Performance Status Scale17 than to the
• Essential tasks of the job or occupation and how
simplified ICF scale. The FVS ratings have been
the visual deficits may affect these.
validated in several studies.8–10
The steps in calculating the FVS, and the visual system Pertinent Eye Exam
impairment rating (VSI) are summarized in Table 12-1. Consider whether the current findings are consistent
Chapter 12
with the current complaints. Consider whether
Table 12-1 explains the steps involved in going
Maximum Medical Improvement (MMI) has been
from the measurements of visual functions (which
reached. Include:
indicate how the eyes function) to an estimate of
functional vision (which indicates how the person • Documentation of the current condition of the eyes
functions). and visual system and relevant anatomic findings.
• Visual acuity measurements with best correction,
12.1a Elements of a Visual
as detailed in Section 12.2.
Impairment Evaluation
Preparing an impairment evaluation report must be • Visual field measurements for each eye, as
considered similar to providing expert testimony (see detailed in Section 12.3.
TA B L E 12 -1
Calculation Steps for the Visual Systema
Measured Visual Functions Estimated Functional Vision
for OD, OS, OU for the person
Visual Acuity Score (VAS) Functional Acuity Score (FAS)
count of letters recognized combines: 60% OU 20% OD 20% OS
Visual Field Score (VFS) Functional Field Score (FFS)
count of points detected combines: 60% OU 20% OD 20% OS
Optional adjustment
for other vision problems
Functional Vision Score (FVS)
estimates general visual ability
as: FAS FFS/100 (other losses)
Combine with Impairment of other Visual system impairment (VSI)
organ systems, if applicable estimates visual ability loss
as: VSI (AMA) 100 FVS
Whole person impairment (WPI)
a
Note: Use of the WPI calculation and other factors to determine monetary compensation is a separate, administrative decision,
beyond the scope of the AMA Guides. OD indicates right eye; OS, left eye; OU, both eyes; and AMA, American Medical
Association.
Guides6e_12_281-320.indd 283 2/17/09 2:49:38 PM

Include other visual function tests, if considered American Medical Association (AMA) impairment
relevant. These may include, but are not limited to: ratings rate loss (0 no loss, 100 total loss).
• Binocularity, eye movement disorders.
Visual System Impairment Rating
• Contrast sensitivity, with and without glare. Calculate the Visual System Impairment (VSI) as
100 FVS. If, applicable, include an adjustment for
• Color vision, dark adaptation, photophobia, and
visual factors that are not reflected in the acuity or
other conditions.
field score (see Section 12.4b).
Prognosis and Rehabilitation Potential
Whole Person Impairment Rating
Consider whether the condition is permanent and
Calculate the whole person impairment rating (WPI)
stable. Since achievement of MMI status does not
as indicated in Section 12.4c. If, applicable, combine
preclude future deterioration, consider whether
this rating with unrelated nonvisual impairment
periodic reevaluation may be indicated. Consider
ratings, using the Combined Values Chart in the
what rehabilitative measures (see Section 12.1c) may
Appendix.
be indicated to improve the subject’s functioning in
light of the permanent impairment. In addition to the equipment needed for a standard
ophthalmologic evaluation, the following tools are
An opinion about the ability to work and other
required for the functional evaluation.
employment-related factors may be requested. If
sufficient information is available, such opinions • Standardized letter chart. Use of a projector
may be given. However, such assessments are beyond chart is acceptable for visual acuities of 20/100
the scope of the Guides (see Section 2.3b). or better. However, a lighted chart in a lighted
Chapter 12
room is preferred because it is more representative

Visual Acuity of normal viewing conditions. Charts with 5
Measure the best-corrected visual acuity for each letters per line, proportional spacing, and a
eye and with both eyes open. Use Section 12.2 to logarithmic (geometric) progression of letter
convert the visual acuity values to Visual Acuity sizes are preferred.18–23 For vision in the normal
Scores (VAS) (see Table 12-2) and to calculate and near-normal ranges, testing at 6 m (20 ft) is
the Functional Acuity Score (FAS) for the person recommended. For testing in the low-vision range,
(see Table 12-3). Note that although for diagnostic testing at 1 m is recommended (see Table 12-2).24
purposes the acuity of each eye separately is most Test charts for this distance are commercially
important, for disability evaluation the acuity with available.25
both eyes open is most important. Accurate measure-
• Standardized reading tests. Reading tests are
ment of distance visual acuity (letter chart acuity)
optional. If performed, they should be standard-
is mandatory; measurement of near acuity (reading
ized tests with continuous text segments as speci-
acuity) is optional.
fied in Section 12.5. A logarithmic progression of
letter sizes is preferred. Letter size designations
Visual Fields
should be in M-units18 because the implementation
Formal visual field studies are indicated, unless
of point size and Jaeger numbers has been shown
the patient waives any consideration of field loss.
to be inconsistent from chart to chart.
Use Section 12.3 to determine the Visual Field
Score (VFS) (see Table 12-5) for the right eye and • Visual field equipment. If a restriction of the visual
for the left eye; combine the plots to determine the field is claimed or suspected, formal visual field
binocular field and calculate the Functional Field testing on standardized equipment is required.
Score (FFS) for the person (see Table 12-6). Note Such tests often are performed by a technician,
that although for diagnostic purposes the field of rather than by the examiner. If no visual field
each eye separately is most important, for disability restriction is claimed, a confrontation visual
evaluation the binocular field is most important. field is acceptable to confirm the absence of field
restrictions.
Functional Vision Score
• Other functional tests, such as a contrast
Combine the Functional Acuity Score (FAS)
sensitivity test or glare test, if problems in these
and Functional Field Score (FFS) to derive the
areas are reported.
Functional Vision Score (FVS) as indicated in
Section 12.4a. Note that the FVS is an ability score • Samples of actual job-related tasks, if these tasks
(0 no ability, 100 normal ability), whereas the are different from average reading tasks.
Guides6e_12_281-320.indd 284 2/17/09 2:49:38 PM

12.1b Interpretation of Symptoms cause a significant ability loss that is not reflected in
and Signs a visual acuity or a visual field loss, they may also
Subjective symptoms of vision loss usually are the be handled as adjustments to the impairment rating
result of objective changes in visual acuity and/or (Section 12.4b).
visual field.
12.1c Vision Rehabilitation
Visual acuity describes the ability of the eye to
This book is mainly concerned with the assessment
perceive details. Visual acuity loss will manifest
of impairments. However, it is the moral and profes-
itself in an inability to perform detail-oriented tasks,
sional obligation of the medical professional to also
such as reading and face recognition. A lay term for
point to rehabilitation as a way to offset the disabling
visual acuity loss is blurred vision. Visual acuity loss
effects of the impairment with enabling countermea-
affects many ADLs. Although visual acuity is gov-
sures (see Section 1.3c). It is important to note that
erned by only a small area of the retina (the fovea,
rehabilitation will not change the impairment or the
the central-most area), it occupies a major part of the
impairment rating; it will only reduce the effect on
visual cortex.
participation.26
Visual field refers to the ability to detect objects
Successful vision rehabilitation needs to address
in the periphery of the visual environment. A lay
many aspects of the problem:
term for peripheral field loss is tunnel vision. Visual
field loss will manifest itself in an inability to detect Vision enhancement that will enable better use
peripheral objects and, often, in a reduced ability to of the remaining vision. Vision enhancement aids
avoid obstacles. The peripheral visual field occupies include high plus reading glasses, magnifiers,
the largest part of the retina, but it occupies a smaller illumination, and filters, etc.
Chapter 12
part of the visual cortex.
Vision substitution will enable activities and partic-
Good visual acuity and good visual field are both ipation by the subject through the use of aids based
needed for the performance of daily living skills. on other senses, such as Braille, long cane, talking
A person with tunnel vision may not notice when books, etc.
someone enters the room. A person with visual acu-
Personal factors, such as depression and coping
ity loss, on the other hand, may notice the newcomer
skills, need to be addressed. Providing appropriate
but may have difficulty recognizing the person’s
vision rehabilitation may do more to lift a reactive
face. Once a person detects an object in peripheral
depression than any medication may do.
vision, that person will use central vision to recog-
nize it. A person with a visual field defect (tunnel The human environment, including family, school,
vision) may not notice a sign on the road or on a or workplace and social groups, needs to be consid-
wall but could read the sign once found, assuming ered. Supportive attitudes can be strongly enabling;
the individual had good visual acuity. A person with prejudicial attitudes are disabling.
normal visual fields but a visual acuity loss will
The physical environment can be similarly dis-
detect the sign but will not be able to read it.
abling through the erection of barriers or can be
Another important function is contrast sensitivity. enabling by providing facilitators, such as workplace
Whereas visual acuity is generally measured with modifications, as mandated by the Americans with
small objects of high contrast, contrast sensitivity Disabilities Act.
refers to the ability to detect larger objects of poor
These services require the efforts of a variety of
contrast. This ability is often needed for daily liv-
rehabilitation specialists; they cannot be provided
ing skills. Facial characteristics are an example of
by the medical professional alone. However, it is the
typical low-contrast objects. Contrast sensitivity
obligation of the medical profession to mention the
loss often accompanies visual acuity loss, but it can
existence of enabling options and to make the appro-
occur separately. Because measurement methods for
priate referrals.
contrast sensitivity are not standardized, this func-
tion is not included in the impairment ratings. Where
indicated, contrast sensitivity loss that exceeds the
effects of the visual acuity loss (see Section 12.4b) 12.2 Impairment of Visual Acuity
may be handled as an individual adjustment.
Other symptoms may result from deficits in glare 12.2a Visual Acuity Notations
sensitivity, color vision, night vision, binocularity, Visual acuity is usually recorded as a fraction com-
stereopsis, suppression, and diplopia. If these deficits paring the individual’s performance to a performance
Guides6e_12_281-320.indd 285 2/17/09 2:49:39 PM

standard. If the individual needs letters that are twice standard US notation (ie, 20/…). The individual
as large or twice as close as those needed by a stan- should be tested with the best available refractive
dard eye (ie, 2 angular magnification), the visual correction. If an ETDRS-type chart is used, the VAS
acuity is 1/2. If letters are needed that are 5 times increases with 1 point for every letter the patient
larger or 5 times closer, the visual acuity is 1/5, and so reads correctly.
forth. In the United States, it is customary to standard-
When testing for visual acuities around the 20/200
ize the numerator at 20. Thus, a visual acuity of 1/2
level (“legal blindness”), the choice of letter chart is
is recorded as 20/40 and a acuity of 1/5 is recorded
particularly important because it affects the assign-
as 20/100. Note that “normal” or “average” vision is
ment of benefits. On traditional charts that have no
better than the 20/20 reference standard. Thus, it is
lines between 20/100 and 20/200, the descriptor
inappropriate to terminate visual acuity measurement
“20/200 or less” becomes, effectively, “less than
at the 20/20 line or to refer to “20/20” as “normal
20/100,” so individuals with 20/125 would be recorded
vision,” let alone as “perfect vision.”27
as 20/200. On newer charts, which also have lines at
20/125 and 20/160, “20/200 or less” is more appro-
12.2b Test Procedures
priately interpreted as “less than 20/160” (see Table
Visual acuity is usually measured with symbols
12-2). If only an older printed chart is available, the
(letters, numbers, pictures, or other symbols)
individual can be brought to 10 ft so that “less than
presented in a letter chart format. It should be
20/160” can be interpreted as “less than 10/80.” The
measured with best correction for the right eye (OD),
individual with 20/125 (10/63) is then reported appro-
for the left eye (OS) and with both eyes open (OU).
priately as better than 20/200. Note that the term legal
Because the required letter sizes can vary widely,
blindness is a misnomer because 90% of individuals
the optimum testing distance is not the same for all
Chapter 12
who have 20/200 or less visual acuity are not blind but
groups, as explained in the following paragraphs.
have significant residual vision that can be enhanced
through vision rehabilitation. The term severe vision
Testing in the Normal Range
loss, as used in ICD-9-CM, should replace the term
Individuals in the normal and near-normal range of
legal blindness.**
vision (20/60 or better, ICD-9-CM; see Table 12-2),
represent the majority of all patients.4 The traditional
Testing in the Low-Vision Range
letter charts and projector charts were designed for
Use of the Guides will often involve individuals
this group. The most common testing distance is
whose visual acuity has dropped to less than 20/60
6 m (20 ft) because at this distance accommodation
(ie, to the low-vision range in ICD-9-CM,4 (see
is relaxed and the optical difference with infin-
Table 12-2). Individuals in the low-vision range
ity may be ignored. When a printed chart is used,
form a minority of the general population but may
the indicated visual acuity values are valid only if
represent the majority of those for whom visual
the individual is located at the distance for which the
impairment evaluations are requested.
chart was designed. If a projector chart is used, the
individual must be located at the distance for which Traditional letter charts often have only a few
the projector was adjusted. Charts with a logarithmic letters for visual acuities worse than 20/100. Such
progression of letter sizes, 5 letters on each row, and charts are inadequate for the low-vision range and
letter spacing that is equal to the letter size (often have promoted the use of vague statements such as
referred to as ETDRS-type charts, referring to the “count fingers” (CF) and “hand motions” (HM).
Early Treatment of Diabetic Retinopathy Study) are More accurate results can be obtained by bringing
the preferred standard.21,22 The original ETDRS pro- the chart closer. Testing at 1 m is recommended
tocol (developed for research studies) uses 3 charts, because it can cover the entire low-vision range,
1 each for right, left, and both eyes. For disability down to 1/50 (20/1000).24
assessment, the use of 1 chart for all 3 measurements
is acceptable.
** Unfortunately, the Social Security Administration (SSA)
The individual is placed at the distance for which in a ruling effective in 2007 has chosen to interpret
the chart was designed and encouraged to read as “Statutory Blindness” in the context of Title II and
far down as possible. A line is considered read when Title XVI different from the usual definition of “legal
the patient correctly reads more than half of the blindness” in other federal, state and local laws and
characters (eg, 3 of 5). Most charts will indicate the regulations. In the context of Title II and Title XVI,
visual acuity value that corresponds to the ability the SSA now interprets “20/200 or less” as “less than
to read each line. When visual acuity is measured 20/100”, with the stipulation that even a single letter
in this way, the result should be recorded using the seen on a 20/100 line will disqualify the applicant.
Guides6e_12_281-320.indd 286 2/17/09 2:49:39 PM

When visual acuity is measured at 1 m, it should be Therefore, CF 3 ft is interpreted as 3/200 (VAS 10),
recorded as a metric Snellen fraction, in which the and HM 5 ft is interpreted as 5/1000 (VAS 1). Tests
numerator records the test distance in meters (in this of finger counting and of hand movements at shorter
case 1 m, thus 1/…) and the denominator indicates distances also assess the central field and therefore
the smallest letter size read in “M-units” (1 M 1.45 should not be considered as proper visual acuity
mm about 1/16 in). The standard US notation may measurements.
be added in parentheses. Thus, the ability to read 8 M
If the best-corrected visual acuity with both eyes
characters at 1 m should be recorded as 1/8 (20/160).
open is not available and cannot be obtained, it may
Charts with a cord attached to maintain the proper
be assumed that vision with both eyes open is equal
distance and labeled for 1-m testing are available
to the best-corrected acuity of the better eye.
commercially.25
Use of Realistic Conditions
Correction for Refractive Error
The evaluation of visual functions should be based
The visual acuity without correction may be reported
on performance under optimal conditions. An excep-
as part of the general eye examination. The impair-
tion can be made, however, when the best possible
ment ratings, however, should be based on the best-
conditions are not feasible in daily life. Examples
corrected visual acuity. It is important, therefore, to
include individuals who would see better with con-
ensure that the refractive correction is appropriate
tact lenses but who cannot tolerate them; those with
for the testing distance. This is especially true for
a large interocular difference in refractive error who
the short viewing distances used for patients with
cannot tolerate full correction of both eyes; and those
low vision. If uncorrected and best-corrected visual
who can achieve better acuity with an extremely high
acuity are the same, this should be stated explicitly.
Chapter 12
or extremely low illumination level that cannot be
achieved under normal daily living conditions or in
Monocular vs Binocular Acuity
the workplace.
Because binocular viewing (both eyes open)
represents the most common viewing condition in Under these and similar conditions, the evaluation
daily life, the impairment rating should consider should be based on measurements obtained under
the best-corrected binocular visual acuity as well realistic daily living (or working) conditions.
as the best-corrected acuity for each eye separately. Document why testing under suboptimal conditions
Although the visual acuity of each eye is important for is most appropriate. When testing multiply disabled
diagnostic considerations, for disability considerations individuals, a distinction must be made between
the binocular value caries the larger weight. failure to see and failure to respond.
Under most circumstances, best-corrected visual
12.2c Steps for Assigning a Visual
acuity measured binocularly will be determined by
Acuity–Based Impairment Rating
the acuity of the better eye. There are exceptions,
however. People with latent nystagmus may have 1. Determine a best corrected visual acuity score
better eye stability, and hence better acuity, when for each eye.
viewing binocularly than when 1 eye is occluded.
Measure visual acuity as outlined in Section 12.2.
Some people with diplopia or with distortions in 1
Use Table 12-2 to replace the visual acuity value
eye may see better when the poorer eye is occluded.
with a score value.
Incomplete Data The left part of Table 12-2 lists the ranges of visual
Whenever possible, determination of an impairment acuity loss used in ICD-9-CM.4 At the top of the
rating should be based on direct examination of the scale are those with normal vision (20/20 or better),
individual. Occasionally, it may be necessary to deter- and at the bottom are those who are blind (no light
mine a tentative impairment rating based on chart perception). In between are those who have lost part
review, when complete data may not be available. If of their vision. This group is said to have low vision
no better information is obtainable, use the following: (the word vision indicates that they are not blind;
the word low indicates that they have less than
Interpret CF ... — ft as .../200.
normal vision). Note that the visual acuity values
Interpret CF ... —m as .../60. follow a logarithmic progression; that is, each line
differs from the adjacent lines by a fixed ratio (each
Interpret HM ... — ft as .../1000.
step 4:5 ratio, 10 steps 10).
Interpret HM ... —m as .../300.
Guides6e_12_281-320.indd 287 2/17/09 2:49:40 PM

TA B L E 12-2 Impairment of Visual Acuitya
Visual Acuityb Visual Acuity Impairment

Impairment Ranges Score Rating Estimated Reading
(based on ICD-9-CM) US Notation 1 m Notation (ability) b (ability loss) Abilityc
(NEAR-) Range of 20/12.5 1/0.63 110 ... Normal reading speed

NORMAL Normal
20/16 1/0.8 105 ... Normal reading distance
VISION Vision
20/20 1/1 100 0 Reserve capacity for small
print
20/25 1/1.25 95 5
Near- 20/32 1/1.6 90 10 Normal reading speed

Normal
20/40 1/2 85 15 Reduced reading distance
Vision (mild
loss) 20/50 1/2.5 80 20 No reserve for small print
20/63 1/3.2 75 25
LOW Moderate 20/80 1/4 70 30 Near-normal with

VISION Low Vision reading aids
20/100 1/5 65 35
Uses low-power magnifier
20/125 1/6.3 60 40
or large-print books
20/160 1/8 55 45
Severe Low 20/200 1/10 50 50 Slower than normal with
Vision reading aids
20/250 1/12.5 45 55
Uses high-power
Chapter 12
20/320 1/16 40 60
magnifiers
20/400 1/20 35 65
Profound 20/500 1/25 30 70 Marginal with reading aids

Low Vision
20/630 1/32 25 75 Uses magnifiers for spot
reading, but may prefer
20/800 1/40 20 80
talking books
20/1000 1/50 15 85
(NEAR-) Near- 20/1250 1/63 10 90 No visual reading

BLINDNESS Blindness
20/1600 1/80 5 95 Must rely on talking books,
braille, or other nonvisual
20/2000 1/100 ...
sources
or less or less
Total No light perception 0 100

Blindness
a
Use this table to convert the measured acuity values to a Visual Acuity Score (VAS) for each eye. Proceed to Table 12-3 to
combine the scores from each eye to a single Functional Acuity Score (FAS) for the person.
b
Visual acuity values used in this table follow a strict logarithmic progression. The VAS values follow a linear progression.
For clinical use, values such as 20/32 and 20/63 may be rounded to 20/30 and 20/60.
c
Listed performance levels refer to statistical averages. Individual performance may be better or worse than the listed
average.
The central part of Table 12-2 lists impairment 1 point for each letter read on a standard acuity
ratings. This conversion is based on Weber-Fechner’s chart with 5 letters per line (ETDRS-type); it is an
law, which states that a proportional increase in the ability scale on which higher values indicate better
stimulus corresponds to a linear increase in sensation. function. The impairment rating, which is a scale of
The Visual Acuity Score (VAS) is a linear scale with ability loss, is obtained by subtracting the VAS from
fixed increments (5 points per line) based on counting 100. Note that the VAS extends beyond 100 (as does
Guides6e_12_281-320.indd 288 2/17/09 2:49:40 PM

normal visual acuity), but that ability loss is counted After the best-corrected visual acuity values for
only when visual acuity is less than 20/20. binocular vision (OU), for the right eye (OD), and for
the left eye (OS) have been obtained and converted
The right part of Table 12-2 lists the estimated
to Visual Acuity Scores, these values need to be
impact of visual acuity loss on reading ability.
combined to a single Functional Acuity Score (FAS)
These ranges are based on a general ability scale,
for the person to provide an estimate of that person’s
which is not vision-specific and can be adapted to
ability to perform acuity-related daily living tasks.
many different functional abilities.28 The scale has
This is done using Table 12-3.
the following gradations.
The formula for combining the Visual Acuity Scores
100 10 Range of normal Normal functioning, (VAS) for OU, OD, and OS (see Table 12-3) is:
with reserve capacity
FAS (3 VASOU VASOD VASOS)/5
80 10 Mild loss Normal functioning,
but loss of reserve
In this calculation the binocular acuity provides 60% of
capacity
the weight; the right and left eye each contribute 20%.
60 10 Moderate loss Normal functioning,
Note that the person’s FAS is not simply the VAS
but need for some aids
of the better eye. For example, an individual with 1
40 10 Severe loss Restricted blind eye will have a 0 VAS for that eye. If the other
functioning, slower eye is normal, the FAS will be near-normal, but not
than normal, even as good as when both eyes were normal. See the
with aids legend for Table 12-4.
Chapter 12
20 10 Profound loss Restricted The acuity-related impairment rating is calculated by
functioning, marginal subtracting the FAS from 100. Note that the FAS can
performance, even be larger than 100 but that the impairment rating is
with aids truncated at 0.
0 10 Near-total or Cannot perform;
total loss needs substitution
skills TA B L E 12-3
Calculation of the Acuity-Related
The 3 parts of Table 12-2 fit well with each other. Impairment Ratinga
This confirms that the VAS is a reasonable esti-
Calculated Visual
mate of acuity-related visual abilities and that the Measured Snellen Values Acuity Scores
impairment rating is a reasonable estimate of acuity-
OU: letter chart acuity: 20/ → VAS OU: 3
related performance loss. This has been confirmed
in several studies.8–10 The right side of Table 12-2 OD: letter chart acuity: 20/ → VAS OD: 1
may be used to obtain an impression of the effect OS: letter chart acuity: 20/ → VAS OS: 1
of various impairment levels. Additional examples Add OU, OD, and OS
may be found in Table 12-4. Also note that these Divide by 5 to calculate the Functional Acuity Score
ranges closely resemble the ICF ranges in Table 1-3; (FAS): for the person
the main difference is that the ICF ranges combine Acuity-Related Impairment Rating 100 FAS
severe and profound loss into 1 broad range.
Optionally, calculate a Visual Acuity Score for reading
It should be remembered that the dividing lines (near) acuity as indicated in Section 12.4.
between the ranges do not indicate stepwise If the outcome is significantly different from the letter
chart acuity score, document the differences and
increases in ability. They are like mileposts along a
calculate the average:
road. They provide useful reference points, but the
FAS global ⴝ (FAS letter chart ⴙ FAS reading)/2
landscape does not change suddenly when a marker
is passed; rather, the landscape changes gradually a
Use this table to combine the Visual Acuity Scores (VAS)
and continuously between the markers. from each eye to a single Functional Acuity Score (FAS) for
the person. If visual fields are normal and no individual
adjustments are made, the calculation can stop here, since
2. Combine the visual acuity scores (VAS) to obtain the visual system impairment rating (VSI) will equal the
acuity-related impairment rating. If visual field loss is present,
a functional acuity score (FAS) for the person. proceed to Tables 12-5, 12-6, and 12-7. OD indicates right eye;
OS, left eye; and OU, both eyes.
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Ta b l e 12- 4 Classification of Impairment of Visual Acuitya
Calculation Results
FAS: 100-93 FAS: 92-73 FAS: 72-53 FAS: 52-33 FAS: 32-13 FAS: 12-0
VA-IR: 0–7 VA-IR: 8–27 VA-IR: 28–47 VA-IR: 48–67 VA-IR: 68–87 VA-IR: 88–100
AMA Classes
Class 0 Class 1 Class 2 Class 3a Class 3b Class 4
Numerical Visual Acuity Values, Assuming Equal Vision in Both Eyes
20/12.5 20/32 20/80 20/200 20/500 20/1250 to no

light perception
20/16 20/40 20/100 20/250 20/630
20/20 20/50 20/125 20/320 20/800
20/25 20/63 20/160 20/400 20/1000
Numerical Visual Acuity Values, Assuming Vision in 1 Eye Only, Other Eye NLP
20/12.5 20/32, 20/40 20/100, 20/125 20/320, 20/400 20/1000 to no

light perception
20/16 20/50 20/160 20/500
20/20 20/63 20/200 20/630
20/25 20/80 20/250 20/800
Chapter 12
International Ranges of Vision Lossb (based on ICD-9-CM and others)
Range of normal Mild Moderate vision Severe Profound vision (Near-) Total
vision vision loss loss vision loss loss vision loss
Population surveys: no code Low vision Blindness
Estimated Ability to Perform VISUAL ACUITY–Related Activities (such as reading)
Normal (or near-normal) Performance Restricted (or failing) Performance
Has reserve for Lost reserve for Fair with low Slow with high No recreational No visual reading
small print small print magnification magnification reading
Needs and Means for Vision Rehabilitation
No need for aids Transition from Vision enhancement aids, Transition from Substitution
no aids to eg, magnifiers, lighting enhancement aids eg, Braille
enhancement aids to substitution
aids
a
This part of the table shows how the result of the impairment calculations can be categorized into certain classes or ranges.
Note that, unlike in other chapters, the calculations come first, and the assignment of classes follows. Use Tables 12-2 and 12-
3 to calculate the exact visual acuity–related impairment ratings (VA-IR).
Several examples are listed. The first set demonstrates cases where acuity in both eyes is reduced to the same extent, for
example, 20/50 20/50 would rank in the range of mild loss, AMA class 1. The second set shows cases where 1 eye is lost
(no light perception, or NLP); note that 20/50 NLP is considered a moderate loss, AMA class 2. The rating is dominated by
the binocular value, but the condition of the lesser eye also affects the rating; in this case shifting it 1 class/range lower. The
listed examples assume that the visual fields are normal.
b
This part of the table refers to the internationally recommended ranges of vision loss, 4 to their estimated impact on ADLs,
and to needs and means for rehabilitation (see Section 12.1c). Note that the listed performance levels refer to statistical
averages. Individual performance may be better or worse than the statistical average.
3. Consider reading acuity (optional). If the reading acuity, as calculated in Section 12.4,
is significantly worse than the letter chart acuity,
Determination of reading acuity (near vision) the FAS may be adjusted to the average of the letter
is optional and is explained in more detail in chart (or distance) acuity score and the reading
Section 12.4. Reading acuity is typically determined (or near) acuity score. The probable reason for the
binocularly, but it may be determined monocularly discrepancy should be explored and explained.
if this gives better results.
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12.2d Calculation Examples for Visual Current Symptoms: Can perform all office functions.
Acuity Loss
Physical Exam: Left eye replaced by good-fitting
Note: In the following examples it is assumed that the
prosthesis.
visual acuity loss is the only deficit. Visual fields and
other visual functions are presumed to be normal. Clinical Studies: Best-corrected acuities: VOU:
20/15, VOD: 20/15, VOS: NLP.
Functional Acuity Score (use Tables 12-2 and 12-3):
CLASS 1
VOU 20/15 105 3 315
Mild Loss
VOD 20/15 105 1 105
EXAMPLE 12-1: 15% IMPAIRMENT DUE TO VOS NLP 01 0
VISUAL ACUITY LOSS
Functional Acuity Score 420/5 84
Diagnosis: History of retinoblastoma.
History: Driving instructor questioned student’s
Impairment Rating: 100 84 16% visual
visual acuity. Student always liked to sit in front of
impairment.
the class to see the blackboard.
Comment: Based on visual acuity, this person’s
Current Symptoms: Has difficulty with distant
condition is one of mild vision loss (class 1). The
road signs.
visual field in the left eye is also lost (see Section
Physical Exam: No ocular abnormalities. 12.3). However, because this loss is not independent
Chapter 12
of the visual acuity loss (see Section 12.4a) and does
Clinical Studies: Best-corrected acuities:
not exceed the visual acuity–based loss, the FVS
VOU: 20/40, VOD: 20/40, VOS: 20/40. Visual fields
will still be equal to the FAS (see Example 12-14.
are normal in both eyes; no other deficits in visual
functions.
Functional Acuity Score: Use Table 12-2 to EXAMPLE 12-3: 25% IMPAIRMENT DUE TO
determine the VAS for each eye; use Table 12-3 to VISUAL ACUITY LOSS
combine the values to an FAS:
VOU 20/40 85 3 255
History: Farm worker; scratched the left eye on a
VOD 20/40 85 1 85 branch several years ago.
VOS 20/40 85 1 85 Current Symptoms: Farm work is OK, no interest
in reading or fine crafts.
Physical Exam: Dense corneal scar in left eye.
Diagnosis: Unexplained amblyopia, possibly
congenital. Clinical Studies: Best-corrected acuities:
VOU: 20/40, VOD: 20/40, VOS: 20/400.
impairment. Functional Acuity Score (use Tables 12-2 and 12-3):
Comment: This rating places the person in the range VOU 20/40 85 3 255
of mild vision loss (class 1). Persons in this range can
VOD 20/40 85 1 85
generally function normally, but they need to bring
reading material close. VOS 20/400 35 1 35
EXAMPLE 12-2: 16% IMPAIRMENT DUE TO Diagnosis: Vision loss due to corneal opacity.
VISUAL ACUITY LOSS
Subject: 45-year-old woman. impairment.
History: Office worker; left eye was enucleated in Comment: Even though the left eye has much poorer
childhood. vision than in Example 12-1, this person’s impair-
ment is still in the range of mild vision loss (class 1).
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Note that the impairment rating is influenced much Current Symptoms: Relies on talking books and
more by binocular function than by the function of the videomagnifier for her studies.
lesser eye.
Physical Exam: Irregular foveal reflex bilaterally.
Clinical Studies: Best-corrected acuities: VOU:
20/200, VOD: 20/300, VOS: 20/200.
CLASS 2
Functional Acuity Score (use Tables 12-2 and 12-3):
Moderate Loss
VOU 20/200 50 3 150
EXAMPLE 12- 4: 36% IMPAIRMENT DUE TO VOD 20/300 40 1 40
VISUAL ACUITY LOSS
VOS 20/200 50 1 50
History: Noticed gradual vision loss over several
Diagnosis: Stargardt juvenile maculopathy.
years. Afraid of surgery.
Current Symptoms: Increasing difficulties with
impairment.
reading.
Comment: This person’s impairment rating is in
Physical Exam: Early lens opacity right eye; dense
the range of severe vision loss (class 3a, sometimes
cataract left eye.
called “legal blindness” in the United States; see
Clinical Studies: Best-corrected acuities: comment in Section 12.2b) and will cause limitations
Chapter 12
VOU: 20/60, VOD: 20/60, VOS: 20/800. in the ability to perform ADLs even with aids.
Persons in this range need to rely more heavily on
Functional Acuity Score (use Tables 12-2and 12-3):
assistive devices. Also note that persons at this level
VOU 20/60 75 3 225 are far from blind (blind is: FVS 0, VSI 100);
the term legal blindness should be replaced by the
VOD 20/60 75 1 75
term severe vision loss (same definition) as used in
VOS 20/800 20 1 20 ICD-9-CM.
Diagnosis: Vision loss due to cataract.
CLASS 1
Mild Loss
impairment.
Comment: Although 20/60 is still in the range of
EXAMPLE 12-6: 10% VISUAL ACUITY
mild vision loss (class 1), the very poor condition
IMPAIRMENT DUE TO UNILATERAL
of the other eye drops the person’s impairment to
OPTIC NEURITIS
the range of moderate vision loss (class 2). Persons
in this range can perform ADLs but may require Subject: 27-year-old woman.
some aids, such as a handheld magnifier, to perform
History: Right-handed; enjoyed good health with
detail-oriented tasks, such as reading. If the VOU
accurate vision until 6 months ago, when a pain-
were not available, assume that VOU VOD (the
less, progressive vision loss developed in the left
better eye) and proceed as mentioned earlier.
eye. During the subsequent 6 months, visual clarity
returned slightly.
Current Symptoms: Vision is blurred when she
CLASS 3a tries to read the newspaper with the affected eye;
Severe Loss she has not been able to see television images clearly
with this eye. She can perform all ADL functions
with the unaffected eye.
EXAMPLE 12-5: 52% IMPAIRMENT DUE TO
VISUAL ACUITY LOSS Physical Exam: Near and far acuity is: VOU: 20/20,
VOD: 20/20, VOS 20/200. The eyes are externally
normal; ophthalmoscopy reveals moderate pallor
History: College student; vision loss since teens. of the optic disk. The pupil of the left eye is slightly
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dilated and poorly reactive to a direct light stimulus. Functional Acuity Score (use Tables 12-2 and 12-3):
No reaction in the right eye to stimulation of the left
VOU 20/30 90 3 270
eye. When the right eye is stimulated with bright
light, there is prompt constriction of the pupil in the VOD 20/30 90 1 90
left eye. No other cranial nerve signs.
VOS 20/30 90 1 90
Clinical Studies: Visual evoked potentials:
prolongation of the P100 in the left eye.
Visual Fields: Both eyes miss the entire lower field,
Functional Acuity Score (use tables 12-2 and 12-3)
which accounts for 60% of the FFS (FFS 40) (see
VOU 20/20 100 3 300 Section 12.3).
VOD 20/20 100 1 100 Functional Vision Score: 90 40/100 36
VOS 20/200 50 1 50 Diagnosis: Optic neuritis with altitudinal hemianopia,
both eyes. This person ranks in class 3a, far worse
than the case in Example 12-6.
Visual Fields: Not affected.
Impairment Rating: Visual System Impairment
Diagnosis: Optic neuritis, left eye. (VSI) rating 100 36 64%; Whole Person
Impairment (WPI) rating 60%.
impairment. Comment: This case demonstrates that the effect of
bilateral disease is far worse than that of unilateral
Comment: In this case, where the condition is
Chapter 12
disease. This patient had to give up his job when the
unilateral and the visual fields are not affected, the
disease became bilateral. It also demonstrates that
ADL impact is minimal (mild loss, class 1). In the
visual field loss can be debilitating, even when letter
next case, where the condition has become bilateral
chart acuity is fairly good. Loss of both upper fields
and the fields are affected, the disabling effect is far
would have been slightly less debilitating (FFS
worse.
60, FVS 90 60/100 54, VSI, WPI 46).
It would have interfered with reading slightly less,
and mobility (eg, seeing potholes) would have been
easier. The condition would still rank in class 3a.
CLASS 3a
Severe Loss
EXAMPLE 12-7: 60% WHOLE PERSON

12.3 Impairment of the
IMPAIRMENT DUE TO BILATERAL Visual Field
OPTIC NEURITIS
Subject: 53-year-old physician. 12.3a Test Procedures

If no visual field impairment is claimed (by the
History: Suffered an attack of ischemic anterior
patient) or suspected (by the physician), a confronta-
optic neuropathy in the left eye, 4 years ago. He lost
tion visual field may be used to confirm a normal
the inferior field in that eye. Since the right eye was
field (visual field impairment rating 0). In all
normal, he could continue working.
other circumstances (visual field impairment rating
Current Symptoms: Recently, he suffered a similar 0), formal visual field tests should be performed
attack in the right eye. Since both eyes are now by qualified personnel according to the instructions
affected, he had to give up his practice. provided with the equipment.
Physical Exam: The eyes are externally normal;
Confrontation Visual Field
ophthalmoscopy reveals superior pallor of both optic
This method uses only the examiner’s hands. Seated
disks.
in front of the individual, the examiner moves his or
Clinical Studies: Visual acuity in both eyes and her hands from the periphery inward to test for the
binocularly reaches 20/30 on a letter chart. Both eyes peripheral field limits. This method is an acceptable
miss the entire lower field. Reading is more difficult way to confirm a normal visual field in individuals
than the letter chart acuity suggests, since it is hard to in whom no field loss is claimed, but it is too gross
follow the line and since he cannot see the next line. for a proper evaluation in cases where a field loss is
claimed or suspected.
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Tangent Screen Testing fields of each eye should be measured separately,

This method uses a flat, black screen on which vari- and a binocular field plot should be derived from the
ously sized objects may be moved. This method is superimposition of the two monocular field plots.
difficult to standardize and loses accuracy beyond
45°. It is not acceptable for the accurate assessment Tests Used
of permanent impairment. When Goldmann equipment is used, the III-4-e
isopter should be plotted. If only a larger isopter is
Goldmann-Type Testing available, this isopter may be used, but it should be
The Goldmann visual field equipment provided the understood that this may result in an underestima-
first standardized field measurement technique. Testing tion of the field loss (FFS too high). If only smaller
is done in a bowl so that all testing distances are equal isopters are available, the test cannot be used for
while the background and stimulus luminances can be impairment evaluation, since this would result in an
controlled tightly. The usual mode of testing is known overestimation of the field loss (FFS too low). One
as kinetic perimetry because an operator moves a test study has shown that using the V-4-e isopter instead
stimulus of constant size and intensity. of the III-4-e one increases the FFS (decreases the
impairment rating) by about 20 ponts.29
The test results are plotted as isopters, contour lines
that outline the areas where stimuli of various intensi- When automated, static perimetry is used, the results
ties can be perceived. The functional implications of are displayed as a gray scale, not as isopters. Therefore,
certain isopter patterns are relatively easy to interpret. a pseudoisopter equivalent to the Goldmann III-4-e
Agencies, such as the Social Security Administration, isopter must be constructed as explained in Example
often require testing of the Goldmann III-4-e isopter 12-8 and Fig 12-5A and 12-5B. On the Humphrey
Chapter 12
for eligibility determinations. equipment, this would be the isopter for a 10-dB
stimulus. Plots of the central 30° are the plots most
Automated Perimetry often used for medical diagnostic purposes. If these
In recent decades, there has been a move from manual are the only plots available, the assumption must be
to automated perimetry. (Commonly used equip- made that the field beyond 30° is completely normal,
ment includes Humphrey, Octopus, Dicon, and other which may result in an underestimation of the actual
brands.) This has been accompanied by a move to field loss; therefore, seeking a full-field Humphrey plot
static perimetry. In static perimetry, the stimulus is not or a Goldmann plot is advisable. Only if the remaining
moved; the presentations are limited to various fixed field radius on the 30° central plot is smaller than 20°
locations where stimulus size and intensity are varied. in all directions and confrontation testing indicates
no further peripheral vision or remaining temporal
Automated perimetry results are commonly plotted
islands (as may happen in retinitis pigmentosa [RP]),
as a gray scale. Such reports are better suited for
the combination of a central Humphrey plot and a
automated statistical analysis. They are less intuitive
peripheral confrontation test may be used.
for human interpretation with regard to functional
vision. Most clinical tests are limited to the central
12.3b The Visual Field Score
30° radius because this is the most important area
The VFS, which is the basis for the calculation of
for medical diagnostic purposes. For the functional
visual field–based impairment ratings, parallels
assessment of visual field loss, however, testing to a
the VAS. The VAS can be determined by counting
60° radius or beyond is mandatory.
the letters read correctly on a standardized visual
acuity chart. Similarly, the VFS can be determined
Binocular Fields
by counting the points seen on a standardized visual
Considering both monocular and binocular function
field grid. The combination rules are also similar.
is even more important for a functional assessment of
the field of vision than it is for visual acuity because
Testing Grid
intact field areas in one eye may compensate for field
The testing grid is constructed by drawing 10
loss in the other eye. In cases of asymmetric field loss,
meridians: 2 in each of the upper quadrants and 3 in
the binocular field of view may be substantially better
each of the lower quadrants. The optimal positions
than the field of either eye alone.
for the 10 meridians are as follows: 25°, 65° (upper
Direct testing of the binocular visual field presents right), 115°, 155° (upper left), 195°, 225°, 255° (lower
problems, however, because the amount of conver- left), 285°, 315°, and 345° (lower right). Along these
gence in a bowl perimeter cannot be monitored and meridians, 5 points (spaced 2° apart) are assigned
fixation monitoring devices will not work when the to the central 10° and 5 points (spaced 10° apart)
head, rather than the eye, is centered. Therefore, the are assigned to the periphery beyond 10°; thus, a
Guides6e_12_281-320.indd 294 2/17/09 2:49:44 PM

60° radius will represent 10 points. The nasal and • The VFS numbers are approximately proportional
superior meridians may not reach 60°, but the lateral to the logarithm of the field area. They thus comply
field will extend further. Thus, the average normal with Weber-Fechner’s law. Although quantification
field will score about 100 points. of the activity limitations resulting from field
loss is difficult, the VFS appears to provide a
Figure 12-1 summarizes the point assignments. The
reasonable approximation.28
circle represents a 10° radius.
The VFS is summarized in Table 12-5, which is similar
This arrangement has the following effects:
to Table 12-2 in organization. Table 12-5 provides
• The Visual Field score (VFS) for the central 10° is reference points for concentric field losses.Since actual
50 points. This reflects the fact that the central 10° field losses are rarely exactly concentric, Table 12-5
area of the visual field corresponds to 50% of the cannot be used to determine an exact VFS. Use the
primary visual cortex. rules in Section 12.3c and Table 12-6 to determine a
VFS for each eye and for the binocular field.
• This choice maintains the traditional assumption
that a visual field loss to a 10° radius is equally Then proceed to Table 12-7 to combine the scores
disabling as a visual acuity loss to 20/200. from each eye into a single FFS for the person.
• Functionally, it also means that 50 points are
12.3c Assigning a Field-Based
assigned to the central field, which is important for
Impairment Rating
reading and manual activities, and 50 points are
Calculation of a visual field–based impairment
assigned to the peripheral field, which is important
rating requires the following steps.
for mobility.
Chapter 12
1. Determine the extent of the visual field for
• Choosing the measured meridians within the
each eye.
quadrants rather than along the horizontal and
vertical meridians avoids the need for special rules If Goldmann visual field plots are available,
for hemianopias. determine the III-4-e isopter for each eye. If only
automated visual field plots are available, determine
• A complete homonymous hemianopia receives a
a pseudoisopter by drawing a line surrounding all
50-point score. This implies that it is considered
points with a sensitivity of 10 dB or better, excluding
equally disabling as a field restriction to a 10°
points with less than 10-dB sensitivity (see Fig 12-5).
radius or as a visual acuity loss to 20/200.
If automated field plots are used, these should be full-
• Choosing 3 meridians in the lower quadrants field plots (Humphrey 60-2 or the equivalent). The 30°
and 2 in the upper quadrants acknowledges the plot may be used in isolation if the 30° central field
functional importance of the lower field by giving plot (Humphrey 30-2 or the equivalent) shows that
it 50% extra weight. there is no vision beyond 20° and when confrontation
testing has determined that there are no peripheral
• ICD-9-CM defines severe, profound, and near-
islands of vision. (See Section 12.3a.)
total visual field loss as concentric restriction to a
10°, 5°, and 2.5° field radius.4 These categories fit 2. Determine the Visual Field Score (VFS) for
the VFS scale. each eye.
Use the pattern explained in Fig 12-1. This pattern
can be implemented in several ways, explained
F I G U R E 12 -1 below.
Distribution of the Grid Points 2.a. Paper and pencil
for Visual Field Evaluation
Starting with a visual field plot of the III-4-e
5
isopter (or the equivalent), draw 10 meridians, 2 in
10 10 10 each upper quadrant and 3 in each lower quadrant.
5 To space the meridians evenly, use the following
10 10 10 5
5 approximate positions: 25°, 65° (upper right), 115°,
155° (upper left), 195°, 225°, 255° (lower left), 285°,
5 315°, and 345° (lower right).
15 15 15 5 5
5
Determine the extent of each meridian. Within
5
15 15 15 10° from fixation, round to the nearest 2° value;
5
outside 10° round to the nearest 10° value. Convert
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Ta b l e 12- 5 Impairment of Visual Fielda
Average
Radius Visual Field Impairment Estimated Ability for
Impairment Ranges Special if Loss Is Score Rating Visual Orientation and
(based on ICD-9-CM) Conditions Concentric (ability) (ability loss) Mobility (“O ⴙ M”) Tasks
(NEAR-) Range of 60° 110 ... Normal visual orientation

NORMAL Normal
105 ... Normal mobility skills
VISION Vision
100 0
95 5
Near-Normal Loss of 50° 90 10 Normal “O M”

Vision one eye performance
85 15
Needs more scanning
40° 80 20
Occasionally surprised by
75 25
events on the side
LOW VISION Moderate Upper field 30° 70 30 Near-normal

Low Vision Lost performance
65 35
Requires scanning for
20° 60 40
obstacles
55 45
Severe Low Hemianopia 10° 50 50 Visual mobility is slower
Vision than normal
Chapter 12
Lower field 45 55
Loss Requires continuous
8° 40 60
scanning
35 65
May use cane as adjunct
Profound 6° 30 70 Must use long cane for
Low Vision detection of obstacles
25 75
May use vision as adjunct
4° 20 80
for identification
15 85
(NEAR-) Near- 2° 10 90 Visual orientation

BLINDNESS Blindness unreliable
5 95
Must rely on long cane,
0° 0 100
sound, guide dog, and
other blind mobility skills
Total No visual field
Blindness
a
Note: This table follows the clinical usage of describing field losses on the basis of the remaining radius. In the rehabilitation and
disability literature, field losses are often described on the basis of the remaining diameter (eg, a concentric field loss to a radius of 10°
leaves a field with a diameter of 20°).
TA B L E 12- 6 Conversion of Field Radius to Field Score
Rounded peripheral field limits:

Extent: 0° 2° 4° 6° 8° 10° 20° 30° 40° 50° 60° 70° or more
Score: 0 1 2 3 4 5 6 7 8 9 10 11
Subtract for scotomata within 10°:

Radial extent: 1° 2° 3° 4° 5° 6° 7° 8° 9°
0 1 1 2 2 3 3 4 4
Subtract:
Subtract for scotomata outside 10°:

Radial extent: 1–4° 5–14° 12–24° 25–34° 35–44° 45–54°
Subtract: 0 1 2 3 4 5
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Ta b l e 12-7 Calculation of the Visual Field–Related Impairment Ratinga

Measured Visual Field plots Calculated Visual Field Scores
OD: Field plot, right eye → VFSOD: 1
OS: Field plot, left eye → VFSOS: 1
OU: Calculated binocular plot → VFSOU: 3
Add OD, OS, and OU
Divide by 5 to calculate the Functional Field Score (FSS) for the person
Field Related Impairment Rating 100 FAS
a
Use this table to combine the VFS scores from each eye to a single FFS for the person.
the rounded extent to a subscore using Table 12-6 eye has been promised, but not yet delivered for the
(see Example 12-8). Humphrey Field Analyzer.
If a scotoma interrupts the meridian, round 3. Combine the three Visual Field Scores (VFS) to
the extent of the scotoma along that meridian obtain a single Functional Field Score (FFS) for
to the nearest 2° or 10° value and subtract the the person.
corresponding point value (see Examples 12-9,
Determine the binocular field by superimposing the
Chapter 12
12-10). In the presence of scotomata, use of the
monocular fields. For the binocular field, points are
overlay grid (see below) is the preferred method.
counted as seen if seen by both eyes or by 1 eye.
Add the 10 subscores to obtain the VFS for that eye. This determines the binocular VFS.
The average normal field will score about 100 points.
Combine the VFS values for the binocular field, for
2.b. Overlay grid for Goldmann fields the right eye, and for the left eye (see Table 12-7).
The formula is:
Create an overlay grid with 10 meridians (see step
2.a) and grid points on each meridian at 1°, 3°, 5°, FFS (3 VFSOU VFSOD VFSOS)/5
7°, 9°, 15°, 25°, 35°, 45°, 55°, and 65°. If a Goldmann
4. The visual field–based impairment rating is
field plot for the III-4-e isopter is available, place the
100 FFS.
overlay grid over the field plot. Count the grid points
enclosed by the III-4-e isopter (or the equivalent).
12.3d Calculation Examples for
Grid points within scotomata should not be counted.
Visual Field Loss
The total number of points seen is the VFS.
The following examples calculate the VFS for a
Section 12.6, Reporting Aids, provides overlays for single eye. The resulting number cannot be used as
both Goldmann and Humphrey fields that can be an impairment rating, unless combined with a simi-
copied onto a transparency. lar calculation for the other eye and for the binocular
field, as explained earlier.
2.c. Software calculation
A software package, the “Impairment Calculator”30
has been developed that will automate the
calculations for all chapters of the Guides. After CLASS 0
copying the visual field data from either a Goldmann Normal Range
or a Humphrey field test into the appropriate screens,
the software will perform all calculations.
2.d. Automated calculation VISUAL FIELD LOSS
A pilot study in 1992 conducted with a Humphrey Request: Determine the VFS for an eye with the
Field Analyzer controlled by a personal computer Goldmann III-4-e isopter as shown in Figure 12-2, left.
(PC) has shown the feasibility of a fully automated
Method 1: Draw 10 meridians (see instruction 2.a in
test sequence using the points of the overlay grid as
Section 12.3c and Figure 12-2, right).
stimulus positions.31 A program that tests only the
points on the grid and calculates the VFS for each Measure the extent in degrees of each meridian.
Guides6e_12_281-320.indd 297 2/17/09 2:49:46 PM

Ta b l e 12- 8 Classification of Impairment of Visual Fielda
Calculation Results
FFS: 100-93 FFS: 92-73 FFS: 72-53 FFS: 52-33 FFS: 32-13 FFS: 12-0
VF-IR: 0–7 VF-IR: 8–27 VF-IR: 28–47 VF-IR: 48–67 VF-IR: 68–87 VF-IR: 88–100
AMA Classes
Average Visual Field Radius, Assuming Equal Field Loss in Both Eyes and Normal Acuity
Better than 60° 50° 30° 10° 6° 2°

60° 45° 25° 9° 5° to
55° 30° 20° 8° 4° no light
35° 15° 7° 3° perception
Average Visual Field Radius, Assuming Field Loss in 1 Eye Only With Normal Acuity, Other Eye NLP
70° 50°, 45° 25°, 20° 8°, 7° 3°

65° 40° 15° 6° to
60° 35° 10° 5° no light
55° 30° 9° 4° perception
Chapter 12
International Ranges of Vision Lossb (based on ICD-9-CM and others)
Range of normal Mild Moderate vision Severe Profound vision (Near-) Total
vision vision loss loss vision loss loss vision loss
Population surveys: no code Low vision Blindness
Estimated Ability to Perform VISUAL FIELD–Related Activities (such as mobility)
Normal O M Normal O M, Scanning for Slow mobility, Must use cane No visual mobility
(orientation and some scanning obstacles may use cane
mobility)
No need for aids Transition from Vision enhancement aids eg, contrast, Transition from Substitution eg,
no aids to lighting, avoid clutter enhancement aids cane, guide dog
aids
a
This table shows how the result of the impairment calculations can be categorized into certain classes or ranges. Note that, unlike in
other chapters, the calculations come first, and the assignment of classes follows. Use Tables 12-5, 12-6, and 12-7 to calculate the exact
visual field–related impairment ratings (VF-IR).
Several examples are listed. The first set demonstrates cases where the visual field in both eyes is reduced to the same extent, for
example, a 30° radius in both eyes would rank in the range of mild loss, AMA class 1. The second set shows cases where one eye is lost
(no light perception, or NLP); note that 30° NLP is considered moderate loss, AMA class 2. This shows that the rating is dominated by
the binocular value, but that the condition of the lesser eye also affects the rating; in this case shifting it 1 class/range lower. The listed
examples assume that the visual acuity is normal.
b
The bottom part of this table refers to the internationally recommended ranges of vision loss, 4 to their estimated impact on ADLs, and
to needs and means for rehabilitation (see Section 12.1c). Note that the listed performance levels refer to statistical averages. Individual
performance may be better or worse than the statistical average.
Guides6e_12_281-320.indd 298 2/17/09 2:49:47 PM

FIGURE 12-2
Normal Visual Fielda
Field With Measured Meridians Field With Overlay Grid
90
50° = 9 50° = 9
90
70° = 11 60° = 10
180 0 180 30 70 0
85° = 11 53° = 9
85° = 11
45° = 9
70° = 11 60° = 10
270
a
X indicates solid dots missed; boldface open circle (O), open dots seen.
Chapter 12
Use Table 12-6 to convert the extents to subscores. Method 1: Determine the peripheral field limits and
the peripheral subscore as in Example 12-8.
Add the subscores: (10 9) (9 11) (11 11
11) (10 9 9) 100. (For simplicity, the peripheral score is kept the same.)
Method 2: Create an overlay grid (see the template Determine the extent of the scotoma in each of the
in Section 12.6 and Figure 12-3). sample meridians.
Count the points within the III-4-e isopter. The dia- Subtract the amounts indicated in Table 12-6.
gram in Figure 12-2, right, has 100 solid dots within
The VFS is 90.
the 60° circle and 8 open dots outside. The score is
easily counted as: 100 solid dots missed (symbol: Method 2: Using the overlay grid, do not count the
X) open dots seen (symbol: O). For this field plot: 18 points within the scotoma. See Figure 12-3, right.
FFS 100 4 4 100.
Method 3: Enter the data in the AMA Impairment
Method 3: Enter the data in the AMA Impairment Calculator.
Calculator.
Comment: The VFS is reduced by 18 points from
Comment: For this normal visual field the VFS is 100 to 82 (18% impairment). This places the individ-
100; therefore, the impairment rating is 0%. Note ual in the range of mild vision loss (class 1). Because
that the extra points seen laterally compensate for the scotoma is in the midperiphery, central vision
the points missed nasally and superiorly. is not affected and far peripheral vision still warns
of obstacles. Thus, the effect on daily living skills
is relatively minor. The effect on the whole person
depends on the exact condition of the other eye.
CLASS 1
Mild Loss
VISUAL FIELD LOSS
VISUAL FIELD LOSS This individual has a juxtafoveal scotoma due to
early macular degeneration. Letter chart acuity is
Request: Determine the VFS for an individual with
still unaffected. The central area (up to 10°) of the
a midperipheral ring scotoma due to early RP. The
field is as indicated in Figure 12-4, left.
central field is not affected. The Goldmann III-4-e
isopter is as indicated in Figure 12-3, left. Request: Determine the VFS.
Guides6e_12_281-320.indd 299 2/17/09 2:49:47 PM

FIGURE 12-3
Midperipheral Scotomaa
Scotoma With Measured Meridians Scotoma With Overlay Grid
90
50° = 9 50° = 9
–10° = –1 –8° = –1
90
70° = 11 60° = 10
–20° = –2 –0° = –0
180 0 180 30 70 0
85° = 11 50° = 9
–30° = –3 –8° = –1
85° = 11
–34° = –3 45° = 9
72° = 11 60° = 10 –18° = –2
–30° = –3 –20° = –2
270
a
Chapter 12
Method 1: Subtract points from each meridian as Method 3: Enter the data in the AMA Impairment
indicated in Figure 12-4, left. Calculator.
100 20 80 (20% impairment) Comment: Although this scotoma is far smaller
than the one in the previous example, it will signifi-
Method 2: Subtract the solid dots that are not seen
cantly interfere with reading and similar tasks. This
(symbol X) (see Figure 12-4, right).
explains why a much smaller scotoma in a more
100 20 80 (20% impairment) critical area results in a similar impairment rating.
(See also Examples 12-15 through 12-17.)
FIGURE 12- 4
Juxtafoveal Scotomaa
Scotoma With Measured Meridians Scotoma With Overlay Grid
–4° = –2 90 –4° = –2 90
10 10
–6° = –3
–0° = –0
180 0 180 0
–7° = –3 –3° = –1
–4° = –2
–5° = –2
–6° = –3 –5° = –2 270
a
Note: These diagrams depict only the central 10° area. X indicates solid dots missed.
Guides6e_12_281-320.indd 300 2/17/09 2:49:48 PM

CLASS 3B Therefore, the binocular visual field is constructed

Profound Loss by superimposing the two monocular plots. On the
superimposed plot, only areas missed by both eyes
are counted as defects; areas seen by either one of
the eyes are counted as seen. The resulting binocular
VISUAL FIELD LOSS
score can vary dramatically, depending on the loca-
A Goldmann visual field test is not available for this tion of the defects.
individual. Automated static perimetry has been per-
formed, with the result indicated in Fig 12-5, left.
Follow these steps:
CLASS 0
1. Construct a pseudoisopter around the points with Normal Range
better than 10-dB sensitivity.
2. Measure the extent in the 10 meridians. If this EXAMPLE 12-12: 2% IMPAIRMENT WITH
is a Humphrey 30-2 plot, the test points are 6° CONSIDERATION OF BINOCULAR VISUAL
apart. The recorded spots are 3°, 9°, 15°, 21°, and FIELD LOSS
27° from the center.
An individual has a nasal defect in the left eye. The
The resulting subscores are shown in Fig 12-5, right. right eye is normal (see Fig 12-6).
Alternatively: Enter the data in the AMA Visual Field Score: Visual Field Score, using the over-
Impairment Calculator. lay grid (100 solid dots missed open dots seen).
Chapter 12
The VFS is 28. The field-related impairment rating OD: 100
is 100 28 72 (class 3b). OS: 100 24 3 79
OU: 100 2 7 105 3 315 See comment 2
Comment: This may be a case of advanced RP. The
Functional Field Score 494/5 99
automated field test did not test points beyond 30°
Impairment rating 1%
from fixation. The calculated VFS is acceptable only
if there is additional evidence that there is no further Comment 1: Because the defect in the left eye cor-
peripheral vision. A full-field automated test is pre- responds to a seeing area of the right eye, most of the
ferred. In the absence of such a test and in advanced defect in the left eye is not counted in the binocular
cases like this one, evidence from a confrontation plot. Because the binocular field carries 60% of the
visual field may be acceptable. weight of the FFS, the FFS is minimally affected
(class 1).
12.3e Calculating the Binocular Field
Existing perimeters are not equipped to provide
reliable measurements of the binocular visual field.
FIGURE 12-5
Tunnel Vision: Automated Perimetry Plot
Tunnel Vision: Plot with Pseudoisopter Extent of Same Pseudoisopter for the
10 Measured Meridians
4 0 0 0
0 16 18 0 5 0 24° = 7 15° = 6
0 6 14 22 18 18 16 11
0 0 12 21 18 24 25 20 0 0 17° = 6 17° = 6
0 0 12 14 18 28 22 22 18 16
0 0 0 0 0 23 0 0 16 18
0 0 0 0 0 0 0 0 0 0 0° = 0 0° = 0
0 0 0 0 0 0 0 0
0° = 0 0° = 0
0 0 0 0 0 0
0° = 0 6° = 3
0 0 0 0
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FIGURE 12- 6
Effect of Nasal Field Loss on the Binocular Fielda
Visual Field Left Eye (OS) Visual Field Right Eye (OD)
90 90
180 30 70 0 180 30 70 0
270 270
OS OD
90
Chapter 12
Binocular Visual Field

(superimposing OD, OS)
180 30 70 0
270
OU
a
Comment 2: Note that Visual Acuity/Field Scores Visual Field Score: Determine the Visual Field Score,
(VAS/VFS) 100 are allowed when calculating the using the overlay grid (100 solid dots missed open
Functional Acuity/Field Score (FAS/FFS). Only dots seen).
when combining the Functional Acuity and Field
OD: 100
Scores to a single FVS, are scores truncated at 100.
OS: 100 20 80
See Section 12.4a.
OU: 100 4 4 100 3 300
Impairment rating 4%
EXAMPLE 12-13: 4% IMPAIRMENT WITH
CONSIDERATION OF BINOCULAR VISUAL Comment: Because the temporal defect in the left
FIELD LOSS eye extends beyond the area seen by the right eye,
both the left eye score and the binocular score are
An individual has a temporal defect in the left eye
affected. Thus, the FFS is affected more than in
(see Figure 12-7).
Example 12-12.
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FIGU R E 12-7
Effect of Temporal Field Loss on the Binocular Fielda
Visual Field Left Eye (OS) Visual Field Right Eye (OD)
90 90
180 30 70 0 180 30 70 0
270 270
OS OD
Binocular Visual Field 90

(superimposing OD, OS)
Chapter 12
180 30 70 0
270
OU
a
adjustments in cases where functional vision is lim-

12.4 Impairment of the ited by factors other than visual acuity and visual
Visual System field. Section 12.4b describes such adjustments.
Subtracting the FVS from 100 will provide the
The preceding calculations have provided us with
visual impairment rating for the visual system (VSI).
2 separate impairment estimates. The FAS pro-
See Section 12.4c and Table 12-9 for the conversion
vides a statistical estimate for visual acuity–related
of the VSI rating to a WPI. The entire procedure was
abilities, such as reading (Table 12-4, lower half)
summarized in Table 12-1.
while the FFS provides a statistical estimate for
visual field–related abilities, such as orientation
12.4a Calculating an Impairment Rating
and mobility (Table 12-8, lower half). To obtain an
for the Visual System
overall estimate of visual impairment, the 2 impair-
The FAS and the FFS were calculated as weighted
ment estimates must be combined to a single FVS.
averages of the VAS and VFS for each eye. This is
Because the calculations outlined so far consider
appropriate because a good visual acuity or good
only the visual acuity and visual field aspects of
visual field in one eye can compensate for loss of the
vision, there must also be room for individual
Guides6e_12_281-320.indd 303 3/3/09 6:37:52 PM

same function in the other eye. Visual acuity–related 2. If visual field data are not available and if the
functions and visual field–related functions, how- patient agrees that there is no clinical reason to
ever, are largely independent (see Section 12.1b). suspect visual field loss, the FFS may be assumed
Good visual acuity cannot compensate for a loss to be 100. In this case, the FVS is the same as
of visual field, and vice versa. Therefore, the FAS the FAS, and the impairment rating for the visual
and the FFS are combined using a multiplication system is the same as the impairment rating for
formula, as is used to combine other unrelated the visual acuity loss.
impairments.
Rule for Central Scotomata, Where Field Loss
Basic Rule and Acuity Loss Are Not Independent
To calculate the FVS, the FAS and the FFS are mul- The dense array of points in the central 10° area of
tiplied as if they represented percentage scores: the visual field grid means that paracentral scoto-
mata (blind spots adjacent to the point of fixation)
FVS (FAS FFS)/100
will be counted even if they do not affect the central
For example, if the FAS is 80 (a 20% impairment) acuity. This is appropriate because it has been shown
and the FFS is 75 (a 25% impairment), the FVS is that such scotomata can interfere significantly with
calculated as follows: 80% 75% 60% (a 40% reading ability and with other ADLs.
impairment).
However, if the scotoma is central (ie, it covers the
Note that this calculation can be performed only on point of fixation), it affects both visual acuity and
the basis of the residual ability scores. Any calcula- visual field and the 2 impairment ratings can no
tions (adding, averaging, or multiplying) based on longer be treated as independent. Using the basic
Chapter 12
the impairment ratings (which indicate ability loss) formula, central scotomata would be counted twice:
would give erroneous answers. The combined effect once through their effect on visual acuity and once
of two impairment ratings is not easily captured through their effect on the central field. Therefore, a
in a simple formula but can be derived from the third additional rule is needed.
Combined Values Chart in the Appendix which also
3. If visual acuity is reduced, some central visual
shows that 20% impairment 25% impairment →
field losses will not be counted, as specified in
40% impairment.
Table 12-9.
Additional Rules Thus, for every 10 points of VAS loss, field losses in
Some additional rules are needed to avoid unrealistic one ring of 10 grid points are ignored. This means
calculations. that these points are counted as if they were seen.
This adjustment is made for each eye separately. The
1. For the purpose of this calculation, Functional
effect of this rule is that individuals with a small
Acuity and Functional Field Scores that are
island of good acuity within a pericentral scotoma
greater than 100 are treated as if they were 100.
(blind spot surrounding the point of fixation) will
Thus, losses are counted only if the performance
get credit for this scotoma, but that those with a
drops below the performance standard. The
central scotoma that affects visual acuity will not
average performance of healthy eyes often is
get double benefits. The adjustment does not affect
better than the performance standard (20/20).
peripheral field losses. Thus, a person with periph-
This better performance is taken into account in
eral field loss due to glaucoma who also has a central
calculating the Functional Acuity or Field Scores
loss due to macular degeneration will get credit for
(see Example 12-2), but it is not counted as a
the central loss as well as for the peripheral field loss
reduction of the impairment rating.
(see Examples 12-15 through 12-17).
TA B L E 12-9 Correction for Central Scotomata
If the Visual Acuity Score is 100-90 89-80 79-70 69-60 59-50 49 or less
that is, if the VAS loss is 0-10 11-20 21-30 31-40 41-50 50
and visual acuity is 20/30 20/50 20/80 20/125 20/200

20/200
Ignore central field loss up to 2º 4º 6º 8º 10º
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12.4b Individual Adjustments A 5-point loss can result from a 5-line acuity loss in
Although visual acuity loss and visual field loss one eye (20/20 20/60), since (3 100 100
represent significant aspects of visual impairment, 75)/5 95. It can also result from a 1-line acuity loss
they are not the only factors that can lead to a loss of in both eyes (20/25 20/25), since (3 95 95
functional vision and to a limitation in the ability to 95) /5 95.
perform ADLs. This edition of the Guides does not
A 10-point loss can result from a 10-line acuity loss
provide detailed scales for other functions, such as
in one eye (20/20 20/200), since (3 100 100
the following:
50)/5 90. It can also result from a 2-line acuity
• Contrast sensitivity. This is the ability to perceive loss in both eyes (20/30 20/30), since (3 90
larger objects of poor contrast. Loss of this abil- 90 90)/5 90.
ity can interfere significantly with many ADLs. It
A 20-point loss can result from the total loss of one
is often, but not always, associated with a loss of
eye (20/20 NLP), since (3 100 100 0)/5
visual acuity.
80. It can also result from a 4-line acuity loss in both
• Glare sensitivity (veiling glare), delayed glare eyes (20/50 20/50), since (3 80 80 80)/5
recovery, photophobia (light sensitivity), and 80. Note that the equivalence of 20/50 in both eyes to
reduced or delayed light and dark adaptation. total loss of one eye has been unchanged since 1925.
These are other functions that may interfere with Additional impairments will be less severe than total
proper contrast perception. loss of one eye, hence the limitation to 15 points.
• Color vision defects. These defects are not uncom- These examples also demonstrate why the AMA
mon but usually do not interfere significantly Guides do not allow visual impairment ratings
Chapter 12
with generic ADLs. Severe color vision defects that do not consider binocular vision since a rat-
(achromatopsia) are usually accompanied by ing of only one eye does not provide an accurate
visual acuity loss. In some vocational settings the assessment of the overall functioning of the person.
impact of minor color vision deficiencies can be Although it is mathematically possible to calculate
significant. This is one example of the fact that a rating for one eye, this calculation would not be
generic impairment ratings may not reflect job- realistic, since the outcome of that calculation would
specific employability ratings. As has been stated only equal the AMA impairment rating for the per-
earlier (see Sections 12.1a, 2.4b), assessment of the son if both eyes were affected to the same extent.*
employment-related consequences of vision loss is
The same rule should be observed as in the case of
important but is beyond the scope of these Guides.
central scotomata. Deficits should only be counted
• Binocularity, stereopsis, suppression, and diplo- to the extent that their effect exceeds the effect of the
pia. These functions vary in their effect on ADLs. related visual acuity or visual field deficit. Note the
Their significance often depends on the environ- following examples.
ment and vocational demands.
1. An individual with a congenital dark adaptation
Standardized measurement techniques on which deficit with normal acuity and normal visual
standardized ability estimates can be based have fields may be given a limited impairment rating
not yet been developed for most of these functions. based on this deficit. In someone with rod
Furthermore, their effect may be partially accounted dystrophy (as in RP) manifested by field loss as
for by a loss of visual acuity and may vary signifi- well as dark adaptation problems, the impairment
cantly according to environmental demands. rating will be determined by the field loss and no
additional rating is given for the dark adaptation
If significant factors remain that affect functional
deficit.
vision and that are not accounted for through visual
acuity or visual field loss, a further adjustment of 2. Many people with visual acuity loss due to
the impairment rating of the visual system may be macular degeneration also have a loss of contrast
in order. The need for the adjustment must be well sensitivity. Because the impairment rating is
documented. The adjustment should be limited to an dominated by the visual acuity loss, no additional
increase in the impairment rating of the visual sys-
tem (reduction of the FVS) by, at most, 15 points. *The AMA Guides do not sanction nonbinocular ratings as they
do not represent the true visual impairment rating of the
The following benchmarks may be used to judge the person. When providers are asked to provide ratings for one
effect of additional impairments on the ability to eye only, they may use the Visual Acuity and Visual Field Scores
for that eye, including any other necessary adjustments, but
perform ADLs. should indicate explicitly that these values do not represent an
impairment rating for the person, as required by the Guides.
Guides6e_12_281-320.indd 305 2/17/09 2:49:52 PM

rating is given for the contrast sensitivity loss. This adjustment affects the translation of the impair-
Occasionally, individuals will have a bothersome ment rating of the visual system (VSI) to an impair-
contrast sensitivity loss while the visual acuity is ment rating of the whole person (WPI) as shown
still normal. In these cases, a limited impairment in Table 12-8. Since the effectiveness of vision
rating may be given based on the contrast substitution skills will vary from person to person
sensitivity loss. and cannot be predicted from the visual acuity and
visual field measurements, the adjustments in Table
3. Congenital red-green color vision deficits exist in
12-8 are generalized estimates. That the WPI is not
about 7% of males, acquired color vision deficits
reduced further, even for blind persons who have
also exist. These deficits do not interfere with
made very effective adjustments, reflects the fact
generic ADLs and do not receive an impairment
that vision substitution skills alleviate the effects of
rating. A printer with such a deficit would have
vision loss but do not eliminate the vision loss itself.
no problems with black-and-white printing, but he
or she may have difficulty judging the accuracy The rule is as follows:
of color prints. This deficit does not enter into
If the VSI is
50%, WPI VSI.
the functional impairment considerations in this
If the VSI is 50%, WPI 50 0.7 (VSI 50)
chapter (see Figure 12-1 and Sections 2.1) since
it affects employability in a specific job. Total Figure 12-8 illustrates this graphically.
color blindness (achromatopsia) is extremely rare.
At this point it may also be appropriate to consider
It is accompanied by visual acuity loss, in which
apportionment between preexisting conditions and
case the visual acuity loss will determine the
the effect of the current injury (see Sections 12.1a
impairment rating.
and 2.5c).
Chapter 12
4. Diplopia may exist in varying degrees. Not only

the angle and the existence of diplopia should 12.4d Nonvisual Impairments
be considered but also the extent to which it Nonvisual impairments are not rated as part of the
interferes with ADLs and the extent to which visual system. If a visual condition is accompanied
suppression may reduce the awareness of double by facial disfigurement, this is rated according to
vision. In the rare event that the diplopia is so Table 11-5. The resulting impairment rating (if any)
severe that it warrants continuous occlusion of is then combined with the visual impairment rating
one eye, that eye may be counted as having no of the whole person, using the Combined Values
vision (see Section 12.2b), which results in a 20 Chart in the Appendix. It should be remembered
point loss (see the list earlier in this section). that the effects of facial disfigurement are often job
By comparison, continuous occlusion of 1 full related. While facial disfigurement may have mini-
quadrant of gaze might be counted as a 5-point mal consequences for a telephone operator, it would
reduction. For other conditions, the examiner be significant for a receptionist who greets people.
should use reasonable judgment. Assessment of job-related effects is beyond the scope
of these Guides (see Section 2.1). The same holds
12.4c Impairment of the Whole Person true for other nonvisual impairments.
Individuals with mild, moderate, and severe vision
loss (classes 1, 2, and 3a) may benefit from vision 12.4e Calculation Examples Combining
enhancement techniques such as large print, opti- Visual Acuity Loss and Visual Field Loss
cal or electronic magnification, better illumination,
and better contrast. In classes beyond this range, a
CLASS 1
shift to vision substitution techniques occurs; this
Mild Loss
may include talking books, Braille, and long cane.
Because of these techniques, a totally blind person
is not totally incapacitated. In the previous section, a EXAMPLE 12-14 (SEE ALSO EXAMPLE 12-2):
downward adjustment of the FVS of up to 15 points 16% IMPAIRMENT DUE TO VISUAL ACUITY
was allowed for additional impairments whose effect LOSS COMBINED WITH VISUAL FIELD LOSS
exceeds that of the visual acuity and/or visual field
loss. A similar, but opposite, adjustment is made
in classes 3a, 3b, and 4 to account for the effects of History: As stated in Example 12-2, the individual
vision substitution skills that alleviate the effects of lost the left eye (enucleated in childhood); the right
the permanent vision loss. eye is normal.
Current Symptoms: Can perform all office functions.
Guides6e_12_281-320.indd 306 2/17/09 2:49:53 PM

FIGURE 12- 8
Conversion From VSI to WPI
Graphically:
VSI: 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
WPI: 0 5 10 15 20 25 30 35 40 45 50 57 64 71 78 85 90 95 100
Numerically:
VSI: 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
WPI: 0 5 10 15 20 25 30 35 40 45 50 53.5 57 60.5 64 67.5 71 74.5 78 81.5 85
TA B L E 12 -1 0 Classification of Impairment of the Visual System and of the Whole Persona
Chapter 12
Calculation Results
FVS: 100–93 FVS: 92–73 FVS: 72–53 FVS: 52–33 FVS: 32–13 FVS: 12–0
VSI: 0–7 VSI: 8–27 VSI: 28–47 VSI: 48–67 VSI: 68–87 VSI: 88–100
WPI: 0–7 WPI: 8–27 WPI: 28–47 WPI: 48–60 WPI: 61–72 WPI: 73–85
AMA Classes
International Ranges of Vision Loss (based on ICD-9-CM etc)
Range of normal Mild Moderate vision Severe vision loss Profound vision (Near-) Total
vision vision loss loss loss vision loss
WHO ranges for international Low vision Blindness

statistics
Estimated Ability to Perform Activities of Daily Living (statistical estimates, individual performance may vary)
Has reserve Lost reserve Some need for Slower, even with Marginal visual No visual
capacity capacity visual aids aids performance performance
No need for aids Transition from Vision enhancement aids, Transition from Substitution
no aids to eg, magnification, contrast, lighting enhancement aids eg, cane, braille
aids
a
See Tables 12-4 and 12-8 for specific examples of visual acuity and visual field loss.
Guides6e_12_281-320.indd 307 2/17/09 2:49:53 PM

Physical Exam: Left eye replaced by good-fitting surrounded by a scotoma; beyond this scotoma the
prosthesis. peripheral field is normal.
Clinical Studies: Best-corrected acuities: VOU: Functional Acuity Score: Normal visual acuity
20/15, VOD: 20/15, VOS: NLP. means FAS 100.
Functional Acuity Score: 84 (as calculated in Functional Field Score: The grid points at 3° and 5°
Example 12-2). are missed in all 10 meridians (20 points lost). The VFS
is 100 10 2 80.
Functional Field Score:
Functional Vision Score: Because the field loss does
OD full field 100 1 100
not include the center of fixation, the rule for central
OS no field 01 0
scotomata does not apply. The FVS is FAS FFS /100
OU full field 100 3 300
100 80/100 80.
Diagnosis: Age-related maculopathy.
Functional Vision Score: In this case, the visual acu-
ity loss and the visual field loss are not independent. Impairment Rating: 100 80 20% impairment
Multiplying the two ratings, FAS FFS/100 of the visual system (VSI), which is also the WPI
(84 80)/100 67, would count the same deficit (see Table 12-10).
twice. Because the field loss includes the point of fixa-
Comment: The impairment rating reflects the sig-
tion, the rule for central scotomata applies. Because
nificant effect of a perifoveal scotoma on reading
the 100% field loss in the left eye does not exceed the
ability and other daily living skills (class 1). Without
100% visual acuity loss in that eye, the field loss is
the perifoveal scotoma, the impairment would have
Chapter 12
ignored for the FVS calculation (ie, counted as if FFS

been 0% (class 0).
were 100 0% impairment). The FVS thus equals the
FAS. The FVS (84 100)/100 84.
Diagnosis: History of retinoblastoma.
CLASS 2
Impairment Rating: 100 84 16% impairment Moderate Loss
of the visual system, which is also the impairment of
the whole person (see Table 12-10).
Comment: The loss of 1 eye reduces the FVS, but VISUAL ACUITY LOSS COMBINED WITH VISUAL
only to a level of mild loss, indicating a significant FIELD LOSS
loss of reserves but not a significant restriction of the
Subject: 68-year-old man previously described in
ability to perform ADLs (AMA class 1).
Example 12-15.
To simplify the presentation of the following cases,
History: Prior history of macular degeneration.
the assumption is made that both eyes have identical
conditions so that the Functional Acuity and Field Current Symptoms: Progressive vision loss.
Scores equal the Visual Acuity and Field Scores of Reading is possible only with a strong magnifier.
the eye that is discussed. In real cases there usually
Physical Exam: Progressive macular degeneration,
will be differences in the scores.
now including the foveal area.
Clinical Studies: Has lost the central island of his
vision. All grid points at 1°, 3°, and 5° are lost.
PERIFOVEAL VISUAL FIELD LOSS
Functional Acuity Score: Visual acuity dropped to
20/160. The VAS, considered alone, is 20/160
History: No prior history of eye disease. 55 (45% impairment rating).
Current Symptoms: Reading is no longer enjoyable. Functional Field Score: Since the grid points at 1°,
3°, and 5° are lost, the VFS, considered alone, is
Physical Exam: Atrophic macular degeneration
100 10 3 70 (30% impairment rating).
(geographic atrophy).
Functional Vision Score: Because the field loss
Clinical Studies: Best-corrected acuities: VOU:
now includes the center of fixation, the rule for
20/20, VOD: 20/20, and VOS: 20/20. Visual field
central scotomata applies. For the calculation of the
studies reveal a central island of good foveal vision
FVS, the central field loss of 30% is ignored because
Guides6e_12_281-320.indd 308 2/17/09 2:49:54 PM

it does not exceed the 45% visual acuity loss. Diagnosis: Age-related maculopathy. Chronic open-
Therefore, the FFS is entered into the calculation as angle glaucoma.
if it were 100. The calculation is: FAS FFS/100
Impairment Rating: 100 41 59% VSI, which
55 100/100 55.
translates to a 56% WPI (class 3a; see Table 12-10).
Diagnosis: Progressive age-related maculopathy.
Comment: The impairment rating is now affected
Impairment Rating: 100 55 45% VSI, which by the visual acuity loss as well as by the peripheral
is also the WPI (class 3; see Table 12-10). field loss.
Comment: In Example 12-15, the impairment rating
was determined by the visual field loss. In this case,
the visual acuity loss dominates.
12.5 Visual Acuity Measurement
at Near (Reading Acuity)
CLASS 3A
Consideration of reading acuity in the calculation of
Severe Loss
the Functional Acuity Score (FAS) is optional. It is
warranted only if the reading acuity is significantly dif-
EXAMPLE 12-17: 59% IMPAIRMENT DUE TO ferent from the distance acuity. In that case, it is appro-
VISUAL ACUITY LOSS COMBINED WITH VISUAL priate to use the average of the FAS for letter chart
FIELD LOSS acuity, as discussed earlier, and the FAS for reading, as
shown in Table 12-11. This section contains instructions
Subject: 75-year-old man previously described in
Chapter 12
for accurate reading acuity measurement.
Examples 12-15 and 12-16.
History: Prior history of macular degeneration. In 12.5a Near Acuity vs Distance Acuity
recent years the individual has also been followed up (Reading Acuity vs Letter Chart Acuity)
for glaucoma. Near acuity may be measured with a reduced-size
letter chart or with continuous text. When the objec-
Current Symptoms: Reading remains possible with
tive is the assessment of functional vision—as is the
a strong magnifier, but the individual complains of
purpose of these Guides—continuous textual read-
being startled by objects in his peripheral vision.
ing material should be used.
Physical Exam: The macular degeneration appears
Under most circumstances, letter chart acuity and
stationary. The optic disc shows cupping.
reading acuity—if measured appropriately and with
Clinical Studies: The patient now shows peripheral the proper refractive correction—will be similar. If
field loss, due to glaucoma. significant differences between reading acuity and
letter chart acuity exist, measurement errors, inappro-
Functional Acuity Score: The visual acuity is still
priate refractive correction, and/or other complicating
20/160; VAS 55 (45% impairment rating).
factors should first be suspected. The nature of these
Functional Field Score: In addition to the 30 central factors needs to be explored, documented, and cor-
points, 25 peripheral points are now lost. The VFS, rected where possible. Accurate calculation of the
considered alone, is 100 30 (central loss) 25 reading acuity requires accurate measurement of the
45 (55% impairment rating). letter size (see Section 12.5b) as well as of the view-
ing distance. Many practitioners record only the letter
Functional Vision Score: Although the visual field
size that has been read and not the reading distance.
loss alone (55%) is worse than the visual acuity loss
Table 12-11 shows that this is inappropriate because
alone (45%), for the calculation of the FVS, the central
small changes in the reading distance can result in
field loss is ignored since this part of the vision loss is
significant changes in visual acuity, especially if the
already accounted for in the visual acuity impairment
reading distance is short. At these short distances
rating (see Table 12-9 and the previous example). The
appropriate refractive correction also is mandatory.
peripheral field loss, which is independent of the visual
acuity loss, is not ignored. Therefore, the FFS is now One cause of a true discrepancy between reading acuity
entered into the calculation as if it were 100 25 75. and letter chart acuity might be that the individual uses
Therefore: FVS FAS FFS/100 55 75/100 a small central island within a ring scotoma for letter
41 (59% impairment rating). acuity while using a larger, more eccentric area for
Guides6e_12_281-320.indd 309 2/17/09 2:49:55 PM

TA B L E 12 -11 Determination of Reading Acuity and Impairment Rating, Using Letter Size and Viewing Distancea
Viewing Distance (glasses to text, not valid for magnifiers)
ICD-9-CM
5 cm 6.3 cm 8 cm 10 cm 12.5 cm 16 cm 20 cm 25 cm 32 cm 40 cm 50 cm 100 cm
Letter Size 2b 2.5 3.2 4 5 6.3 8 10 12.5 16 20 40
20 D 16 D 12.5D 10 D 8D 6.3 D 5D 4D 3.2 D 2.5 D 2D 1D
3.2 p 0.4 M 45 40 35 30 25 20 15 10 5 0
Above
J1 20/160 20/125 20/100 20/80 20/63 20/50 20/40 20/32 20/25 20/20 20/16 20/8
4p 0.5 M 50 45 40 35 30 25 20 15 10 5 0
J1-3 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/40 20/32 20/25 20/20 20/10
5p 0.63 55 50 45 40 35 30 25 20 15 10 5
M
J1-5 20/250 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/40 20/32 20/25 20/12
Normal Range
6.3 p 0.8 M 60 55 50 45 40 35 30 25 20 15 10
J1-6 20/320 20/250 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/40 20/32 20/16
8p 1M 65 60 55 50 45 40 35 30 25 20 15 0
J2-6 20/400 20/320 20/250 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/40 20/20
10 p 1.25 70 65 60 55 50 45 40 35 30 25 20 5
M
J3-10 20/500 20/400 20/320 20/250 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/25
12 p 1.6 M 75 70 65 60 55 50 45 40 35 30 25 10
Chapter 12
J5-11 20/630 20/500 20/400 20/320 20/250 20/200 20/160 20/125 20/100 20/80 20/63 20/30
16 p 2M 80 75 70 65 60 55 50 45 40 35 30 15
Near-Normal
J4-12 20/800 20/630 20/500 20/400 20/320 20/250 20/200 20/160 20/125 20/100 20/80 20/40
20 p 2.5 M 85 80 75 70 65 60 55 50 45 40 35 20
J6-14 20/1000 20/800 20/630 20/500 20/400 20/320 20/250 20/200 20/160 20/125 20/100 20/50
25 p 3.2 M 90 85 80 75 70 65 60 55 50 45 40 25
J7-16 20/1250 20/1000 20/800 20/630 20/500 20/400 20/320 20/250 20/200 20/160 20/125 20/63
32 p 4M 95 90 85 80 75 70 65 60 55 50 45 30
Moderate Low Vision

J14-16 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/400 20/320 20/250 20/200 20/160 20/80
40 p 5M 100 95 90 85 80 75 70 65 60 55 50 35
J16-18 20/2000 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/400 20/320 20/250 20/200 20/100
50 p 6.3 M 100 95 90 85 80 75 70 65 60 55 40
J18 20/2500 20/2000 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/400 20/320 20/250 20/125
63 p 8M 100 95 90 85 80 75 70 65 60 45
J18,19 20/3200 20/2500 20/2000 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/400 20/320 20/160
80 p 10 M 100 95 90 85 80 75 70 65 50
Low Vision
J19,20 20/4000 20/3200 20/2500 20/2000 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/400 20/200
100 p 12.5 100 95 90 85 80 75 70 55
M
J20 20/5000 20/4000 20/3200 20/2500 20/2000 20/1600 20/1250 20/1000 20/800 20/630 20/500 20/250
Near-total Visual Acuity Loss Profound Low Vision Severe
a
Columns indicate reading distances. Rows indicate letter sizes. The resulting reading acuity ratings are found at the intersections. The upper number in each
box represents the Impairment Rating (100 VAS, truncated at 0 and at 100). The lower number represents the Snellen distance equivalent. Note that the
visual acuity values and impairment ratings are arranged in diagonal bands. The same visual acuity value can be represented by many different combinations
of viewing distance and letter size. For each diagonal band the outer edge of the table indicates the ranges of vision loss in ICD-9-CM.
b
indicates inches.
Guides6e_12_281-320.indd 310 2/17/09 2:49:55 PM

reading. Another cause might be that when measuring preferred. The preferred step size is the same as for let-
letter chart acuity, people are usually pushed for thresh- ter charts. The viewing distance should be measured
old or marginal performance, whereas reading tests and recorded carefully. Measurement with a diopter
more often aim at a level of sustainable performance. ruler simplifies calculations (see Section 12.5d) and
For this reason, the magnification requirement for read- provides a direct comparison to the required accommo-
ing acuity may be somewhat greater than that for letter dation or reading add. Letter size specification in M-
acuity. The difference is known as the magnification units is mandatory if any calculations or comparisons
reserve needed for reading fluency. are involved. One M-unit equals 1.454 mm, which is
slightly smaller than 1/16 in. Measuring the letter size
12.5b Letter Size Notations in units of 1/16 in overestimates the visual acuity by
Another reason for discrepancies can be found in slightly less than half a standard step size.
the use of inaccurate letter size notations. The com-
To test reading acuity for the normal and near-
monly used Jaeger numbers refer to the labels on the
normal range, many cards are available. Most
boxes in the printing house in Vienna where Jaeger
will indicate distance equivalents. Note that these
selected his print samples in 1854. They have no
distance equivalents are valid only if the designated
numerical value, and their implementation on current
distance is used. Reading cards with a cord attached
reading cards is notoriously variable. The J-numbers
for the correct reading distance are recommended.25
listed in Table 12-11 present the range of J-designa-
tions found for each letter size when 20 current read- Many individuals undergoing impairment evaluation
ing cards were surveyed. All current letter sizes were will fall in the low-vision range. They may require
larger than Jaeger’s original ones. Note that a range shorter reading distances and/or larger print sizes.
of 4 Jaeger sizes is not uncommon. Table 12-11 shows the proper visual acuity values
Chapter 12
and impairment ratings for many combinations of
Some charts use a notation in printer’s points. Point
letter size and viewing distance.
sizes have a numerical value but may vary depending
on the type style used (eg, 8-pt Arial 9-pt Times
12.5d Modified Snellen Formula
Roman). Many reading cards list distance equiva-
The visual acuity values found in Table 12-11 could
lents. This notation is valid only if the card is used
be calculated using the standard form of the Snellen
at the distance for which the card was designed. At
fraction V m/M, in which the viewing distance
any other distance, the use of distance equivalents is
is specified in meters (1 m 100 cm 40 in; 1 in
utterly confusing.
2.5 cm) and the letter size in M-units. Use of the
The only letter size unit that is based on a well-defined standard Snellen fraction becomes awkward when
standard and thus allows a comparison between letter the viewing distance (in meters) is itself a fraction.
chart acuity and reading acuity is the M-unit. M-units In this case, it is more convenient to use the recipro-
are based on Snellen’s original definition and refer cal of the viewing distance, which is known as the
directly to the actual letter size (X-height for uppercase diopter (2 D 1/2 m, 5 D 1/5 m, etc). The use of
letters on a letter chart, x-height for lowercase letters in reciprocal values also has the advantage of turning
a reading segment). In either case, 1 M-unit subtends 5 the Snellen fraction into a multiplication, which is
minutes of arc at 1 m and equals 1.454 mm (10% less more easily calculated in one’s head because it uses
than 1/16 inch). whole numbers instead of fractions within fractions.
The traditional formula
12.5c Measurement Guidelines for
Reading Acuity (Near-Vision Acuity) V m/M
Visual acuity measurement at near is more complex
thus becomes
than visual acuity measurement at distance because
both letter size and viewing distance can vary. When 1/V M/m M 1/m M D
reading acuity is measured, follow these guidelines.
where M letter size in M-units, m viewing dis-
If binocular reading is possible, the binocular reading tance in meters, and D viewing distance in diopters.
acuity should be recorded. If binocular reading is not
possible or not preferred, the reading acuity of the eye 12.5e Instructions
that is preferred for actual reading should be used. To find the optimal combination of reading distance
and letter size, start at the reading distance that cor-
The measurement of reading acuity requires a read-
responds to the individual’s current reading add and/or
ing card with calibrated reading segments. Cards with
accommodative power. Increase the reading add
proportionally spaced segments of equal length are
Guides6e_12_281-320.indd 311 2/17/09 2:49:57 PM

(reduce the reading distance) to reach smaller print. individual to move the card back and forth to find
Using Table 12-11, find the visual acuity at the inter- the best possible focus. If the refractive correction
section of the letter size row and the reading distance (reading add) is not optimal for the distance used,
column. Alternatively, using the M D formula and a the measured acuity will not be the best-corrected
diopter ruler, calculate the 1/V value. For each combi- visual acuity. Measurement of the reading distance
nation of viewing distance and letter size read, compare in diopters has the advantage of easy comparison to
the reading add to the viewing distance in diopters to the reading addition.
verify the appropriate refractive correction. Also, com-
pare the M D value to verify that the visual acuity
values are consistent.
12.6 Reporting Aids
12.5f Correction of Refractive Error
This section contains examples of forms that may be
To verify that the refractive correction is appropriate
copied to facilitate reporting.
for the viewing distance, it is often useful to ask the
Chapter 12
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FIGURE 12-9
Evaluation of Permanent Visual Impairment
Performed by ——————————————————————————————— Date ———————————————————
Address —————————————————————————————————————————————————————————
Patient Name ————————————————————————— Age: ——— M/F: ——— Occupation: —————————
Current Visual Symptoms—Do the Current Symptoms explain the claimed Ability Loss?
Pertinent History, Cause of Vision Loss—Does the History explain the Cause of Current Symptoms? Apportionment?
Pertinent Eye Exam—Is the Eye Exam consistent with Current Symptoms?
Prognosis, Rehabilitation Potential—Is the Current Condition permanent; can Rehabilitation alleviate the consequences?
Visual Acuity Traditional chart ← 円 → Logarithmic chart (ETDRS) at 1 m
Visual Acuity: 20/12 /16 /20 /25 /30 /40 /50 /60 /80 /100 /125 /160 /200 /250 /300 /400 /500 /600 /800 /1000 /1250 /1600 /2000
Visual Acuity Score: 110 105 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0
Best-Corrected Visual Acuity → Visual Acuity Score (VAS)
Chapter 12
Contrast/Glare sensitivity (optional)
R Rx: 20/ VAS-R R 20/ VAS R
L Rx: 20/ VAS-L L 20/ VAS L
Both eyes open: 20/ VAS-Both 3 Both 20/VAS Both 3
Total: Total:
FAS: Functional Acuity Score (ⴝ total/5) FAS —————
Visual Field Visual Field Score Total stimuli seen of 50 stimuli in central 10 50 stimuli in periphery.
Central Peripheral
R: /50 /50 VFS-R:
L: /50 /50 VFS-L:
Either: /50 /50 VFS-Either: 3: (stimuli seen by either Right or Left eye)
Total:
FFS: Functional Field Score (ⴝ total/5)
FVS: Functional Vision Score (ⴝ FAS ⴛ FFS/100)
Adjustments for Color vision/Binocularity/Stereopsis/Suppression/Diplopia/Other (Subtract Max. 15 points) – EXPLAIN.
Visual System Impairment rating: (100 FVS adjustment) %

Adjustments for unrelated nonvisual conditions –EXPLAIN calculations.
Whole Person Impairment Rating (unless additional physical impairment) %
I hereby certify that the above findings were determined on the date noted above, and that the measurements obtained
and the calculations performed are in strict accordance with the requirements in the book Guides to the Evaluation of
Permanent Impairment, Sixth Edition, Chapter 12, The Visual System, published by the American Medical Association.
Copies of the relevant visual field plots or other supporting data will be supplied as requested.
Name —————————————————— Signature —————————————————————— Date ——————————
Guides6e_12_281-320.indd 313 2/17/09 2:49:57 PM

Overlays for Conversion of The number of points that were seen (not marked)
Goldmann Visual Field Plots determines the Visual Field Score (VFS) for the
Right eye. This number is easily calculated by
considering that there are 50 small dots and 50
General closed dots. If any of the open dots (beyond 600)
The Goldmann plot shows isopters. These are lines were seen, they are added to the VFS.
that outline the area where a particular stimulus can
3. Place the other transparency over the Goldmann
be seen. The AMA visual field impairment rating
plot for the Left eye.
is based on the area where the III4e stimulus can be
seen. 4. Similarly, mark the points outside the III4e isopter
with a backward slash (\). If there are blind spots
The area where the stimulus can be seen depends
within this isopter, also mark the points inside the
on the size and brightness of the stimulus. A larger
blind spots. The number of points that were seen
stimulus will be seen in a larger area. For diagnostic
(not marked) determines the Visual Field Score
purposes it is common to plot several isopters. For
(VFS) for the Left eye.
the AMA calculations, only the III4e isopter is rel-
evant; any additional isopters should be ignored. 5. Place the two transparencies on top of each other
and notice the points that have a double mark (X).
If only smaller isopters have been plotted, the AMA
These are the missing points for the binocular
rating cannot be calculated, since it would be pos-
field. Points that have only one slash
sible to increase the field loss to any desired degree
(/ or \, but seen by the other eye) are not consid-
by reducing the stimulus.
ered missing in the binocular field.
Chapter 12
If only a larger isopter (IV4e or V4e) has been plot-

Calculate the number of points seen for the bin-
ted, the result will be an underestimation of the field
ocular field.
loss compared to the III4e isopter. The difference may
vary from person to person and is not insignificant. In 6. Calculate the weighted average of points seen to
one study an average difference of 20 VFS points was obtain the Functional Field Score (FFS) for the
found between the III4e and V4e isopters.29 person.
(OD + OS + 3x OU) / 5 =
Instructions
Subtract this number from 100 to obtain the
Copy a Goldman Visual Field Plot to sheets of ace-
Visual Field Impairment rating.
tate as used for overhead projectors. Do this twice.
7. Make a photocopy of the diagrams for documen-
1. Place one transparency over the Goldmann plot for
tation. If a dry-erase marker was used, wipe the
the Right eye.
acetate clean to be used for another subject.
2. Using a dry-erase or similar marker, mark the
points outside the III4e isopter with a forward
Opposite Page
slash (/). If there are blind spots within this isop-
ter, also mark the points inside the blind spot. F I G U R E 12 -1 0
Overlay Grid for Goldman Fields
(Note: Not actual size)
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Chapter 12
Guides6e_12_281-320.indd 315 2/17/09 2:49:59 PM

Overlays for Conversion of based on that HFA number. If the circle is in an

Humphrey visual field plots area containing more than one HFA number, it is
counted based on the average HFA value.
2. Using a dry-erase or similar marker, mark each of
General
the small circles where the threshold sensitivity
Humphrey visual field plots do not describe an isop-
is above 10. If the circle is in an area that covers
ter as do Goldmann fields. They describe the sensi-
more then one number, mark it if the average is
tivity at various points of a grid, but the Humphrey
above 10. On the diagonals, some HFA numbers
grid is different from the AMA grid.
straddle a line; count them for both areas.
The points on the AMA grid used to calculate the
If a central VFS cell contains a number, that cell
Visual Field Score (VFS) are dense in the center and
is counted multiple times to arrive at the VFS
sparser in the periphery, to reflect differences in the
score. For instance: if the cell contains “4x” the
functional significance of various visual field areas;
value of that one HFA number determines the
the VFS score is based on points seen. The points
seen or missed status of four VFS points.
on the Humphrey (HFA) grids are evenly spaced, to
detect diagnostically significant structural losses. 3. For each diagram, count the unmarked circles. This
Therefore, a one-to-one correlation of the two grids corresponds to the VFS points that were not seen.
is impossible. In the center one HFA point may cor- For each eye: add the not-seen counts for the 60-4
respond to several VFS points; in the periphery sev- and 30-2 fields and for the 10-2 field, if available.
eral HFA points contribute to one VFS point. This constitutes the not-seen count for each eye.
The HFA 10-2 plot corresponds to the inner 50 VFS Note that points can only be claimed as missed if
Chapter 12
points. they have been tested. If a 60-4 plot is not avail-

able the outer points cannot be claimed as lost;
The HFA 30-2 and 24-2 plots cover 20 of the outer
this limits the claimant’s field loss score. Have a
50 VFS points and provide an estimate of the inner
60-4 test or a Goldmann test done to prevent this.
50 VFS points. If a 10-2 plot is available (preferable),
only the 20 outer points are counted from these 4. To determine the binocular field, superimpose the
grids. If a 10-2 plot is not available, the central 16 plots for the right and the left eye and count the
HFA points are used to estimate the central 50 VFS points that have not been marked in either eye.
points. This is the count of points missed in binocular
vision.
The HFA 60-4 plot covers the outermost 30 of the
VFS points.
5. Calculate the weighted average of points missed to
obtain the Visual Field Impairment rating.
Instructions
(OD + OS + 3x OU) / 5 =
Copy the diagrams (Figure 12-11) on page 317 to a
sheet of acetate as used for overhead projectors. Cut Subtract this number from 100 to obtain the
the sheet to separate the diagrams for the right and Functional Field Score (FFS) for the person.
the left eye.
6. Make a photocopy of the diagrams for documen-
1. Place the appropriate diagram over each HFA plot tation. If a dry-erase marker was used, wipe the
of absolute threshold values. Each number of the acetate clean to be used for another subject.
HFA plot should appear in the center of one of the
small squares.
Opposite Page
Each circle in the conversion diagrams cor- F I G U R E 12 -11
responds to one VFS point. If the circle is in a
Overlay Grids for Humphrey Field Plots
square that corresponds to one HFA number, it is
counted as seen (HFA >10) or not seen (HFA <10)
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Chapter 12
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Guides to the Evaluation of Permanent

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Development of Standards for the Characterization Ophthalmol. 1982;94:91–96.
of Vision Loss and Visual Functioning. Geneva, 22. National Eye Institute. Measurement Guidelines for
Switzerland: WHO/PBL/03.91; 2003. Available as PDF Collaborative Studies. Bethesda, Md: National Eye
at: http://whqlibdoc.who.int/hq/2003/WHO_PBL_03.91. Institute; 1982.
pdf. Accessed May 2007.
The NEI (ETDRS) guidelines combined the Sloan letter set
8. Fuhr PSW, Holmes LD, Fletcher DC, et al. The AMA with the Bailey-Lovie layout and thus created the de facto
Guides Functional Vision Score is a better predictor of international standard for visual acuity measurement. The NEI
vision-targeted quality of life than traditional measures rules specify a rating system similar to the Visual Acuity Score.
of visual acuity or visual field extent. Vis Impairment
Res. 2003;5(3):137–146. 23. International Council of Ophthalmology. Visual
acuity measurement standard (approved 1984). Ital J
9. Massof RW, Fletcher DC. Evaluation of the NEI Visual Ophthalmol. 1988;II/I:1–12. Available as PDF at: www.
Functioning Questionnaire as an interval measure of icoph.org/standards. Accessed May 2007.
visual ability in low vision. Vis Res. 2001;41:397–413.
10. Massof RW. The measurement of vision disability.
Optom Vis Sci. 2002;79:516–552.
Guides6e_12_281-320.indd 318 2/17/09 2:50:01 PM

Testing Methods 28. Colenbrander A. The Functional Vision Score: A

24. Colenbrander A. Visual acuity measurement coordinated scoring system for visual impairments,
for low vision. In: Kooiman AC, et al, eds. Low disabilities, and handicaps. In: Kooiman AC, et al,
Vision: Research and New Developments in eds. Low Vision: Research and New Developments
Rehabilitation. Studies in Health Technology and in Rehabilitation. Studies in Health Technology and
Informatics. Amsterdam, The Netherlands: IOS Press; Informatics. Amsterdam, The Netherlands: IOS Press;
1994:542–551. 1994:552–561.
25. Low Vision Test Chart. One side: letter chart from 50 29. Langelaan M, Wouters B, Moll AC, de Boer MR, van
M to 1 M (acuity: 1/50, 20/1000 to 1/1, 20/20), 1 m cord Rens GHMB. Functional Field Score: the Effect of
attached. Other side: reading segments from 10 M to using a Goldmann V-4e instead of a Goldmann
0.6 M, diopter ruler included, standardized segments II-4e isopter. Invest. Ophth. and Vis. Sc. 2006, 47 (5);
for reading rate measurements. Reading segments are 1817-1823.
available in English, Spanish, Portuguese, French, 30. American Medical Association. Impairment Calculator
Italian, German, Dutch, Finnish, Swedish, and Tagalog. [computer program]. Chicago, Ill: American Medical
Precision Vision, 944 First St, LaSalle, IL 61301. Association; 2004.
Fax: 812-223-2224; e-mail:
precisionvision@mindspring.com. 31. Colenbrander A, Lieberman MF, Schainholz DC.
Preliminary implementation of the functional vision
26. Colenbrander A. Dimensions of visual performance– score on the Humphrey field analyzer: Proceedings
Low Vision Symposium. American Academy of the International Perimetric Society, Kyoto, Japan,
of Ophthalmology. Trans Am Acad Ophthalmol 1992. In: Mills RP, ed. Perimetry Update 1992/1993.
Otolaryngol. 1977;83:332–337. The Hague, The Netherlands: Kugler Publications;
27. Colenbrander A. Measuring vision and vision loss. 1993:487–496.
In: Tasman W, Jaeger EA, eds. Duane’s Clinical
Ophthalmology. Vol 5. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2001:chap 51.
Chapter 12
Guides6e_12_281-320.indd 319 2/17/09 2:50:02 PM

320
CHAPTER 13
The Central
and Peripheral
Nervous System
13.2 Method for Rating Impairments due to

Nervous System Disorders
13.3 Criteria for Rating Cerebral Impairments
13.4 Criteria for Rating Impairment due to

Spinal Cord Dysfunction and Movement
Disorders
13.5 Criteria for Rating Impairments of the

Introduction
Chapter 13
Upper Extremities due to CNS Dysfunction
The goals of this chapter of the AMA Guides are:
13.6 Criteria for Rating Impairments of
Station, Gait, and Movement Disorders • To provide an evolutionary but not revolutionary
revision of the chapter.
13.7 Criteria for Rating Neurogenic Bowel,
• To strive for a more concise presentation of
Bladder, and Sexual Dysfunction
material in concert with the general goals of the
Sixth Edition.
13.8 Criteria for Rating Neurogenic
Respiratory Dysfunction • To clarify tables and improve the rater’s ability
to choose reliably between impairment rating
13.9 Criteria for Rating Peripheral categories.
Neuropathies, Neuromuscular Junction
• To avoid duplication of materials between
Disorders, and Myopathies
chapters. It was the collaborative decision of the
editorial board of the Sixth Edition of the Guides
13.10 Criteria for Rating Impairments Related
to maintain most ratings related to limbs in the
to Complex Regional Pain Syndrome
upper and lower extremity chapters (Chapters 15
and 16, respectively), to refer visual disorder rat-
13.11 Criteria for Rating Impairments Related
ings to the visual disorders chapter (Chapter 12),
to Craniocephalic Pain
and to provide most ratings of nerves of the head
and neck in the ear, nose, and throat (ENT)
13.12 Criteria for Rating Miscellaneous
chapter (Chapter 11). Complex Regional Pain
Peripheral Nerves of the Head and Trunk
Syndrome (CRPS) is rated only in the upper
extremities and lower extremities chapters.
13.13 Nervous System Impairment Evaluation
Summary
321
Guides6e_13_321-346.indd 321 2/17/09 2:54:17 PM

• To maintain consistency between this chapter on Disorders of articulation (dysarthria) and phona-
neurology and the mental and behavioral disorders tion (dysphonia) are rated in the ENT chapter.
chapter (Chapter 14) in terms of ratings of higher
A summary of chapters to cross-reference appears in
cortical function.
Table 13-1.
• To maintain consistency between the neurology
and upper and lower extremities chapters in terms
of complete loss of limb function.
• To maintain consistency between the neurology
and the digestive system chapter (Chapter 6) in
This chapter emphasizes the deficits or impairments
terms of loss of bowel control.
that may be identified during a neurologic evalua-
• To maintain consistency between the neurology tion. For some nervous system impairments listed,
and the urinary and reproductive systems chapter hand dominance is important to determine the
(Chapter 7) in terms of bladder and sexual degree of impairment.
function.
• To provide impairment ratings for migraine Guides user should become familiar with Chapters 1
headaches and miscellaneous peripheral nerves and 2 and the Glossary. Chapters 1 and 2 discuss the
that were not ratable in the previous edition. Guides’ purpose, applications, and methods for per-
This chapter provides criteria for evaluating permanent
impairments due to documented dysfunction of the
various parts of the nervous system. The nervous
system affects virtually every organ system in the Neurologic impairments should be assessed as they
body—gut, heart, bladder—and therefore not all affect Activities of Daily Living (ADLs). ADLs
disorders of nervous system function are rated within reflect both the “basic” and “advanced” tasks
this chapter. To avoid duplication, readers will be that people ordinarily perform on a daily basis1–3
referred as needed to other chapters in the AMA (Table 13-2). The physician who rates impairment
Guides. should document which ADLs cannot be performed
independently by the patient, and the severity of
• Disorders of the brain and spinal cord, painful
Chapter 13
impairment of each loss. The physician should note

neuropathies of the head and trunk, peripheral
whether the patient’s report of ADL loss is consis-
neuropathies, neuromuscular junction disorders,
tent with the neurologic impairment evident in the
and myopathic disorders are rated in this chapter.
physician’s office.
• Cranial neuropathies affecting cranial nerves I,
A minimal impairment in ADLs might be seen in
V, VII, VIII, IX, X, XI, and XII are dealt with in
a patient with epilepsy, in whom there are seizures
the ENT chapter (Chapter 11) with the exception
approximately every 2 months despite optimal medi-
of trigeminal and glossopharyngeal neuralgia.
cal mangement. Such a patient would not be able to
Disorders of visual acuity and ocular motility
drive but would be able to carry out all other ADLs.
(cranial nerves II, III, IV, and VI) are rated in the
Another example of minimal ADL impairment
visual system chapter (Chapter 12).
might be seen in a patient with mild hemiplegia who
• Disorders of the spinal nerves are most often rated has recovered most of his or her motor abilities but
when assessing the spine and are assessed in that cannot walk long distances, even with a cane, and
chapter. cannot do heavy lifting or vigorous activities. All
basic ADLs are intact.
• Focal neuropathies are most often rated when
assessing the upper and lower extremities. They Moderate impairment of ADLs might be seen in a
have been assigned to those chapters and are not patient who needs minimal to moderate assistance
rated here. CRPS is rated in the upper and lower with basic ADLs but does not require extensive
extremity chapters. assistive care throughout the day. The patient with
severe impairment of ADLs performs few or none of
• Expressive and receptive language disorders of
their basic ADLs and needs extensive assistive care
language (dysphasias) are rated in this chapter.
throughout the day.
Guides6e_13_321-346.indd 322 2/17/09 2:54:18 PM

The Central and Peripheral Nervous System 323
TA B L E 13 -1
Summary of Chapters Used to Rate Various Neurologic Disorders
Disorder/Condition Chapter Title Chapter No.
Disorders of cerebral function Central and Peripheral Nervous System 13
Disorders of spinal cord function Central and Peripheral Nervous System 13
Craniocephalic pain Central and Peripheral Nervous System 13
Trigeminal neuralgia, glossopharyngeal neuralgia Central and Peripheral Nervous System 13
Miscellaneous nerves of the head and trunk Central and Peripheral Nervous System 13
Disorders of the neuromuscular junction Central and Peripheral Nervous System 13
Peripheral neuropathy Central and Peripheral Nervous System 13
Myopathic disorders Central and Peripheral Nervous System 13
Radiculopathy and other disorders of the spinal roots Spine 17
Plexus injuries and other plexopathies Upper Extremities 15

Lower Extremities 16
Focal neuropathy or mononeuropathy relating to the Upper Extremities 15
limbs Lower Extremities 16
Complex Regional Pain Syndrome Upper Extremities 15
Lower Extremities 16
Visual disorders Visual System 12
Vestibular disorders Ear, Nose, Throat, and Related Structures 11

Disorders of cranial nerves except for trigeminal and Ear, Nose, Throat, and Related Structures 11
glossopharyngeal neuralgia
Dysarthria and dysphonia Ear, Nose, Throat, and Related Structures 11
Primary mood disorders, anxiety disorders, and psychotic Mental and Behavioral Disorders 14
disorders a
a
See Section 13.3d for further discussion.
Chapter 13
TA B L E 13 -2
Activities of Daily Living 13.1a Interpretation of Symptoms
Basic Advanced and Signs
Nervous system disorders can present with general-
Bowel status Driving a car
ized or focal symptoms. Symptoms may include
Bladder status Sexual function
alterations in level of consciousness, confusion,
Grooming Medical care: prepares and takes memory loss, difficulties with language, headache,
correct medications visual blurring, double vision, fatigue, facial pain
Toileting Money management and weakness, ringing in the ears, dizziness, vertigo,
Feeding Communicative activities: use of difficulty swallowing or speaking, weakness of 1 or
phone, writing checks, writing letters multiple limbs, difficulty walking or climbing stairs,
Transfers from Traveling as passenger in car, bus, shooting pain, numbness and tingling in the extremi-
chair to bed or train ties, tremor, loss of coordination, loss of bladder or
Indoor mobility Shopping: lifting or carrying rectal control, and loss of sexual function.
groceries
Dressing Food preparation
Note that many of these symptoms describe the
functional impairment experienced by the individ-
Stairs Housework
ual. The neurologic evaluation and ancillary clini-
Bathing Community ambulation with or cal testing determine the origin of these symptoms.
without assistive device, but not
requiring a mobility device Difficulty walking, for example, may result from
problems in different areas of the central and/or
Moderate activities: moving table,
pushing vacuum cleaner, bowling, peripheral nervous system, as well as for a wide vari-
golf ety of musculoskeletal dysfunctions. The neurologic
Vigorous activities: running, heavy examination may find a spastic paraparesis associ-
lifting, sports ated with a spinal cord lesion. Magnetic resonance
Guides6e_13_321-346.indd 323 2/17/09 2:54:19 PM

imaging (MRI) of the spine may show the cause Lumbar puncture (spinal tap) is a procedure by
to be demyelinating plaques, which also may show which cerebrospinal fluid is removed through a
abnormal somatosensory evoked response since the medium-sized needle, usually at the L3-4 interspace,
pathway travels through the areas of demyelination in order to examine the presence of cells, proteins,
in the spinal cord. glucose, or infection. Indications include evaluation
of infections of the nervous system and, sometimes,
13.1b Description of Clinical Studies multiple sclerosis.
A detailed neurologic examination enables the phy-
An electroencephalogram (EEG) records the spon-
sician to identify the location of nervous system
taneous electrical activity generated by the cerebral
impairment. The purpose of ancillary testing is to
cortex and is useful for recording the site and type of
assess the severity and location of the lesion and
electrical discharge associated with seizure activity.
confirm the underlying pathology. It is important
Remember that a large percentage of cortical spikes
to remember that an abnormality found on ancil-
are not recorded because they arise from deeper
lary testing (anatomic or physiologic) is not always
structures and there is significant attenuation by
assigned an impairment rating if ADLs are unaf-
the cerebrospinal fluid and dura. Therefore, a sei-
fected. The nervous system is able to compensate for
zure disorder is not necessarily accompanied by an
a variety of lesions due to its plasticity and redun-
abnormal EEG. Also, many diseases and metabolic
dancy, sometimes resulting in limited representation
abnormalities produce nonspecific EEG abnormali-
on the neurologic examination.
ties. The EEG may be normal when the neurologic
Common clinical studies for evalution of the nervous examination is clearly abnormal since many areas
system include those described below. Readers are of the brain are inaccessible to the recording elec-
referred to standard textbooks for further discussion trodes and the EEG is time specific, that is, normal
of these tests. The brief description below does not between discharges. Conversely, EEG abnormalities
represent an endorsement of any of these tests or may be found in a significant number of “normal”
imply that they are required on a routine basis. asymptomatic persons.
Neuropsychologic assessment and consultation can Evoked potentials are able to record components of
help characterize cognitive and behavioral altera- response in the nervous system following multiple
tions and therefore is useful in the clinical assess- somatosensory, visual, and auditory stimuli. The
ment and planning of patient management. The integrity of these afferent pathways is evaluated.
Chapter 13
results of this assessment must be interpreted in the These studies may be used in the clinical evaluation
context of clinical and other test information. Many of multiple sclerosis, optic neuritis, and acoustic neu-
factors affect neuropsychological performance—age, roma. Also, a variety of neurotoxins (eg, solvents or
education, socioeconomic status, and cultural back- heavy metals) may produce alterations in the evoked
ground—and they must therefore be considered for potentials.
their influence on test results. Neuropsychological
Carotid duplex examination includes Doppler flow
tests may be able to distinguish between abnormal
velocity of different areas in the carotid artery and
and normal performance but offers less informa-
thus estimates the severity of stenosis in the carotid
tion as to the cause of the problem. Traumatic brain
artery. It is performed in the evaluation of cerebro-
injury, for example, may have a profile similar to
vascular disease.
that of other forms of dementia.
Computed tomographic scan (CT) shows the anat-
The neuropsychological assessment and test bat-
omy of the brain, spinal cord, skull, and vertebral
tery covers many functional domains—attention,
column. X-ray beams are used to differentiate densi-
language, memory, visuospatial skills, executive
ties of bone-calcified tissue, gray matter, white mat-
function, intelligence, motor speed, and educa-
ter, cerebrospinal fluid, and air. Concommitant use
tional achievement—using tests with established
of intravenous contrast demonstrates areas where the
validity and reliability. Neurologic disorders that
blood-brain barrier is disrupted. Although CT scans
have different behavioral ramifications amenable
are not ideal for examination of soft tissue, they are
to neuropsychological evaluation include traumatic
useful when seeking to detect fresh central nervous
brain injury, dementia, Parkinson’s disease, human
system (CNS) hemorrhage or bone lesions.
immunodeficiency virus, encephalopathy, multiple
sclerosis, epilepsy, neurotoxic exposure, chronic A CT myelogram uses a CT scan, after contrast
pain, and personality assessment in individuals with material is injected into the dural sac, to show altera-
neurologic disease. tions in the anatomy between the dural sac and the
structures that surround it. Since this is an invasive
Guides6e_13_321-346.indd 324 2/17/09 2:54:19 PM

technique, it may be used for diagnostic aid or Quantitative sensory tests are portable tests, easily
preoperative planning. conducted in the clinician’s office, which provide a
quantitative assessment of sensation. The integrity of
Magnetic resonance imaging uses a powerful
large myelinated fibers is monitored with vibration
magnetic field to align the protons of the tissue
threshold. Warm and cold temperature thresholds
that are excited by a radio frequency, subsequently
assess medium myelinated and unmyelinated fibers
forming an image from the different intensities of
not reflected in nerve conduction studies. Since
radio waves emitted from the different tissues. T1-
these are psychophysical tests, the cooperation of
weighted images show soft tissue anatomy, while
the individual being tested is required to process
T2-weighted images demonstrate edema and cere-
information from cutaneous receptors and provide
brospinal fluid. Contrast agents enhance lesions
the appropriate response. These tests can provide
when there is disruption in the blood-brain barrier. A
information about nerve fibers not examined by
variety of MRI techniques enhance the ability to see
nerve conduction studies.
different types of pathology.
Autonomic function assessment is performed when
Magnetic resonance angiography (MRA) allows
cardiovascular, thermoregulatory, sphincter, and/
vessel visualization with images of different intensi-
or sexual dysfunction is believed to be caused by
ties that reflect velocity and flow patterns. Basically,
dysautonomia. For example, postural hypotension
visualization of vessels reflects physical differences
tests would include measuring heart rate and blood
between moving and stationary protons.
pressure response to the Valsalva maneuver and
Positron emission tomography (PET) allows exami- heart rate response to deep breathing, postural
nation of cerebral function by tomographic images. change, and stress. The integrity of both the central
Because of the complexity, cost, and limitation of and efferent autonomic pathways is examined
isotopes with short half-lives, most studies at present with these studies. Sweating abnormalities can be
are limited to research protocols, although clinical documented by warming the individual and then
studies are available to document, in some individu- applying a powder that changes color when wet.
als, the presence of Parkinson’s disease in its early
stages. 13.1c Reaching Maximum Medical
Improvement and Issues of Patient
Single-photon emission computed tomography
Compliance
(SPECT) assesses brain perfusion by use of tracers.
Chapter 13
Impairment ratings for conditions such as migraine
Since there is a strong relationship between local
headache, epilepsy, or neurologic disorders with behav-
metabolism and blood flow, SPECT provides indi-
ioral dysfunction require special discussion. A general
rect information about metabolism. Therefore, it may
principle in the AMA Guides is that a condition is rated
show abnormalities in dementia and neurodegenera-
as “permanent” when it is not expected to change sig-
tive diseases.
nificantly over the next 12 months. However, with cer-
Nerve conduction and needle electromyography tain conditions, the clinician must also assess response
(EMG) studies help to determine which nerves are to treatment before providing an impairment rating:
involved and their anatomic location. Also evi-
• A thorough assessment includes a history of the
dent will be whether sensory, motor, or both fibers
reponse to treatment, and a determination whether
are predominantly involved and whether axonal
there has been an adequate treatment course.
degeneration, deymelination, or a combination of
both is present. Skillful differentiation of periph- • Has the treatment been sufficiently aggressive and
eral neuropathy and neuromuscular disorders may of adequate duration?
also be possible. Expert neuromuscular knowledge
• Has treatment resulted in improvement in patient
and understanding of pathologic manifestations of
function?
disease processes are necessary for the appropriate
application and performance of these tests, particu- • Have a suitable number of treatment options been
larly the EMG. These tests are mostly objective and applied?
require minimal cooperation from the individual
• Has medication compliance been assessed?
being tested. They reflect pathology in the largest,
Has the patient been cooperative with treatment
fastest-conducting nerve fibers. The interpretation of
interventions?
these tests must be correlated with a detailed neuro-
logic evaluation. • Response to treatment should be documented.
Treatment may result in only a partial remission.
Guides6e_13_321-346.indd 325 2/17/09 2:54:20 PM

One should attempt to evaluate whether residual TA B L E 13 -3

problems represent symptoms or medication side Neurologic Impairments That Are Combined
effects. Limitations which remain after optimal With the Most Severe Cerebral Impairment
treatment represents the degree of impairment. Cranial nerve impairments
• As medication side effects must be considered as Upper extremity function
part of the impairment, optimal pharmacological Lower extremity function
management includes trials of medications which Neurogenic bladder function
both minimize side effects and maximize efficacy. Neurogenic bowel function
This is of special importance to the patient with
Neurogenic sexual function
antileptic medications.
Neurogenic respiratory function
• The rating physician should seek objective evi- Peripheral nervous system disorders
dence of impairment due to intermittent impair-
Migraine headaches and craniocephalic pain
ments. Seek documentation of missed work or
school days. Examine medication records from
pharmacy to assure what medications are being
taken. Scrutinize medical and other records for
permanent alteration or an intermittent alteration in
corroboration of daytime sleepiness or seizures.
consciousness, awareness, or arousal (Tables 13-4
through 13-6).
Step 2. Evaluate mental status and highest integra-
13.2 Method for Rating tive functioning (Tables 13-7 and 13-8).
Impairments due to Nervous Step 3. Identify any difficulty with understanding
System Disorders and use of language (Table 13-9).
Step 4. Evaluate any emotional or behavioral distur-
The first step in assessing CNS impairment is to bances, such as depression, that can modify cerebral
assess the most severe category of cerebral impair- function (Table 13-10).
ment, if any, from 4 categories:
Step 5. Identify the most severe cerebral impairment
Chapter 13
1. State of consciousness and level of awareness, listed above. Combine the most severe impairment
whether permanent or episodic. from categories 1 through 4 with any or multiple
distinct neurologic impairments listed in Table 13-3
2. Mental status evaluation and integrative
using the Combined Values Chart in the Appendix.
functioning.
3. Use and understanding of language. 13.3a Disturbances in Level of
Consciousness and/or Awareness
4. Influence of behavior and mood.
Individuals experiencing disturbances in conscious-
Next, the rater assesses impairment (if any) of the ness may be suffering from a range of symptoms
cranial nerves, upper and lower extremities, bowel from episodes of altered awareness to being in a
and bladder (due to neurogenic problems), sexual persistent vegetative state or an unresponsive coma.
function, neurologic respiratory impairment, and These conditions are evaluated based on clinical
peripheral nervous system. These are then combined findings on the neurologic examination and ancil-
with the single most severe category of cerebral lary testing such as CT, MRI, SPECT, EEG, evoked
impairment, using the Combined Values Chart in the potentials, and vestibular testing. The examination
Appendix. and tests will provide the extent of the underlying
pathology and help examiners form a prognosis for
patient management.
These neurologic disturbances may result in global
13.3Criteria for Rating Cerebral loss of consciousness, responsiveness, or focal or
Impairments lateral neurologic impairments. Table 13-4 lists cri-
teria for determining permanent impairment ratings
Step 1. The initial step in assessing cerebral function in individuals with these conditions, considering the
is to determine whether disturbance is present in the severity of their condition and their ability to per-
level of consciousness or awareness. This may be a form activities of daily living.
Guides6e_13_321-346.indd 326 2/17/09 2:54:20 PM

TA B L E 13 - 4 Criteria for Rating Impairment of Consciousness and Awareness
Consciousness and Awareness

WHOLE PERSON
IMPAIRMENT
RATING (%) 0% 1%–10% 11%–30% 31%–50% 51%–100%
DESCRIPTION No alteration Brief repetitive Brief repetitive Prolonged State of semi-

in state of or persistent or persistent alteration coma with total
consciousness alteration alteration of state of dependence and
or limitation in of state of of state of consciousness, subsistence on
performance of consciousness consciousness maximal assist of nursing care and
ADLs dependent for artificial medical
and/or and
ADLs means of support
minimal moderate
or
limitation in limitation in
performance of performance irreversible coma
ADLs of ADLs requiring total
medical support
CLASS 2 language. The CT and MRI reveal profound cortical

30% Impairment of the Whole Person and subcortical damage. She is totally dependent for
all aspects of her care.
EXAMPLE 13-1: UREMIC ENCEPHALOPATHY
13.3b Episodic Neurologic Impairments
A 55-year-old man with progressive renal failure The Guides rates episodic neurologic impairments
Chapter 13
who receives renal dialysis 3 times a week has that are persistent and permanent. Episodic condi-
repeated episodes of lapses of concentration and tions involve syncope or loss of awareness, con-
alteration of awareness for the past 3 years. His vulsive disorders, and arousal and sleep disorders.
physical exam reveals disheveled appearance and Episodic indicates more than 1 occurrence. When
clear deficits on extended mental status examination. these conditions originate from a problem in the ner-
The EEG reveals poorly developed alpha activity vous system, they should be evaluated according to
with a preponderance of theta activity diffusely. the guidelines given in this chapter. For similar man-
The CT is normal. Serum urea nitrogen (BUN), ifestations that originate in other body systems (eg,
creatinine, and calcium levels are elevated. He is cardiovascular or respiratory) and secondarily affect
partially dependent on others for many aspects of his the CNS, see the chapter or chapters corresponding
basic ADL activities. to the originating body systems.
In assessing permanent impairment due to episodic
conditions, first ensure that the individual’s condition
has reached Maximum Medical Improvement (MMI)
CLASS 4
and is unlikely to change significantly. Document the
pattern of occurrence, estimate the effect of the condi-
tion on the individual’s ability to perform ADLs, and
EXAMPLE 13-2: PERSISTENT VEGETATIVE evaluate the effects of appropriate treatment. Record
STATE results from appropriate physiologic evaluations (eg,
electrocardiogram, cardiovascular evaluations, or EEG)
A 39-year-old woman suffered profound traumatic
to document the disorder’s severity and to provide
brain injury. After 2 months in a coma she
information about prognosis.
progressed to a vegetative state. Eyes are now
open, and eye movements are roving. There are Describe episodic disorders according to their onset,
no purposeful limb movements, no response to frequency, duration, and effect on performance of
environmental stimuli, and no comprehension of daily activities. Document and describe the results
Guides6e_13_321-346.indd 327 2/17/09 2:54:21 PM

of seizure control. Daytime loss of consciousness The criteria for evaluating episodic loss of con-
with tonic or clonic seizures, nocturnal episodes with sciousness or awareness are given in Table 13-5.
daytime residua, or brief lapses of awareness or com-
munication from minor seizures may interfere sig-
nificantly with daily activities. Minor seizures with
alterations of awareness or consciousness, transient CLASS 1
manifestations of unconventional behavior, or inter- 10% Impairment of the Whole Person
ruptions of daytime activity can result in an inability
to perform ADLs. Impairment ratings for major or
EXAMPLE 13-3: PARTIAL EPILEPSY
minor seizures are calculated on the basis of how
they affect the ability to perform ADLs. A 20-year-old woman had onset of generalized tonic-
clonic convulsions in middle school. She has sensa-
The same criteria apply to impairments related to
tions in the right hand progressing to generalized
transient loss of awareness or consciousness (syn-
tonic-clonic convulsions and a brief postictal period
cope or dizziness) after a period of cerebral ischemia
lasting 2 to 3 hours. An EEG showed rare spikes in
that may be due to various mechanisms, including
the left temporal area, and MRI was normal. Despite
orthostasis, reflex actions, or cardiopulmonary dis-
optimal antileptic therapy she continues to have 1 to
orders. Examiners may need to refer to other Guides
2 minor brief focal right-hand sensations and inter-
chapters to estimate the magnitude of impairments
ruption of speech approximately every 2 months. She
related to cardiovascular disorders.
is unable to drive because of the persistent seizures.
TA B L E 13 - 5 Criteria for Rating Impairment due to Episodic Loss of Consciousness or Awareness
Episodic Loss of Consciousness or Awareness

Chapter 13
WHOLE PERSON
IMPAIRMENT
RATING (%) 0% 1%–10% 11%–20% 21%–35% 36%–50%
DESCRIPTION No alteration Paroxysmal Paroxysmal dis- Severe paroxys- Uncontrolled

in state of disorder with order that inter- mal disorder of paroxysmal dis-
consciousness predictable feres with some such frequency order of such
or limitation in characteristics daily activities that it limits severity and
performance of activities to those constancy that it
and or
ADLs that are super- severely limits the
unpredictable moderate blood vised, protected, individual’s daily
occurrence that pressure drop or restricted activities
does not limit of 25/15 mm Hg,
or or
usual activities with loss of
but is a risk to the awareness or repeated severe repeated severe
individual (eg, consciousness blood pressure blood pressure
cannot drive) lasting 1 to losses of 30/20 losses of 30/20
2 minutes and mm Hg, with loss mm Hg, with
or
that interferes of awareness or uncontrolled loss
blood pressure with some daily consciousness of consciousness
drop of 15/10 activities lasting 1 to 2 and muscle
mm Hg without minutes control without
compensatory recognized cause
and
increase in pulse and with risk of
rate and lasting additional neuro- body injury
more than 2 min- logic symptoms
utes after precipi- or signs of focal
tating event, with or generalized
mild awareness nature
loss that limits
daily activities
Guides6e_13_321-346.indd 328 2/17/09 2:54:21 PM

CLASS 3 Neurologic disorders associated with increased day-

35% Impairment of the Whole Person time sleepiness include central sleep apnea syndrome,
narcolepsy, idiopathic hypersomnia, periodic limb
movement disorder, restless leg syndrome, depression,
EXAMPLE 13- 4: PARTIAL EPILEPSY
brain tumors, posttraumatic hypersomnolence, mul-
A 45-year-old police officer was shot in the left fron- tiple sclerosis, encephalitis and postencephalopathy,
tal area and recovered without neurologic paresis Alzheimer’s disease, Parkinson’s disease, multiple
but experienced persistent seizures. Despite optimal system atrophy, and neuromuscular disorders with
medical management, the minor complex seizures sleep apnea. It is expected that the diagnosis of exces-
of the right hand and leg continue to almost continu- sive daytime sleepiness has been supported by formal
ous seizures with loss of consciousness. Other than studies in a sleep laboratory. The Epworth Sleepiness
his inability to drive, ADLs are intact. The MRI Scale is an example of a scale that assesses the likeli-
revealed contusion of the left frontotemporal area, hood of dozing in different situations.4 Sleep problems
and EEG showed slowing in the same area with associated with pain or orthopedic injury are not to be
frequent polyspike waves. He is completely disabled rated in this section.
from gainful employment due to the seizures.
See Table 13-6 for impairment due to sleep and
arousal disorders.
13.3c Arousal and Sleep Disorders
Arousal and sleep disorders include disorders related
to initiating and maintaining sleep or inability to
sleep; excessive somnolence, including sleep-induced
CLASS 1
respiratory impairment; and sleep-wake schedules.
Impairment categories that may arise from sleep
disorders relate to (1) the nervous system, with
EXAMPLE 13-5: CENTRAL SLEEP APNEA
reduced daytime attention, concentration, and other
cognitive abilities; (2) mental and behavioral factors, A 47-year-old man has increased daytime sleepiness.
including depression, irritability, interpersonal dif- He has reduced daytime alertness. He is able to
ficulties, and social problems; (3) the cardiovascular complete necessary work, but works less efficiently.
system, with systemic and pulmonary hyperten- Physical exam and CT were normal. Sleep labora-
Chapter 13
sion, cardiac enlargement, congestive heart failure, tory study revealed central sleep apnea. His daytime
or arrhythmias; and (4) the hematopoietic system. sleepiness persists despite optimal management, but
The Pulmonary System, Chapter 5, also discusses does not interfere with his activities of daily living.
impairment as it relates to obstructive sleep apnea.
TA B L E 13 - 6 Criteria for Rating Impairment due to Sleep and Arousal Disorders
Sleep and Arousal Disorders

WHOLE PERSON
IMPAIRMENT
RATING (%) 0% 1%–5% 6%–10% 11%–30% 31%–50%
DESCRIPTION Normal daytime Reduced daytime Reduced daytime Reduced daytime Severe reduction
alertness; no alertness; sleep alertness; inter- alertness; moder- of daytime alert-
impairment of pattern such that feres with ability ate impairment ness; individual
ADLs individual can to perform ADLs in ADLs unable to care for
perform ADLs (eg, cannot drive) self in any situa-
tion or manner
Guides6e_13_321-346.indd 329 3/3/09 6:38:44 PM

CLASS 2 TA B L E 13 -7
10% Impairment of the Whole Person Mental Status Exam for the Neurologically
Impaired Patient
1. Level of consciousness
EXAMPLE 13-6: NARCOLEPSY
2. Attention
A 37-year-old woman suffered 2 workplace
3. Memory
demotions because of declining work performance
4. Intellectual function
and poor memory. She complains of morning
headaches and excessive daytime somnolence. 5. Language function
She has multiple daily irresistable urges to nap. If 6. Psychosensory function
this occurs while driving, she has to pull off the 7. Psychomotor function
road. She was advised to stop driving. Naps last 8. Constructional ability
10 to 15 minutes, after which she feels refreshed.
9. Higher cognitive function
Physical exam and MRI of the brain were normal.
10. Thought content
Sleep laboratory study findings were consistent
with narcolepsy. Her symptoms persist despite best 11. Behavioral observations
medical management. 12. Mood and general emotional status
13. Emotional reactions
13.3d Mental Status, Cognition, and
Highest Integrative Function
Mental status and integrative function deficits
include the general effects of organic brain syn- 13-8). This information can be obtained from
drome; dementia; and some specific, focal, and someone who has close and continual contact with
neurologic deficiencies. Mental status tests are used the individual.
to screen and follow up individuals, frequently with
Special mention should be made of mild traumatic
repeated testing. They usually cover measures of
brain injury (MTBI), which has been the subject
orientation, attention, immediate recall, calculations,
of extensive research in the last ten to twenty
abstraction, construction, information, and recall.
years. In contrast to previously held belief, the
Diagnosis should be based on a detailed mental
symptoms of mild traumatic brain injury generally
status examination, often in concert with neuropsy-
Chapter 13
resolves in days to weeks, and leave the patient

chological assessment and testing.5 The mental status
with no impairment.6,7
exam for the neurologically impaired patient is out-
lined in Table 13-7. Patients with persistent postconcussive symptoms
generally have noninjury related factors which
Neuropsychological test battery covers many func-
complicate their clinical course. Postconcussive syn-
tional domains—attention, language, memory,
drome is a relatively rare sequelae of MTBI, seen in
visuospatial skills, executive function, intelligence,
1-5% of all MTBI patients.
motor speed, and educational achievement—using
tests with established validity and reliability.
Individuals with severe cognitive impairments
that have been identified on mental status tests
CLASS 0
will usually not benefit from neuropsychological
evaluation. Neuropsychological testing may offer
the most insight into the patient with more subtle
cognitive deficits. Neurologic disorders that have EXAMPLE 13-7: MILD TRAUMATIC BRAIN INJURY
different behavioral ramifications amenable to
A 62-year old man slips on an icy pavement, fall-
neuropsychological evaluation include traumatic
ing forward and strking his head anteriorly. He has
brain injury, dementia, Parkinson’s disease, human
a brief seizure, was unresponsive for approximately
immunodeficiency virus, encephalopathy, multiple
30 seconds. He awakened with severe headache and
sclerosis, epilepsy, neurotoxic exposure, chronic
nausea. He was brought to an emergency room by
pain, and personality assessment in individuals with
ambulance. Upon arrival in the emergency room
neurologic disease.
he had a normal neurological exam, a brief period
The criteria for evaluating mental status and cogni- of retrograde amnesia, and a scalp contusion.
tive impairment are based on the amount of inter- Computerized tomography of the head was normal.
ference with the ability to perform ADLs (Table His headache and nausea abated over the next week.
Guides6e_13_321-346.indd 330 2/17/09 2:54:23 PM

TA B L E 13 - 8 Criteria for Rating Neurologic Impairment due to Alteration in Mental Status,

Cognition, and Highest Integrative Function (MSCHIF)
Alteration in MSCHIF
WHOLE PERSON
IMPAIRMENT RATING (%) 0% 1%–10% 11%–20% 21%–35% 36%–50%
EXTENDED MENTAL Normal Mild Moderate Severe Most profound

STATUS EXAM abnormalities abnormalities abnormalities abnormalities
NEUROPSYCHOLOGICAL Normal Mild Moderate Severe Most profound

ASSESSMENT AND abnormalities abnormalities abnormalities abnormalities
TESTING a
DESCRIPTION Normal Alteration in Alteration in Alteration in Alteration in

MSCHIF MSCHIF but MSCHIF that MSCHIF that MSCHIF that
patient is able interferes with significantly prohibits per-
to assume all ability to assume interferes formance of
usual roles and some normal roles with ability to normal roles or
perform ADLs or perform ADLs assume normal performance of
roles or per- ADLs
form ADLs
a
Neuropsychological testing may not always be required but may serve as a useful resource.
CLASS 3
pantomime. Dysphasia is a language impairment that
is less severe than aphasia (which literally means “no
Chapter 13
speech”) but still is associated with a lesion in the
EXAMPLE 13-8: TRAUMATIC BRAIN INJURY dominant parietal lobe. It presents as a communica-
tion problem due to receptive or expressive dysphasia
A 25-year-old man had a head-on collision and was
or a combination of the two. Inability to have a mean-
brought to the hospital unconscious. He had 4 weeks
ingful conversation because no nouns are used is an
of posttraumatic amnesia. One year later he has
example of dysphasia. Other common errors include
moderate inability to follow commands and find his
errors of grammatical structure, word-finding diffi-
room. He is disoriented to time, person, and place. He
culties, and word substitution. Dysphasia and aphasia
wanders alone and gets lost in familiar surroundings.
are different from dysarthria, which is imperfect artic-
He has loss of interest in home activities and current
ulation of speech due to disordered muscle control.
events. He has severe learning problems, impulsivity,
Dysphonia is an impairment of sound production that
and social disinhibition. There is no focal or lateral
causes difficulty speaking and understanding.
paralysis. Attention and gait are slow. He participates
with some basic ADLs but needs direction for all and Dysphasia is the most common communication
is dependent for all advanced ADLs. impairment diagnosis, since most individuals usually
retain some ability to communicate. An inability to
13.3e Communication Impairments: understand language has a poorer prognosis than an
Dysphasia and Aphasia inability to express language. Speech therapy is of
Communication involves comprehension, understand- little value in the absence of comprehension; there-
ing, language, and effective interaction between and fore, compensatory techniques may not be learned
among individuals. Aphasia is a condition in which when a receptive aphasia or dysphasia exists. Tests
language function is defective or absent. It includes a for dysphasia should be conducted after it is estab-
lack of comprehension with deficits in vision, hear- lished how confused or disoriented the individual is
ing, and language (both spoken and written) and also and which side of the brain is dominant for speech.
the inability to implement discernible and appropriate Cognition should also be evaluated after dysphasia
language symbols by voice, action, writing, or mechanisms have been excluded.
Guides6e_13_321-346.indd 331 3/3/09 6:38:47 PM

Aphasia and dysphasia test batteries are frequently herself in conversations. She is unable to name
devised by the clinician and cover the following objects on sight but can point to an object when seen
simple tasks: (1) listening to spontaneous speech on a printed card. She is able to read and compre-
or responses to simple questions; (2) pointing com- hend language. She has a mild periodic dysnomia in
mands and questions that can be answered “yes” trying to name objects.
or “no” to test comprehension; (3) repeating words
and phrases; (4) naming objects that have high- and
low-frequency use; (5) reading comprehension and
reading aloud (reading is related to educational CLASS 3
achievement, which must be known before inter- 35% Impairment of the Whole Person
preting reading comprehension and reading aloud
results); and (6) writing and spelling.5
EXAMPLE 13-10: APHASIA
If comprehension is relatively intact, the aphasia
A 45-year-old left-handed man was struck from the
screening battery may be adequate to place an
right side as a passenger in the front seat of a vehicle.
individual in class 1 or 2. However, individuals
He was not wearing a seat belt, and his head hit the
with dysphasia may score poorly on aphasia and
windshield and mirror. Although there was no loss
dysphasia test batteries while they demonstrate com-
of consciousness, a contusion was noted over the left
municative competency for ADLs. This communica-
parietal area on CT. He does not comprehend simple
tive competency may be measured by means of the
commands, cannot work, and needs distant supervi-
Communicative Abilities in Daily Living, in which
sion in the home. He can name objects from sight
nonverbal communication is assessed.8 Table 13-9
but has difficulty understanding verbal and written
describes the criteria for rating impairment due to
commands.
aphasia or dysphasia.
13.3f Emotional or Behavioral
Impairments
Emotional, mood, and behavioral disturbances illus-
CLASS 1
trate the relationship between neurologic disorders
and mental and behavioral disorders. Emotional
disturbances originating in verifiable neurologic
Chapter 13
EXAMPLE 13-9: DYSPHASIA impairments (eg, stroke or head injury) are assessed
using the criteria in this chapter. Psychiatric features
A 45-year-old right-handed woman suffered head
may also exist with primary neurologic disorders.
trauma that resulted in periodic difficulty expressing
Psychiatric features can range from irritability to
TA B L E 13 -9 Criteria for Rating Impairment due to Aphasia or Dysphasia
Aphasia or Dysphasia
WHOLE PERSON
DESCRIPTION Normal Minimal Moderate Severe Total inability

mental status disturbance in impairment in inability in to communicate
comprehension comprehension comprehen- or comprehend
and production and production of sion and language symbols
of language language symbols production
symbols for for daily living of language
daily living symbols for
daily living
Guides6e_13_321-346.indd 332 3/3/09 6:38:47 PM

outbursts of rage or panic and from aggression to EXAMPLE 13-12: 50% IMPAIRMENT DUE TO
withdrawal. Neurologic impairments producing psy- EMOTIONAL OR BEHAVIORAL IMPAIRMENTS
chiatric conditions are assessed using the neurologic
A 25-year-old right-handed man suffered severe
examination, with an expanded neuropsychiatric
frontal lobe damage due to a traumatic brain injury.
history and the necessary ancillary tests. Psychiatric
He recovered to a point at which he has signs of
impairments may include depression, manic states,
frontal lobe release and upgoing plantar responses
emotional fluctuations, socially unacceptable behav-
bilaterally, but no clinically notable paresis or
ior, involuntary laughing or crying, impulsivity,
sensory disorders. He has marked dementia and
general disinhibition with obsessive and scatological
severely violent behavior, in which he is a constant
behaviors, and other kinds of CNS responses. Just
physical threat to himself and others despite optimal
as in the chapter on impairment due to mental and
psychopharmacological management. He requires
behavioral disorders (Chapter 14), the rater should
institutionalization due to his constant violent behav-
carefully assess 4 main parameters, including in
ior. He scores a 1 to 10 on the Global Assesment of
patients with organic emotional and behavioral dis-
Functioning.
orders: (1) ability to perform ADLs; (2) social func-
tioning; (3) concentration; and (4) decompensation in
formal settings. The reader should refer to Chapter
14, Mental and Behavioral Disorders, for additional
background information.
13.4 Criteria for Rating
Impairment due to Spinal Cord
Psychiatric manifestations and impairments that do
not have documented neurologic impairments are Dysfunction and Movement
evaluated using the criteria in Chapter 14. Disorders
Examples of neurologic conditions that are associ-
ated with changes in emotion and affect include the 13.4a Spinal Cord Disorders
following: (1) right hemisphere infarct and inap- The spinal cord conveys nerve impulses for motor,
propriate jocularity; (2) left hemisphere infarct and sensory, and visceral functions. Disorders of impulse
deep dejection and dysphasia; (3) left-sided tempo- transmission can result in permanent impairment.
rolimbic seizure foci and ideational disorders; and The magnitude of the impairment is estimated
(4) right-sided temporolimbic seizure foci and mood according to the effects on the ability to perform
Chapter 13
disturbances. Use Table 13-10 to determine impair- ADLs and the results of neurologic examination
ments of emotional or behavioral disturbances due to and testing.
neurologic disorders.
Impairments resulting from spinal cord injuries and
other adverse conditions include those relating to
station and gait, use of the upper extremities, respira-
tion, urinary bladder function, anorectal function,
EMOTIONAL OR BEHAVIORAL IMPAIRMENTS
sexual function, and pain.
A 60-year-old right-handed former boxer has
Sensory disturbances, including the loss of sense
been frequently knocked out for brief periods. He
of touch, sense of pain, temperature perception,
has episodes of mild confusion and occasional
and sense of vibration and joint position, as well
unsteadiness of gait, with difficulty in speech and
as paresthesias, dysesthesias, and phantom limb
articulation. He has mild head tremor. Physical
sensations, may indicate spinal cord dysfunction.
exam reveals no paresis or sensory defect, but he
Autonomic system disorders, including disturbances
has difficulty with higher cortical functions on
in sweating patterns, regulation of circulation, and
mental status exam testing. He has difficulty with
regulation of temperature, may occur. Impairment
inappropriate jocularity and interpersonal rela-
is determined according to the amount of functional
tionships, which are distinctly different than his
impairment and the level of involvement.
personality and behavior when he was younger.
He has moderate symptoms in social and occu- When an individual with a spinal cord injury has
pational settings. He would score a 51 to 60 on impairments of several functions or systems (eg,
the Global Assessment of Functioning (see Table upper extremities, lower extremities, and of bladder,
13-10). bowel, sexual functioning, or respiratory system
Guides6e_13_321-346.indd 333 2/17/09 2:54:24 PM

TA B L E 13 -1 0
Global Assessment of Functioning (GAF) Impairment Score
GAF Description GAF
Impairment
Score
91–100 Superior functioning in a wide range of activities; life’s problems never seem to get out of hand; 0%
is sought out by others because of his or her many positive qualities. No symptoms.
81–90 Absent or minimal symptoms (eg, mild anxiety before an exam), good functioning in all areas, 0%
interested and involved in a wide range of activities, socially effective, generally satisfied with life, no
more than everyday problems or concerns (eg, an occasional argument with family members)
71–80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors 0%
(eg, difficulty concentrating after family argument); no more than slight impairment in social,
occupational, or school functioning (eg, temporarily falling behind in school work)
61–70 Some mild symptoms (eg, depressed mood and mild insomnia) 5%
or
some difficulty in social, occupational, or school functioning (eg, occasional truancy, or theft
within the household) but generally functioning pretty well, has some meaningful interpersonal
relationships
51–60 Moderate symptoms (eg, flat affect and circumstantial speech, occasional panic attacks) 10%
or
moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts with
coworkers)
41–50 Serious symptoms (eg, suicidal ideation, severe obsessional rituals, frequent shoplifting) 15%
or
any serious impairment in social, occupational, or school functioning (eg, no friends, unable to
keep a job)
31–40 Some impairment in reality testing or communication (eg, speech is at times illogical, obscure, or 20%
irrelevant)
or
major impairment in several areas, such as work or school, family relations, judgment, thinking,
or mood (eg, depressed man avoids friends, neglects family, and is unable to work; child fre-
Chapter 13
quently beats up younger children, is defiant at home and is failing at school)

21–30 Behavior is considerably influenced by delusions or hallucinations 30%
or
serious impairment in communication or judgment (eg, sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation)
or
inability to function in almost all areas (eg, stays in bed all day; no job, home, or friends)
11–20 Some danger of hurting self or others (eg, suicide attempts without clear expectation of death, 40%
frequently violent, manic excitement)
or
occasionally fails to maintain minimal personal hygiene (eg, smears feces)
or
gross impairment in communication (eg, largely incoherent or mute)
1–10 Persistent danger of severely hurting self or others (eg, recurrent violence) 50%
or
persistent inability to maintain minimal personal hygiene
or
serious suicidal act with clear expectation of death
Guides6e_13_321-346.indd 334 2/17/09 2:54:25 PM

neurologic impairments), the Combined Values 13.5 Criteria for Rating

Chart in the Appendix should be used to combine Impairments of Upper
the whole person impairment estimates for the
several functions. The clinician should use Tables Extremities due to CNS
13-11 through 13-16. In this edition of the Guides, Dysfunction
dyesthetic pain due to spinal cord impairment can be
rated using Table 13-17. The basic tasks of everyday living depend on dexter-
ous use of the dominant upper extremity. Loss of use
Accompanying disorders, such as trophic lesions,
of that extremity results, in most instances, in greater
urinary calculi, osteoporosis, nutritional distur-
impairment than would be the case with impairment
bances, infections, and reactive psychological states,
of the limb on the nondominant side. Table 13-11
may occur. The degree to which any of these condi-
is used to rate upper extremity dysfunction from
tions augments spinal cord impairment should be
any lesion in the brain or spinal cord. Use this table
based on the criteria given in the Guides chapters
for rating upper extremity dysfunction (manifested
dealing with those disorders.
by weakness, tremor, or pain) that affects ADLs.
The upper extremity impairment may result from,
13.4b Movement Disorders
but is not limited to, traumatic brain injury, stroke,
Movement disturbances resulting from cerebral
neurodegenerative diseases (eg, Parkinson’s disease,
dysfunction are impairments that may affect ADLs.
progressive supranuclear palsy), multiple sclerosis,
Mild tics may have no impact on ADLs, while other
spinal cord injury, and sequelae of CNS infection.
involuntary movements, such as tremors (resting,
postural, and intention), chorea, athetosis, hemibal- When the spinal cord disorder affects both upper
lismus, and dystonia tone may prevent meaningful extremities, combine the ratings for the dominant
use of the extremity. Besides abnormal movements, and nondominant upper extremity.
difficulty with coordination for either dexterous or
The impairment ratings given in Table 13-11 are
precise movements may interfere with activity; these
determined from neurologic examination of motor
difficulties can develop from lesions in the basal
strength, coordination, and dexterity. Functional
ganglia or cerebellum. Coordinated movements
activities such as buttoning a shirt, lacing shoes,
include gait that may manifest as ataxia requiring
writing, and performing a pegboard task can assess
use of an ancillary device. Movement disorders,
abilities needed for daily activities. Ratings are listed
Chapter 13
therefore, are assessed for their interference with
for the nondominant and dominant limb.
ADLs as described in Tables 13-11 and 13-12 for the
upper and lower extremities.
TA B L E 13 -11 Criteria for Rating Impairments of the Upper Extremities due to CNS Dysfunction
Upper Extremity CNS Dysfunction

WHOLE PERSON 1%–5% 6%–15% 16%–30% 31%–50%

IMPAIRMENT RATING (%) Nondominant Nondominant Nondominant Nondominant
1%–10% 11%–20% 21%–40% 41%–60%
0% Dominant Dominant Dominant Dominant
DESCRIPTION Patient has no Individual can Individual can Individual Individual cannot
impairment use the involved use the involved can use the use the involved
of upper extremity for extremity for involved extremity for
extremity ADLs and hold- ADLs, can grasp extremity ADLs
function ing but has and hold objects only as a gross
difficulty with with difficulty, assist in ADLs
digital dexterity but has no digital
dexterity
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TA B L E 13 -12 Criteria for Rating Impairments due to Station and Gait Disorders
Station and Gait Disorders

WHOLE PERSON
DESCRIPTION No disorder Rises to stand- Rises to standing Rises and Cannot stand
of gait or ing position; position; walks maintains without help,
station walks but has some distance standing posi- mechanical sup-
difficulty with with difficulty tion with dif- port, and/or an
elevations, and without ficulty; cannot assistive device
grades, stairs, assistance, but is walk without
deep chairs, limited to level assistance
and/or long surfaces
distances
13.6Criteria for Rating 13.7 Criteria for Rating

Impairments of Station, Gait, Neurogenic Bowel, Bladder,
and Movement Disorders and Sexual Dysfunction
Problems maintaining balance and a stable gait can
13.7a Neurogenic Bowel
develop from a CNS or peripheral neurologic impair-
The ability to control emptying provides the criterion
ment. On physical examination, the physician may
for evaluating permanent impairment of the anus
observe loss of equal arm or leg movement, falling
and rectum due to spinal cord or other neurologic
or staggering to one or the other side, inability to
dysfunction (Table 13-13).
Chapter 13
control starting or stopping, and arrhythmic body or

extremity movements. Increased tone in the lower
13.7b Neurogenic Bladder
extremities from a CNS lesion such as traumatic
The ability to control bladder emptying provides the
brain injury, stroke, spinal cord injury, or multiple
criterion for evaluating permanent bladder impair-
sclerosis may result in a spastic paraparesis or spas-
ment resulting from spinal cord and CNS disorders
ticity in 1 limb. Loss of station or Romberg sign
(Table 13-14). Documentation by cystometric or
(falling with eyes closed) may indicate dysfunction
other tests may be necessary. When evaluating
in the peripheral nerves or their ascending pathways
impairments of the bladder, the physician also must
to the brain. Peripheral neuropathy, identified by
consider the status of the upper urinary tract. Refer
physical examination and electrodiagnostic tests, is
to Chapter 7, the Urinary and Reproductive Systems,
frequently associated with complaints of imbalance
and apply the Combined Values Chart in the
or stumbling, since information from sensory recep-
Appendix if impairments of several organ systems
tors is altered.
are present.
Impairment ratings for station and gait disorders
are determined according to the effect on ambula- 13.7c Neurogenic Sexual Dysfunction
tion (see Table 13-12). Other anatomic or functional Awareness and capability of having an orgasm are
changes from other body systems, such as the mus- the criteria for evaluating permanent impairment
culoskeletal system, are combined with the neuro- of sexual functioning that may result from spinal
logic assessment for station and gait. cord or other neurologic system disorders (Table
13-15). The individual’s previous sexual functioning
should be considered by the physician; age is only 1
criterion for evaluating previous sexual functioning.
Adjust for age according to the criteria outlined in
Chapter 7, The Urinary and Reproductive Systems.
Guides6e_13_321-346.indd 336 2/17/09 2:54:26 PM

TA B L E 13 -13 Criteria for Rating the Neurogenic Bowel
Neurogenic Bowel
WHOLE PERSON
DESCRIPTION Fully conti- Continent with Incontinent about Incontinent Totally

nent with- bowel program once a week about once a incontinent
out special despite optimal day despite
program bowel program optimal bowel
program
anterior and posterior fixation of the fracture. He

13.8Criteria for Rating has no sensation below the C4 dermatome, has no
Neurogenic Respiratory movement in his upper and lower extremities, and
Dysfunction has been weaned from a ventilator. He still has a
tracheostomy in place for intermittent suctioning. He
does not suffer from dysesthetic pain.
Neurologic impairment of one’s ability to breathe is
considered in Table 13-16 only in terms of neurologic Step 1. He has complete paralysis of both upper
limitations. Other aspects of respiratory function are extremities. If one uses Table 13-11 to rate impair-
covered in Chapter 5, The Pulmonary System. ment, he would have a 50% impairment due to non-
dominant limb function, and 60% impairment due to
dominant limb function.
Step 2. He has complete paralysis of both lower
CLASS 5
extremities. Using Table 13-12, one finds that he
has a 50% impairment due to complete loss of gait
Chapter 13
function.
EXAMPLE 13-13: IMPAIRMENT SECONDARY TO
Step 3. He is occasionally incontinent with his
COMPLETE C4 TETRAPLEGIA
bowel management program. With use of Table
A 23-year-old left-handed man suffered a C4 frac- 13-13, he has a 10% impairment due to occasional
ture dislocation resulting in C4 complete tetraple- incontinence.
gia. He underwent acute surgical stabilization with
TA B L E 13 -14 Criteria for Rating the Neurogenic Bladder
Neurogenic Bladder
WHOLE PERSON
DESCRIPTION Fully conti- Less than nor- Requires indwell- Incontinent Total
nent without mal voluntary ing or external about once a incontinence
catheter control but no catheter to main- day despite
or external incontinence tain continence optimal
device with bladder bladder
management management
program
Guides6e_13_321-346.indd 337 3/3/09 6:38:48 PM

TA B L E 13 -15 Criteria for Rating Neurogenic Sexual Dysfunction
Neurogenic Sexual Dysfunction

WHOLE PERSON
IMPAIRMENT RATING (%) 0% 1%–5% 6%–10% 11%–15%
DESCRIPTION No impair- Individual has some sexual Reflex sexual func- No sexual function
ment of sexual function but with difficulty tioning is possible,
function of erection or ejaculation in but there is no
men or lack of awareness, awareness
excitement, or lubrication in
either sex
Step 4. He is managed on an intermittent catheter- impairment is 97% impairment of the whole person
ization program 4 times per day, with frequent leak- for C4 complete quadriplegia.
age requiring an external catheter in between. With
use of Table 13-14, he has a 15% impairment due to
neurogenic bladder.
CLASS 4
Step 5. Reflex sexual functioning is possible, but
he has no awareness. With the use of Table 13-15,
there is a 10% impairment due to neurogenic sexual
dysfunction. EXAMPLE 13-14: IMPAIRMENT SECONDARY TO
T10 COMPLETE PARAPLEGIA
Step 6. He requires a tracheostomy for frequent
suctioning. Use of Table 13-16 results in a 50% A 55-year-old right-handed man suffered T10
impairment. complete paraplegia after an abdominal aneurysm
Chapter 13
repair. He has no sensation below the T10

Step 7. Combine the impairments (50%, 60%, 50%,
dermatome and has no movement in the lower
10%, 15%, 10%, and 50%) using the Combined
extremities, which are spastic.
Values Chart in the Appendix. The resulting
TA B L E 13 -16 Criteria for Rating Neurogenic Respiratory Dysfunction
Neurogenic Respiratory Dysfunction

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4 CLASS 5
WHOLE
PERSON
IMPAIRMENT
RATING (%) 0% 1%–5% 6%–20% 21%–35% 36%–50% 51%–65%
DESCRIPTION No neurologic Individual can Individual is Individual is Tracheostomy Individual has

impairment breath sponta- capable of capable of no capacity for
of respiration neously but has spontaneous only spontaneous
difficulty per- respiration but is sedentary respiration,
forming ADLs restricted to any activities is ventilator
that require exertional activ- dependent
intensive effort ity such as hill
such as running climbing or pro-
longed exertion
Guides6e_13_321-346.indd 338 3/3/09 6:38:49 PM

Step 1. He has normal function in the upper extremi- 13.9 Criteria for Rating Peripheral
ties. If one uses Table 13-11, he would have a 0% Neuropathy, Neuromuscular
impairment.
Junction Disorders, and
Step 2. He has complete paralysis of both lower
extremities. Using Table 13-12, one finds that he
Myopathies
has a 50% impairment due to complete loss of gait
Evaluating the peripheral nervous system requires
function.
documentation of the extent of loss of function due
Step 3. He is continent with his bowel manage- to sensory deficit, pain, or discomfort; loss of mus-
ment program. With use of Table 13-13, he has a 5% cular strength and control of specific muscles or
impairment due to occasional incontinence. groups of muscles; and alteration of autonomic ner-
vous system (ANS) control. Documentation of these
Step 4. He is managed on an intermittent catheter-
deficiencies should include, if possible, descriptions
ization program 4 times per day without leakage in
of the abnormal finding on examinations of the
between. When one uses Table 13-14, he has a 5%
spinal root or roots, portion of the plexus, and/or
impairment due to neurogenic bladder.
peripheral nerve or nerves that are involved. The
Step 5. He has some sexual functioning, but diffi- mechanism or cause of the abnormality assists in
culties with both erection and ejaculation. Erection determining the impairment duration and probable
is improved with medication. With the use of Table prognosis. Ancillary testing by neuroimaging (CT,
13-15, there is a 5% impairment due to neurogenic MRI, and radiography) and physiologic tests (EMG,
sexual dysfunction. nerve conduction studies, and evoked responses) may
assist in reaching final conclusions.
Step 6. He has no impairment of neurogenic respi-
ratory function. Use of Table 13-16 results in a 0% Neurologic evaluation of pain is based first on the
impairment. individual’s description of the character, location,
intensity, duration, and persistence of the discomfort
Step 7. Combine the impairments (0%, 50%, 5%,
and on verification of the anatomic distribution of
5%, 5%, and 0%) using the Combined Values Chart
the neurologic defect. A description of the ways and
in the Appendix. The resulting impairment is 57%
the degrees to which the pain interferes with the
impairment of the whole person for T10 complete
individual’s performance of ADLs and the factors
quadriplegia.
Chapter 13
that augment the discomfort should be included.
Step 8. If the patient suffers from dysesthetic pain, Anatomic descriptions should be made according
use Table 13-17 as described below, and combine to the usual distributions of the roots, plexuses, and
with the Combined Values Chart. nerves of the nervous system when the distal digital
nerves are being evaluated, especially in the hand, as
indicated in the upper and lower extremities chapters
(Chapters 15 and 16).
TA B L E 13 -17 Dysesthetic Pain Secondary to Peripheral Neuropathy or Spinal Cord Injury
Dysesthetic Pain
Document that individual has a peripheral neuropathy or spinal cord injury consistent with dysesthetic pain
WHOLE PERSON
IMPAIRMENT RATING (%) 0% 1%–3% 4%–7% 8%–10%
DESCRIPTION No dysesthetic Mild dysesthetic Moderate dyses- Severe dysesthetic pain

pain pain thetic pain
Guides6e_13_321-346.indd 339 2/17/09 2:54:28 PM

Grading procedures for sensory and motor impair- lower extremities earlier and to a greater extent.
ments in single distal digital nerves of the hand are Impairment due to motor weakness is rated by the
found in Chapter 15, The Upper Extremities. For impact on ADLs,10,11 identical to the patient with
evaluations of neurologic problems of the peripheral spinal cord disorders.
neuromuscular system, the standard techniques of
Function of the ANS may result in difficulties with
neurologic examination are used. Muscle strength
orthostasis, as well as gastrointestinal, urologi-
grading varies from 0 to 5, consistent with the
cal, and sexual urological function. Difficulties
Medical Research Council of the United Kingdom.9
with orthostasis may be rated using Table 13-5.
The contralateral extremity is tested also, and the
Disorders of digestive dysfunction (eg, gastropa-
results are compared with those in the affected limb.
resis) should be rated in Chapter 6, The Digestive
Symptoms of sensory deficits and pain in peripheral System. Urological, anorectal, and sexual dysfunc-
nerves include anesthesia, hypesthesia, dysesthesia, tion due to peripheral neuropathy may be rated
paresthesia, hyperesthesia, cold intolerance, and an using Table 13-15.
intense burning pain. Sensory dysfunction associ-
Many peripheral neuropathies will present with sen-
ated with peripheral nerve disorders is evaluated
sory but little or no evidence of motor or autonomic
according to the following criteria: (1) How does the
dysfunction. Painless sensory neuropathy, generally
pain or sensory deficit interfere with the individual’s
involving the lower extremities to a greater extent
performance of daily activities? (2) To what extent
than the upper extremities, is assessed according
does the pain or sensory deficit follow the defined
to its effect on ADLs. Tables 13-11 and 13-12 are
anatomic pathways of the root, plexus, or peripheral
used for this purpose. Associated complications of
nerve? (3) To what extent does the description of the
peripheral neuropathy (eg, trophic ulcers and neuro-
pain or sensory deficit indicate that it is caused by
genic arthropathy, or Charcot’s joint) are rated in the
a peripheral nerve abnormality? (4) To what extent
extremity chapters.
does the pain or sensory deficit correspond to other
disturbances of the involved nerve structure? Only Although not a frequent problem in impairment rat-
persistent pain or discomfort that leads to permanent ing using the Guides, impairment due to painful
loss of function, despite maximum effort toward peripheral neuropathy can be rated in this edition of
medical rehabilitation and allowing an optimal the AMA Guides using Table 13-17.
period for physiologic adjustment, should be evalu-
Chapter 13
ated as a permanent impairment. Pain that does not

meet more than 1 of these criteria is not considered EXAMPLE 13-15: 16% IMPAIRMENT DUE
to be within the scope of this section. TO PAINFUL SENSORIMOTOR PERIPHERAL
NEUROPATHY
Sensory dysfunction, to be rated, must be con-
sidered permanent. The methods used for spinal A 55-year-old woman has a 45-year history of juve-
nerves, brachial or lumbosacral plexus, and indi- nile-onset diabetes mellitus. Over the last 10 years
vidual nerves are described in the extremity chap- she has experienced increasing symptoms and signs
ters (Chapters 15 and 16). Terms used to describe of peripheral neuropathy in the lower but not the
sensory impairment that may not be readily upper extremities. She has loss of lower extremity
apparent to all readers are defined here. Sensation muscle stretch reflexes, mild bilateral foot drop,
refers to the sensory perception of the primary decreased pinprick sensation up to the midtibia,
sensory modalities, pain, heat, cold, and touch, and reduced position and vibration sense. In the
those involved in protective sensation. Sensibility last 2 years the neuropathy has become markedly
refers to the discriminative features of sensation dysesthetic, and the dysesthesias persist despite
such as graphesthesia, stereognosis, or 2-point dis- treatment with neurogenic pain medications.
crimination. The issue of sensibility is important
Step 1. She has no upper extremity impairment.
to the normal function of the hand.
According to Table 13-11, she has a 0% impairment
of upper extremity function.
13.9a Peripheral Neuropathy and
Dysesthetic Pain Step 2. She rises to standing position and walks but
Impairments due to peripheral neuropathy may has difficulty walking long distances and on grades.
affect motor, sensory, and autonomic function If one uses Table 13-12, she has a 10% impairment
in the nervous system. Motor weakness is gen- of lower extremity function.
erally distal, and more commonly affects the
Guides6e_13_321-346.indd 340 2/17/09 2:54:29 PM

Step 3. She has no dysfunction of bowel, bladder, or 13.10Criteria for Rating

sexual function, so use of Tables 13-13 through 13-15 Impairments Related to Complex
results in a 0% impairment.
Regional Pain Syndrome
Step 4. She has moderate dysesthetic pain, and use
of Table 13-17 results in an impairment rating of 7%.
Complex Regional Pain Syndrome (CRPS), also
Step 5. If the Combined Values Chart (see known as Reflex Sympathetic Dystrophy (RSD)
Appendix) is used, she has a combined impairment has been a troublesome area for impairment rating.
rating (10% and 7%) of 16%. Rating of CRPS in the Sixth Edition is carried out
using Tables 15-26 and 16-15 in the chapters on
Comment: Rate other features of diabetes mellitus
impairment rating of the upper and lower extremi-
(eg, diarrhea from gastrointestinal motility problems,
ties, respectively.
diabetic nephropathy, diabetic retinopathy, and tro-
phic ulcers) in other chapters of the AMA Guides. Although trauma and/or nerve injury are often a
precipitating feature of CRPS, the pathophysiol-
13.9b Neuromuscular Junction Disorders ogy remains unknown. Other precipitants of CRPS
Neuromuscular impairment as present in long- include neurologic disorders (stroke, tumor, or
standing myasthenia gravis or myasthenic syndromes syringomyelia), herpes zoster infection, myocardial
is accompanied by proximal weakness. Impairment infarction, and malignancy.
is rated by the impact on ADLs and is rated using
Common clinical complaints include pain, edema,
Tables 13-11 and 13-12.
motor complaints, allodynia, hyperalgesia, hyper-
pathia, hypoesthesia, hypothermesthesia, and pro-
13.9c Myopathy
prioceptive difficulties. The examiner may note
Myopathies represent a varied group of disorders
edema, altered temperature or color compared with
that includes muscular dystrophy, metabolic myopa-
the asymptomatic side, alteration in motor function
thy, abnormal potassium metabolism and muscle
(difficulty initiating movement, weakness, tremor,
disease, endocrine myopathies, and inflammatory
muscle spasms, or dystonia), hyperhidrosis, dystro-
muscle disease. The unifying clinical feature is
phic changes (skin, subcutaneous tissue, or muscle),
proximal weakness that, in some cases, may involve
range of motion loss, and changes in the hair growth
the neck and face. The proximal weakness is best
pattern.
Chapter 13
rated by its effect on the ADLs. Use Tables 13-11
and 13-12 as well as the cranial nerve tables listed in No diagnostic criteria have been accepted uniformaly
Chapter 11, Ear Nose, Throat and Related Structures. for CRPS, and no laboratory study is considered
definitive. X-ray films, 3-phase bone scan, vascular
13.9d Autonomic Nervous studies (eg, thermography), tests of sudomotor func-
System Disorders tion testing, electrodiagnostic studies, quantitative
The ANS influences the functioning of many organ sensory testing, and laser Doppler imaging each have
systems; thus, failure of the system can increase been shown to exhibit characteristic changes.12
impairment. Neurologic conditions that have ANS
Treatment has included various physical or occupa-
involvement include polyneuropathy of various
tional modalities, medications, anesthetics, and min-
causes, familial dysautonomia, neurodegenerative
imally invasive modalities. Analysis of systematic
disorders, Landry-Guillain-Barré syndrome, syrin-
reviews reveal that interventional modalities used in
gomyelia, porphyria, spinal cord and brain tumors,
routine clinical practice have disappointing levels of
and myelopathy.
scientific support.13-15
Lack of control of blood pressure, abnormal body
thermal regulation, and impaired bladder and bowel
elimination are prominent signs of ANS failure.
Impairments related to transient loss of awareness 13.11Criteria for Rating
or consciousness after a period of cerebral isch- Impairments Related to
emia may be due to various mechanisms, includ-
ing orthostasis, reflex actions, or cardiopulmonary Craniocephalic Pain
disorders, and may be estimated by means of Table
13-5. Referring to other Guides chapters also may
13.11a Migraine Headaches
be necessary to estimate the magnitudes of the
Migraine is a common neurologic disorder affecting
impairments.
more than 1 in 10 people. Disability from migraine
Guides6e_13_321-346.indd 341 2/17/09 2:54:29 PM

may manifest as lost time at work, household roles, 4. How many days in the past 3 months was your
school, family, and social or leisure activities.16 productivity in household work reduced by half
Common symptoms may include throbbing head- or more because of your headaches?
ache, moderate or severe pain intensity exacerbated
5. On how many days in the past 3 months did you
by physical activity, photophobia, phonophobia,
miss family, social or nonwork activities because
nausea, and vomiting. During a migraine attack
of your headaches?
75% of patients have a reduced ability to function,
and approximately 50% report severe disability Scores from the 5 questions are summed, and Table
or require bed rest.17 Migraines can be diagnosed 13-18 is used to determine an impairment rating
with high sensitivity and specificity if 3 or 4 of the for migraine headache.19 Note that nonmigrain-
following criteria are met, summarized in the mne- ous headaches are not ratable using the AMA
monic POUNDing (Pulsating, duration of 4 to 72 Guides. As discussed in Section 13.1c, Reaching
hours, Unilateral, Nausea, Disabling).18 Maximum Medical Improvement and Issues of
Patient Compliance, the rater should assess treat-
The physician should determine that migraine head-
ment compliance, treatment efficacy, and whether
aches have been diagnosed as accurately as possible
MMI has been reached before assigning a rating.
using well-accepted criteria, that the patient has had a
Documentation of impairment on the MIDAS
suitable therapeutic trial of appropriate treatment, and
Questionnaire should be sought from school and/or
that the patient has reached a relative plateau in terms
work records if possible.
of migraine severity and frequency. The Migraine
Disability Assessment (MIDAS) Questionnaire was
developed to assess headache-related disability and has
been shown to have favorable internal consistency, test-
CLASS 3
retest reliability, and validity.19
The MIDAS Questionnaire is as follows:
1. On how many days in the past 3 months did you EXAMPLE 13-16: MIGRAINE HEADACHES
miss work or school because of your headaches?
A 29-year-old man suffered a mild traumatic brain
2. How many days in the past 3 months was your injury with brief loss of consciousness. Initial CT of
productivity at work or school reduced by half or the brain was normal. Two days later his symptoms
Chapter 13
more because of your headaches? of nausea and dizziness completely cleared, but he
suffered a migraine headache. Review of his prior
3. On how many days in the past 3 months did
medical records confirmed his oral history that he
you not do household work because of your
had never previously suffered from migraine head-
headaches?
aches. He progressed through a variety of acute and
TA B L E 13 -18 Grading System for Rating Impairment due to Migraine Headache
Migraine Headache
History of migraine headache impairment despite optimal medical management. Headaches have reached a period of
maximum medical improvement.
MIDAS SCORE (SEE

TEXT) 0 1–5 6–10 11–20 21
DESCRIPTION No migraine Minimal or infre- Mild or infre- Moderate Severe disability

headaches quent disability quent disability disability
WHOLE PERSON 0% 2% 3% 4% 5%
Guides6e_13_321-346.indd 342 2/17/09 2:54:30 PM

prophylactic medications for migraine management are the best parameters for localization of sensory
with only partial success in remedying the head- findings on the face. They can outline impairment
aches. He misses work approximately 2 days per of either side of the face, a branch of, or complete
month because of migraine headaches, and this is trigeminal nerve impairment.
documented by his payroll record. Review of the
Brief episodic trigeminal neuralgia or postherpetic
MIDAS questionnaire reveals:
neuralgia that involves a branch of the trigeminal
• He missed 6 days in the past 3 months due to nerve may be very severe and uncontrolled. Because
headaches. there usually is no documented neurologic impair-
ment except for a trigger point with trigeminal
• His productivity at work was decreased approxi-
neuralgia or allodynia with postherpetic neuralgia,
mately 4 more days in the past 3 months due to
severe, uncontrolled, typical pain may be the impair-
headaches.
ment. Occasionally clinicians may observe patients
• He missed 0 days of household work because of with similar pain due to glossopharyngeal neuralgia.
headaches. Both atypical, episodic facial pain and typical, neu-
ralgic pain may be evaluated (Table 13-19) if they
• He had 0 days with a change in household pro-
have occurred for months and interfere with ADLs.
ductivity due to headaches.
• He missed 1 weekend family occasion due to
headaches.
The MIDAS score is 6 4 0 0 1 11. He
13.12 Criteria for Rating
has a 4% impairment due to migraine headaches. Miscellaneous Peripheral Nerves
of the Head and Trunk
13.11b Trigeminal and Glossopharyngeal
Neuralgia
In recent editions of the AMA Guides, certain
The trigeminal nerve is a mixed nerve with sensory
peripheral nerves have been inadvertently omit-
fibers to the face, cornea, anterior scalp, nasal and
ted. Most cranial neuropathies (whether central or
oral cavities, tongue, and supratentorial dura mater.
peripheral) are rated in the ENT and visual disor-
The nerve also transmits motor impulses to the mas-
ders chapters. Most focal neuropathies are rated in
tication muscles.
Chapter 13
the chapters on upper and lower extremity disor-
Evaluate sensation in the parts served by the 3 major ders. The purpose of the following table is to rate
divisions of the trigeminal nerve with the usual tech- miscellaneous peripheral nerves that are not ratable
niques: pain, temperature, and touch. Compare the in other places in the Guides.
2 sides of the face or body. Bilateral loss of facial
Sensory loss in these nerves results in little or no
sensation is uncommon. Pin, cold, and light touch
impairment in ADLs. However, burning dysesthetic
TA B L E 13 -19 Criteria for Rating Trigeminal or Glossopharyngeal Neuralgia
Trigeminal or Glossopharyngeal Neuralgia

History of trigeminal or glossopharyngeal neuralgia with impairment despite optimal medical management. Headaches
have reached a period of maximal medical improvement.
WHOLE PERSON 0% 1%–2% 3%–5% 6%–10%

DESCRIPTION No neuralgia Mild uncontrolled Moderately severe, Severe, uncontrolled,

facial neuralgic pain uncontrolled facial unilateral or bilateral
that may interfere neuralgic pain that facial neuralgic pain
with ADLs or mild interferes with ADLs that prevents per-
motor loss or moderate motor formance of ADLs or
loss severe motor loss
Guides6e_13_321-346.indd 343 2/17/09 2:54:30 PM

pain may be the source of significant impairment. Craniocephalic pain (Table 13-18)
For example, a patient who has undergone an ingui- Trigeminal and glossopharyngeal neuralgia
nal hernia repair may have the sequela of severe (Table 13-19)
burning pain in the ilioinguinal nerve. Use Table 13- Miscellaneous peripheral nerves (Table 13-20)
20 to rate such painful focal neuropathies that can-
• Rate neurologic impairments from other chapters:
not be rated from other chapters.
Radiculopathy (Chapters 15 and 16)
Plexopathy (Chapters 15 and 16)
Complex regional pain syndrome (Chapters 15
13.13Nervous System and 16)
Impairment Evaluation Summary Cranial neuropathies other than trigeminal/
glossopharyngeal neuralgia (Chapter 11)
Dysarthria and dysphonia (Chapter 11)
• Rate the single most severe cerebral impairment
Vestibular disorders (Chapter 11)
(if any) from Tables 13-4 to 13-10.
Visual disorders (Chapter 12)
• Rate impairments due to:
• Combine the ratings using the Combined Values
Upper extremity dysfunction (Table 13-11) Chart (Appendix).
Lower extremity dysfunction (Table 13-12)
Neurogenic bowel, bladder, and sexual dys-
function (Table 13-13 to 13-15)
Neurogenic respiratory dysfunction
(Table 13-16)
Dysesthetic pain (Table 13-17)
TA B L E 13 -20 Criteria for Rating Miscellaneous Peripheral Nerves

Chapter 13
Miscellaneous Peripheral Nerves

WHOLE PERSON 0% 1% 2%–3% 4%–5%

GREATER OCCIPITAL NERVE No neuralgia Sensory loss only Mild to moderate Severe neurogenic
in an anatomic neurogenic pain pain in an anatomic
LESSER OCCIPITAL NERVE
distribution in an anatomic distribution
GREATER AURICULAR NERVE distribution
INTERCOSTAL NERVE
GENITOFEMORAL
ILIOINGUINAL
ILIOHYPOGASTRIC
PUDENDAL
Guides6e_13_321-346.indd 344 2/17/09 2:54:31 PM

References 12. Singh MK, Patel J, Grothusen J, Foye PM. Complex

regional pain syndromes. eMedicine [database online].
1. Lawton MP, Brody EM. Assessment of older people: Updated June 7, 2006. Available at: http://www.
self-maintaining and instrumental activities of daily emedicine.com/pmr/topic123.htm.
living. Gerontologist. 1969;9:179–186. 13. Cepeda MS, Carr DB, Lau J. Local anesthetic
2. Mahoney FI, Barthel D. Functional evaluation: the sympathetic blockade for complex regional
Barthel Index. Maryland State Med J. 1965;14:56–61. pain syndrome. Cochrane Database Systematic
Rev [database online]. 2005;(4):CD004598.
3. Wade DT, Collins C. The Barthel ADL index: a doi:10.1002/14651858.CD004598.pub2.
standard measure of physical disability? Int Disability
Stud. 1988;10:64–67. 14. Mailis-Gagnon A, Furlan A. Sympathectomy for
neuropathic pain. Cochrane Database Systematic
4. Johns MW. A new method for measuring daytime Rev [database online]. 2002;(1):CD002918.
sleepiness: the Epworth sleepiness scale. Sleep. doi:10.1002/14651858.CD002918.
1991;14:540–545.
15. Mailis-Gagnon A, Furlan AD, Sandoval JA, Taylor R.
5. Strub RL, Black RW. Mental Status Examination in Spinal cord stimulation for chronic pain. Cochrane
Neurology. 3rd ed. Philadelphia, Pa: FA Davis Co; 1993. Database Systematic Rev [database online]. 2004;(3):
6. Ropper AH, Gaorson KC. Concussion. N Engl J Med. CD003783. doi:10.1002/14651858.CD003783.pub2.
2007; 356:166-172. 16. Breslau N, Rasmussen BK. The impact of migraine:
7. McCrea MA. Mild Traumatic Brain Injuryand epidemiology, risk factors, and co-morbidities.
Postconcussion Syndrome: New Evidence Base for Neurology. 2001;56:S4–S12.
Diagnosis and Treatment. Oxford, England: Oxford 17. Holmes WF, MacGregor EA, Dodick D. Migraine-
University Press; 2008. related disability: impact and implications for
8. Holland A. The Communicative Abilities in Daily sufferers’ lives and clinical issues. Neurology.
Living Manual. Austin, Tex: Pro-Ed; 1980. 2001;56:S13–S19.
9. Walton J, Gilliatt RW, Hutchinson M, et al, eds. Aids to 18. Detsky ME, McDonald DR, Baerlocher MO, et al. Does
the Examination of the Peripheral Nervous System. 4th this patient with headache have a migraine or need
ed. London, England: Bailliere Tindall; 2000. neuroimaging? JAMA. 2006;296:1274–1283.
10. Graham RC, Hughes RAC. Clinimetric properties of 19. Stewart WF, Lipton RB, Dowson AJ, et al. Development
a walking scale in peripheral neuropathy. J Neurol and testing of the Migraine Disability Assessment
Neurosurg Psychiatry. 2006;77:977–979. (MIDAS) Questionnaire to assess headache-related
disability. Neurology. 2001;56:S20–S28.
11. Graham RC, Hughes RAC. Modified peripheral
Chapter 13
neuropathy scale: the Overall Neuropathy
Limitations Scale. J Neurol Neurosurg Psychiatry.
2006;77:973–976.
Guides6e_13_321-346.indd 345 2/17/09 2:54:32 PM

346
CHAPTER 14
Mental and
Behavioral Disorders
14.2 Psychiatric/Psychological Evaluation
14.3 Special Features of the Mental and

Behavioral Disorders Independent
Medical Examination
Introduction
14.4 Maximum Medical Improvement
This chapter discusses impairments due to mental
14.5 Concepts for Impairment Ratings disorders and considers mental and behavioral
impairments that may result from them. These are
14.6 Method of Impairment Rating heretofore referred to as Mental and Behavioral
Disorders (M&BD). As did Chapter 13 (The Central
14.7 Examples of Impairment Ratings due to and Peripheral Nervous System), this chapter
Mental and Behavioral Disorders assesses the brain; however, here the emphasis is on
evaluating brain function and its effect on behavior.
The following revisions have been made for the
Sixth Edition:
Chapter 14
• The importance of following the Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR).
• The DSM-IV-TR criteria for diagnosis are
emphasized.
• Specific features of the M&BD Independent
Medical Examination (IME) are delineated.
• A brief discussion of the utility of psychological
testing is included.
• The M&BD impairment rating is based on
3 scales: the Brief Psychiatric Rating Scale,
the Global Assessment of Function, and the
Psychiatric Impairment Rating Scale.
• Only impairments for selected well-validated
major mental illnesses are considered.
347
Guides6e_14_347-382.indd 347 3/6/09 9:40:10 AM

TA B L E 14 -1
14.1 Principles of Assessment Multiaxial System of the DSM-IV-TRa
Axis Condition
14.1a Initial Considerations I Clinical disorders
Before using the information in this chapter, the Other conditions that may be a focus of clinical
Guides’ user should become familiar with Chapters attention
1 and 2 and the Glossary. Chapters 1 and 2 discuss II Personality disorders
the Guides’ purpose, applications, and methods for Mental retardation
performing and reporting impairment evaluations in III General medical conditions
general. The Glossary provides definitions of com-
IV Psychosocial and environmental problems
mon terms used by many specialties in impairment
V Global assessment of functioning
evaluations. It should be emphasized that the pres-
ence of a diagnosis does not necessarily suggest the a
DSM-IV-TR indicates Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision.
patient is impaired.
Clinicians who use this chapter will generally be 14.1c Diagnostic Categories
trained in psychiatry or psychology. Other users of Although the DSM-IV-TR remains the bedrock of
this chapter should have: diagnosis in mental illness, psychiatrists and psy-
chologists are continuously reconsidering and refining
• Expertise in the utilization of Diagnostic and
how to classify the conditions they treat. Proponents
Statistical Manual of Mental Disorders, Fourth
for reliable diagnostic criteria prompted contributors
Edition, Text Revision.
to the Diagnostic and Statistical Manual of Mental
• Expertise in the psychiatric or psychological Disorders, Third Edition (DSM-III) to include specific
evaluation of patients. criteria for diagnosis.2 These criteria needed to be
observable and clearly defined so they could be readily
• Expertise in the diagnosis and treatment of
recognized by different practitioners. The criteria were
mental and behavioral disorders.
then subjected to field trials. The result was a standard-
ized diagnostic nomenclature that mental health profes-
14.1b Diagnosis
sionals could apply to the patients they treated.
The goal of this chapter is to provide ratings for
permanent impairment relating to M&BD. The Over time the DSM has swelled to nearly 300 men-
first critical step is to make a definitive diagnosis, tal and behavioral disorders, and there is significant
which should be based on the American Psychiatric debate regarding the validity and interrater reliability of
Association’s Diagnostic and Statistical Manual of many DSM-IV-TR disorders, as well as the multiaxial
Mental Disorders, Fourth Edition, Text Revision, approach in general. One patient may meet criteria for
commonly known as DSM-IV-TR.1 This manual is several different disorders, and many dissimilar patients
the widely accepted classification system for mental may meet criteria for the same disorder.3 In contrast,
disorders. In general, the history, signs, and symptoms the validity and interrater reliability of the major mental
of mental disorder should justify and confirm the illnesses/disorders; mood disorders (eg, depression or
Chapter 14
diagnosis, which should be made according to DSM-IV- mania) and schizophrenia are well established.
TR criteria. The diagnosis (with the associated factors
The rapid expansion of DSM diagnoses has blurred
of prognosis and course) will form the basis by which
the boundary where mental health ends and illness
one assesses the severity and predicts the probable
begins. According to the National Comorbidity Survey
duration of the impairment.
Replication, one half of Americans will meet the
The criteria for mental disorders include a wide range criteria for a DSM-IV-TR disorder sometime in their
of signs, symptoms, and impairments. The DSM-IV- life.4 Proponents of expanding the number of DSM
TR calls for a multiaxial evaluation, as summarized diagnoses suggest that definitions should be broad
in Table 14-1. Each of 5 axes refers to a different class enough to include milder conditions that can cause
of information. The first 3 axes constitute the major distress or lead to more severe problems later. Others
diagnostic categories. These include the major clinical disagree, arguing that criteria should be tightened: (1)
syndromes and the conditions that are the focus of to ensure that limited resources go to those with more
treatment (Axis I), the personality and developmental serious illness and (2) to avoid alienating a skeptical
disorders (Axis II), and the physical disorders and public who is dubious whether such a large proportion
conditions that may be relevant to understanding and of the population truly suffers from a mental illness.5
managing the care of the individual (Axis III). Axis A useful analogy might be found in the paradigm of
IV refers to psychosocial stressors. Axis V refers to persons experiencing low back pain. Nearly all persons
global functional capacity and reflects the effects of the will suffer low back pain over the course of a lifetime.
psychiatric impairments.
Guides6e_14_347-382.indd 348 3/4/09 10:29:37 AM

Mental and Behavioral Disorders 349
The vast majority of these episodes will be self-limited, • Dementia and delirium (covered in Chapter 13).
will not herald ongoing low back impairment, will
• Mental retardation.
improve regardless of treatment, and will adapt to any
intermittent or continuing symptoms.6 • Psychiatric manifestations of traumatic brain
injury (covered in Chapter 13).
It is not the purpose of this chapter to rate impair-
ment in all persons who may fit a DSM-IV-TR The rules for using this chapter would include:
diagnosis. It is understood that many conditions are
• In the presence of a mental and behavioral disorder
common in the general population, and whether or
without a physical impairment or pain impairment,
not they are included in the DSM-IV-TR, they do
utilize the methodology outlined in this chapter;
not require an impairment rating (eg, brief adjust-
ment disorder, normal grief reactions).7 Patients with • In the event of a mental and behavioral disorder
severe mental illness may have a greater role impair- that is judged independently compensable by the
ment than a patient with a severe physical ailment. jurisdiction involved, the mental and behavioral
disorder impairment is combined with the physi-
Because the Guides is generally used in medicolegal
cal impairment;
settings (eg, Worker’s Compensation), impairment
rating in the Sixth Edition will be limited to 1 of the • Whenever it is specifically required by a compen-
following diagnoses: sation system;
• Mood disorders, including major depressive • In most cases of a mental and behavioral disorder
disorder and bipolar affective disorder. accompanying a physical impairment, the psycho-
logical issues are encompassed within the rating
• Anxiety disorders, including generalized anxiety
for the physical impairment, and the mental and
disorder, panic disorder, phobias, posttraumatic
behavioral disorder chapter should not be used.
stress disorder, and obsessive compulsive disorder.
• Psychotic disorders, including schizophrenia.
When mental illness is profound, occupational 14.2 Psychiatric/Psychological
impairment is obvious. It is more difficult to assess Evaluation
occupational impairment when mental illness is
more subtle, complicated by the legal setting, and
The general psychiatric or psychological evaluation
combined with preexisting personality factors.
involves eliciting a history, review of appropriate
Disorders that are not ratable in this chapter include: records, and a mental status examination. An outline
of the mental status examination is summarized
• Psychiatric reaction to pain: It is inherent in the
in Table 14-2.8 Readers are referred to standard
AMA Guides that the impairment rating for a
psychiatric textbooks for details.
physical condition provides for the pain associ-
ated with that impairment. The psychological There may be adjunctive psychological, neuroradio-
distress associated with a physical impairment is logical, or laboratory testing as well. Neuroradiologic
Chapter 14
similarly included within the rating. imaging is discussed further in Chapter 13, The
Central and Peripheral Nervous System.
• Somatoform disorders.
• Dissociative disorders.
• Personality disorders.
TA B L E 14 -2
• Psychosexual disorders (sexual and gender Mental Status Examinationa
identity). • Appearance
• Factitious disorders. • Activity
• Mood and affect; anxiety
• Substance use disorders: Affective or other men-
tal disorders due to substance abuse are not rated. • Speech and language
• Thought content and organization
• Sleep disorders: Primary sleep disorders are
• Perceptual disturbances
covered in Chapter 13, the Central and Peripheral
Nervous System. Many M&BD are associated • Insight and judgment
with disordered sleep and should be considered as • Neuropsychiatric functions
a feature of the M&BD impairment rating in this a
Adapted from Leon et al. 8
chapter.
Guides6e_14_347-382.indd 349 3/4/09 10:29:38 AM

TA B L E 14 -3
Selected Psychological Assessment Tools in Adults
Personality and Symptoms Assessment
Minnesota Multiphasic Personality Inventory (MMPI) is one of the most widely used objective tests. Developed in the
1940s, the test has been revised in the late 1980s (MMPI-2) and more recently for adolescents (MMPI-A). After the
patient responds to more than 550 questions, at least 54 clinical and 10 validity scales are generated as well as a score of
unanswered responses.
Millon Clinical Multiaxial Inventory (MCMI-III) uses DSM-IV-TR terminology and is helpful in differentiating types of
personality disorders. An adolescent inventory has also been formulated.
Personality Assessment Inventory (PAI) provides information to assist in screening, diagnosis, and treatment for
psychopathology, which parallels DSM-IV-TR categories. Validity scales are included.
Intellectual Assessment
Wechsler Intelligence Test: administered by trained examiner, yields verbal, performance, and full-scale IQ. There are
versions for adults (Wechsler Adult Intelligence Scale–IV edition, or WAIS-IV), for children (Wechsler Intelligence Scale for
Children–IV edition, or WISC-IV), and preschoolers (Wechsler Preschool and Primary Scales of Intelligence III, or WPPSI-
III). In addition to the IQ score, the WAIS-IV yields 4 indices—verbal comprehension, perceptual organization, working
memory, and speed of information processing—and the WISC-IV indices include verbal comprehension, perceptual
organization, freedom from distractibility, and processing speed. Organic disease or preexisting learning disability
may be suspected if there is: (1) a discrepancy in the full-scale IQ and premorbid function; (2) discrepancy of >15 points
between the verbal IQ and performance IQ; (3) high intersubtest scatter, and (4) impaired performance on certain
sections (similarities, digit symbol, block design).
Standardized tests of social adaptive behavior may also be useful in quantifying the effects of intellectual deficits.
Academic Assessment
These scales focus on academic skills: reading, spelling, writing, language, and math:
• Wide Range Achievement Test-IV (WRAT-IV): quick.
• Woodcock-Johnson III NU Tests of Achievement: most comprehensive; useful for learning disabilities.
• Wechsler Individual Achievement Test (WIAT): comprehensive; linked with Wechsler Intelligence Scales.
• Peabody Individual Achievement Test-Revised, Second Edition.
Neuropsychological Evaluation
The most comprehensive assessment of mental function may require up to a day of testing or more. Neuropsychological
testing is most useful when exploring disturbances in mental and behavioral function due to abnormal brain function.
There is a wide range of expertise and experience among examiners who perform neuropsychological testing. The exam
should include assessment of the following:
• Intelligence: see above.
• Academic achievement: see above.
• Learning and memory: Wechsler Memory Scale-III, Rey Auditory Verbal Learning Test, California Verbal Learning Test,
Visual Spatial Learning Test.
• Attention and concentration: Trails A & B, Stroop Color-Word Test, Continuous Performance Test, Symbol Digit
Modalities Test.
• Language: Boston Diagnostic Aphasia Exam, Multilingual Aphasia Exam, Boston Naming Test, Western Aphasia Battery.
Chapter 14
• Visuospatial functioning: Benton Visual Form Discrimination Test, Judgement of Line Orientation, Rey-Osterreith
Complex Figure, Test of Facial Recognition.
• Sensorimotor ability: Finger Tapping Test, Grooved Pegboard Test, Finger Agnosia and Fingertip Number Writing,
Tactile Form Perception.
• Planning, reasoning, problem solving: Wisconsin Card Sorting Test, Category Test, beta mazes.
• Personality and mood: see above.
Standard neuropsychological test batteries include the Halstead Reitan Test Battery and the Luria-Nebraska
Neuropsychological Battery. The Halstead Reitan Test Battery includes the WAIS-III (usually preferred over WAIS-R),
Category Test, Trail Making Test, Aphasia Screening Examination, Rhythm Perception Test, Speech Sound Perception Test,
Finger Tapping Test, Tactile Performance Test, Perceptual Examination, ⫹/⫺ MMPI. An impairment index is derived. It is the
best standardized neuropsychological test battery. Supplement it with the Wechsler Memory Scale-III. The Luria-Nebraska
Neuropsychological Battery is controversial; it is briefer and simpler than the Halstead-Reitan.
Guides6e_14_347-382.indd 350 3/4/09 10:29:38 AM

The use of well-standardized psychological tests, is giving their best effort. The history, records, and
such as the Wechsler Adult Intelligence Scale clinical interview of the patient offer more guidance
(WAIS) and the Minnesota Multiphasic Personality in this last regard. It is standard practice that a neuro-
Inventory-2 (MMPI-2), may improve diagnostic psychological test battery should include instruments
accuracy and support the existence of a mental that include 2 symptom validity tests.
disorder (Table 14-3). A summary of the many
Abnormalities on neuropsychological test batteries
such psychological tests can be found in standard
are not pathognomonic of brain damage. Factors that
textbooks.9,10 Of particular note, the WAIS can be
may have an impact on test results include aging,
useful in documenting mental retardation. Broad-
education, motivation, ethnicity, culture, prescribed
based neuropsychological assessments using, for
medications, substance abuse, pain, peripheral
example, the Halstead-Reitan Neuropsychological
nervous system pathology, and psychiatric disorders.
Test Battery, may be useful in determining
Neuropsychological testing is most useful in patients
deficiencies in brain functioning, particularly
with subtle organic deficits, not obvious ones, where
in individuals with subtle signs such as those
office assessment is often adequate.11,12
sometimes seen in traumatic brain injuries.
All test results should be reviewed by the IME
physician to ensure that:
• The testing was done by a trained examiner and not
14.3 Special Features of
merely cosigned by a supervising psychologist. the Mental and Behavioral
• Test findings are internally consistent. Disorders Independent Medical
• The tester documented which materials were
Examination
reviewed, and testing results were consistent with
The M&BD IME and its impairment rating, while
information in the record.
containing the same elements as the “standard”
• Patient baseline/premorbid level of function was psychiatric/psychological evaluation mentioned
adequately explored and documented. earlier, have distinctive features worthy of further
comment, mentioned in Table 14-4.
• Appropriate normative data are listed for each test.
• The testing performed contained 2 or more 14.3a Physician Alliance
symptom validity tests. Any examiner performing an IME is expected to
have a neutral, unbiased position with regard to the
Despite the wide range of available psychological
patient. However, psychiatrists and psychologists
tests, the patient interview, review of records,
who perform impairment or forensic evaluations that
and mental status exam remain the foundation
deal with work-related injuries have special require-
for evaluation of the patient and determination of
ments and limitations. Mental health clinicians align
the impairment rating. It is well appreciated that
themselves closely with their patients; a commonly
instruments touted to be “objective tests” such as the
Chapter 14
used phrase describing this alignment is “uncon-
Beck Depression Inventory, but which are scored
ditional positive regard.” Thus, for mental health
solely by the patient, are purely subjective. Such
clinicians, it may be even more difficult to reach
inventories may be of greater value in a research
the neutral, unbiased position that is expected of all
setting than for use in an IME. Interpretation
examiners performing IMEs, but it is vital to do so.
of objectively scored tests is still subjective and
depends on the knowledge, training, and experience Treating psychiatrists and psychologists should avoid
of the interpreter. Tests such as the MMPI, which serving as an expert witness or IME examiner for legal
was designed with internal validity scales, were not purposes on behalf of their own patients.13 The dual role
primarily designed to detect malingering. However, can be detrimental to the therapeutic relationship, can
these internal validity checks may be helpful in be a considerable source of bias for the examiner, and
determining if a subject is “faking bad.” can compromise the patient’s legal claim.
The ability of neuropsychologists to detect “faking”
14.3b Source Materials
on neuropsychological test batteries remains contro-
The individual’s own description of his or her
versial. Suffice it to say that the tests are most useful
symptoms and their direct impact on function-
in assessing strengths and weaknesses in cognitive
ing (and limitations) is usually the best source of
functioning of impaired cooperative patients, rather
information. It is important to examine the indi-
than as a barometer of who is “faking bad” and who
Guides6e_14_347-382.indd 351 2/17/09 2:54:54 PM

TA B L E 14 - 4
Suggestions for the M&BD IMEa
• Assess personality structure and health with special attention to antisocial, borderline, histrionic, narcissistic, passive-
dependent, and passive-aggressive features.
• Evaluate principal defense mechanisms. A key example is somatization, which is a low-level defense mechanism.
Scrutinize primary care and secondary medical records for the presence of somatization as a primary defense
mechanism.
• Screen individuals for past and current substance abuse, which can mimic symptoms of other psychiatric diagnoses.
• Evaluate the legal history, especially in regard to prior lawsuits, work-related injuries, bankruptcies, driving under the
influence, incarcerations, restraining orders, and court-ordered child support.
• Obtain military history: overseas service, adjustment to service, type of discharge, pay grade, military arrests, disability
pension.
• Note whether there is a pattern of overendorsing symptoms during the psychiatric interview.
• Assess the patient’s motivation vis-à-vis returning to work. Does the disease process diminish the patient’s motivation,
or does the illness role gratify unconscious or conscious needs in the patient (eg, dependent needs inherent in the
underlying personality construct)? Is secondary gain present? Is some combination of all these elements present?
• Determine if symptom exaggeration or malingering is present. Malingering may be subtle, marked, or frank.
• Ask about the patient’s attitude to the third-party payer (employer, insurance company, etc). Does the injured worker
feel the payer responded appropriately to the patient’s situation?
• Assess the influence of the litigation process on return to work (promoting return to work vs illness behavior). Is there a
history of failed attempts to return to work? Who decided—physician, patient, or attorney—whether there would be a
return to work?
• Determine whether adequate pharmacologic and biological treatment has been provided. Assess whether enough
medications have been tried, at adequate dosage, and of adequate duration. Has the patient frequently rejected
medications because of side effects? Has the patient accepted and complied with reasonable treatment?
a
M&BD IME indicates Mental and Behavioral Disorders Independent Medical Examination.
vidual alone. However, the history from family offering the same history. This raises questions as
members and others who have direct knowledge of to the reliability of the patient’s self-report and the
the person may be useful in indicating the severity need for additional objective data and critical judg-
of any impairment and the impact on functioning. ment. It might also suggest incorrect recording of the
patient’s history by prior examiners.
Reliable collateral information concerning the
individual’s behavior while performing activities
14.3c Motivation and Malingering
of daily living (ADLs) may be drawn from medical
and nonmedical sources. Records from hospitaliza- Motivation
tion, outpatient treatment, day hospital, rehabilita- Motivation for improvement may be a key factor in
tion evaluations, work evaluations, and disability the severity and extent of an individual’s ability to
assessments are useful in assessing the status of the lead a productive life despite a challanging impair-
Chapter 14
patient. Helpful nonmedical sources may include ment, whether that impairment is physical or mental.
records from vocational assessement, sheltered Some have described this as a bridge between impair-
workshops, or day care centers. ment and disability. The examiner also needs to
assess changes in motivation over time and whether
From all these sources of information, of particular
problems in motivation are due to the illness or the
interest will be the 6 essential parameters listed in
primary gain or secondary gains.
Table 14-5. If the descriptions from these sources are
not sufficiently detailed or are in conflict with the
TA B L E 14 - 5
observed clinical picture or the reports of others, it
will be necessary to reconcile these inconsistencies. Functional Impairment Scales for Patients
With M&BD
Any gaps in the history should also be explored.
Self-care and personal hygiene
The patient’s subjective complaints should be scru- Social and recreational activities
tinized as to their consistency with the examiner’s
Travel
clinical experience as well as the natural history of
Interpersonal relationships
the claimed condition. When the historical informa-
tion recorded by various observers differs widely, Concentration, persistence, and pace
this may suggest that the patient is not reliably Employability
Guides6e_14_347-382.indd 352 3/4/09 10:29:39 AM

TA B L E 14 - 6 Malingered psychiatric conditions may be more

Factors That May Affect Motivation common in medico-legal settings commonly involving
Psychiatric illness: schizophrenia, depression the avoidance of unpleasant duty or requirements,
Side effects of neuroleptic or other medication for example, incarceration, military service, or when
someone is seeking insurance or entitlement benefits.
Embellishment and exaggeration
Malingering Deception is usually suspected when the individual’s
Fear of losing entitlements symptoms are vague, ill defined, overdramatized,
Patient’s personality/coping styles
inconsistent, or not in conformity with signs and
symptoms known to occur. In this regard, the
Self-confidence
history, mental status and physical examinations,
Demoralization with chronic disease records, and other available collateral information
Social network support for illness may demonstrate inconsistencies in the nature and
Substance intoxication and abuse intensity of the person’s complaints. For a more
Traumatic brain injury elaborate discussion of malingering, it may be useful
to refer to the works of Meyerson14 and Rogers.15 Table
14-7 offers characteristics suggestive of malingering
based on the work of Resnick (see Rogers15).
Motivation to report symptoms can be influenced by
The use of the term malingering can polarize case
a host of factors, as listed in Table 14-6. These factors
analysis and may lead to personal attacks on the exam-
may change over time. Since psychiatry continues
iner/rater by administrators or judicial decision makers.
to lack definitive testing to confirm most major ill-
It should be used with great caution, since the term
nesses, careful consideration of any complaint lacking
malingering implies that the health provider knows that
apparent basis is warranted. Exclusion or inclusion
the patient’s presentation is intentional and intended to
of somatization disorder, factitious disorder, and/or
defraud the examiner and others. Under ordinary cir-
malingering must be done with care. Assessment of
cumstances, the health provider rarely gets a sufficient
motivation is often challenging and requires skill to
insight into patient illness behaviors to obtain evidence
avoid biased or prejudiced conclusions.
for such definitive labeling. It is usually more clini-
Nevertheless, motivation is a sigificant link between cally accurate, and less likely to create disputes, to use
an impairment and resulting disability. For some alternative phrasing, such as symptom exaggeration or
people, poor motivation can be a major cause of magnification to explain why a recognized psychiatric
poor functioning. Understanding an individual’s disorder could not be identified.
underlying character structure may be important in
determining whether he or she is motivated to ben-
efit from rehabilitation. Personality characteristics 14.4Maximum Medical
typically remain stable throughout the life span. Improvement
However, internal and external events and psycho-
logical reactions can significantly influence the
Chapter 14
A general principle in the AMA Guides is that a con-
course of illness and motivation. An individual with
dition is rated as “permanent” when it is not expected
dependent traits, for example, may become more
to change significantly over the next 12 months. This
dependent as his or her illness progresses.
concept of “plateauing” poses some special problems
in Mental and Behavioral Disorders.
Malingering
Malingerers may present with complaints suggesting
14.4a Variability of Mental Disorders
a mental and behavioral disorder, a physical
In judging the degree of mental impairment, it is
disorder, or both. Examiners should always be aware
important to recognize that there are various types
of this possibility when evaluating impairments.
of mental disorders, each of which, like a physi-
The possibility of avoiding responsibility and/or
cal disorder, has its own natural course and unique
obtaining monetary awards increases the likelihood
characteristics. In addition, the degree of impairment
of exaggeration and/or malingering. Nonspecific
may vary considerably among individuals with the
symptoms, which are difficult to verify, tend to
same diagnosis.
be overrepresented, including headache, low back
pain, peripheral neuralgia, and vertigo. Malingering Some serious mental disorders are chronic. The term
occurs along a spectrum—from embellishment to remission, rather than cure, may be more appropriate.
exaggeration to outright fabrication. Remission may be incomplete, and the time course may
Guides6e_14_347-382.indd 353 2/17/09 2:54:55 PM

TA B L E 14 -7
Characteristics Suggestive of Malingeringa
• Malingerers often overact.
• Malingerer’s descriptions of symptoms and problems are not clear, lack detail.
• Malingerer’s symptoms are more repetitious. Real symptoms are variations on a theme (ie, recurrent dreams in PTSD
are variations on a theme, not absolute repetitions of the event).
• Malingerers struggle to answer when asked about coping strategies, how they cope with the impairment. People who
are psychotic or severely depressed have coping strategies—taking a walk, talking to someone—that come readily to
mind when they are asked how they deal with hallucinations or confusion.
• Malingerers report symptoms more bizarre than real symptoms (eg, giants rather than ordinary-sized people in a visual
hallucination).
• Malingerers are more likely to talk about sudden onset, whereas hallucinations and delusions usually come on
gradually.
• Malingerers are more likely to report constant symptoms (even hallucinations, delusions, impairments—things that
usually are intermittent).
• Malingerers appear to think that if someone is “crazy” (has hallucinations and delusions), that person would necessarily
have cognitive impairments (memory, concentration impairments). They may stumble over memory issues when
persons with psychosis would likely be readily able to answer unless they were severely preoccupied by psychotic
phenomena and unable to communicate in other obvious ways.
a
PTSD indicates posttraumatic stress disorder.
be variable. For example, a period of depressed mood interventions? Rejection of treatment options by
following a stressful life event may be an adjustment the patient should not justify an impairment rating.
disorder, which often is short-term and remits without In certain illnesses (eg, schizophrenia) the lack of
treatment. Alternatively, affective disorders have their insight may interfere with treatment.
own patterns of recurrence and chronicity that respond
• Response to treatment should be documented.
variably to therapeutic intervention.
Treatment may result in only a partial remission.
Both the patient’s clinical course and impairment One should attempt to evaluate whether residual
level may fluctuate. Proper evaluation of an impair- problems represent symptoms or medication side
ment must take into account variations in the level effects. Limitations that remain after optimal
of functioning over time. treatment represents the degree of impairment.
Because the workplace may be a significant stressor, • Because medication side effects must be
the examiner should look for evidence of repeated considered as part of the impairment, optimal
deterioration upon the patient’s return to his or her psychopharmacologic management includes trials
chosen occupation. The individual’s resilience in the of medications, which both minimize side effects
face of stress is a significant factor in whether the indi- and maximize efficacy.
vidual can return to work and maintain function there.
Chapter 14
• If present, have comorbid substance abuse and

physical disorders and their treatment that produce
14.4b Response to Treatment
mental symptoms been addressed in the treatment
The following should be addressed regarding
plan?
treatment response:
• A thorough assessment includes a history of the 14.4c Vocational Issues
reponse to treatment and a determination whether Vocational impairment may represent an important
there has been an adequate treatment course. portion of the overall impairment. One individual
may have a pronounced impairment in other areas
• Has the treatment been sufficiently aggressive and
but still function successfully in the workplace. In
of adequate duration?
another individual, a circumscribed impairment may
• Has treatment resulted in improvement in patient profoundly impair the patient’s ability to work. It
function? would be unusual, however, to find an impairment
that affects work only.
• Have a suitable number of treatment options been
applied? An employer’s willingness to modify existing work
conditions and opportunities may be a central part of
• Has medication compliance been assessed?
the patient’s successful return to work. And as is true
Has the patient been cooperative with treatment
Guides6e_14_347-382.indd 354 3/4/09 10:29:39 AM

with many general medical diagnoses, early return to Clinicians are familiar with the scale, and its popu-
the workplace in some capacity facilitates a success- larity is due to its use as a global measure of overall
ful return to work. psychosocial health or sickness.
One known limitation of the GAF is the result of
14.4d Effects of Structured Settings
combining functional level and symptom severity
Certain structured settings, such as a hospital, half-
into 1 scale. This may result in low scores for high
way house, boarding home, or other group facility,
functioning patients with a single severe symptom.
may be important in maintaining clinical stability.
Alternatively, patients may have a life-threatening
The individual’s ability to function outside of the
mental illness, such as anorexia nervosa, and yet
structured setting may be compromised. Evaluate
might have a very high GAF score. Also, certain
whether there is evidence of repeated deterioration
patients may function better when removed from the
upon attempts to return to the workplace.
stressors of the workplace, which may significantly
impact their GAF score. These issues are remedied by
simultaneously performing the BPRS and the PIRS.
14.5Concepts for 14.5c Psychiatric Impairment Rating Scale
Impairment Ratings The PIRS, slightly modified in the Guides, was
originally developed for the New South Wales Motor
The Guides Sixth Edition uses 3 scales by which Accidents Authority in Australia. Behavioral con-
M&BD impairment is rated: (1) the Brief Psychiatric sequences of psychiatric disorders are assessed on 6
Rating Scale (BPRS), (2) the Global Assessment of scales, each of which evaluates an area of functional
Functioning Scale (GAF), and the (3) Psychiatric impairment (Table 14-5). The PIRS is similar in
Impairment Rating Scale (PIRS). construction to the GAF but has been expanded to
provide greater detail in order to rate impairment.
14.5a Brief Psychiatric Rating Scale
The purpose in including all 3 of these scales is
The BPRS, described by Overall and Gorham,16,17
to provide a broad assessment of the patient with
measures major psychotic and nonpsychotic symp-
M&BD. The BPRS focuses solely on symptom
toms in patients with major psychiatric illnesses. The
severity, the PIRS on role function, and the GAF is a
scale can be applied to adult inpatients and outpa-
blend of the 2. Clearly, interview, review of records,
tients, and has shown excellent reliability in clinical
mental status exam, along with assessment of these 3
trials. It is probably the most researched instrument
scales will provide an excellent basis for arriving at a
in psychiatry.18 The 24-item iteration of the scale will
strongly supportable impairment rating.
be used in the Guides and is shown in Section 14.6a.
14.5d Further Considerations
14.5b Global Assessment
The following should be considered:
of Functioning Scale
The GAF constitutes Axis V of the DSM-IV-TR. • Psychiatric impairment should be rated based
Chapter 14
The GAF is a 100-point single-item rating scale for on Axis I pathology only. Whether there is one
evaluating overall symptoms, occupational function- or multiple Axis I diagnoses, there is only one
ing, and social functioning. Scores from 91 to 100 impairment rating.
measure individuals who have superior functioning
• Underlying personality vulnerabilities and
without active psychopathology. Interval 81 to 90
borderline intellectual function are preexisting
includes individuals with minimal or no active psy-
conditions which are not ratable. Personality
chopathology but function at a lesser level. Clinical
disorders other than antisocial personality disorder
psychiatrists and psychologists may indicate a GAF
lack sufficient interrater reliability, and the law does
score in multiaxial assessment of their patients, and
not recognize sociopathy as a legitimate source of
the scale has undergone considerable psychometric
impairment. As the evaluator assesses each of the
assessment in the scientific community.
6 domains of functional impairment (Table 14-
The GAF has been demonstrated to have satisfactory 5), it is important to consider what portion of the
interrater reliability, and directions for use and inter- impairment is due to the potentially unremitted
pretation of the scores are readily available in the illness versus the portion driven by possible chronic
DSM-IV-TR. The GAF has been widely used both in preexisting personality vulnerabilities and/or
clinical practice and in hundreds of research studies. borderline intellectual functioning.
Guides6e_14_347-382.indd 355 3/4/09 10:29:40 AM

• Compromise of activity of daily living (ADL) Readers are to refer to the Appendix at the end of this
function due to financial constraints or lack of chapter for detailed instructions on performing the
transportation is not to be rated. BPRS. “Gut impression” scoring of the 24 constructs
is not adequate.
• The examiner must assess not simply the number of
activities that are restricted but the overall degree of Using Table 14-8, circle the number headed by the
restriction or combination of restrictions. For exam- term that best describes the patient’s present condi-
ple, a person who is able to cook and clean might tion. Rate construct items 1 to 14 on the basis of the
be considered to have marked restriction of daily individual’s self-report. Note that items 7, 12, and
activities if he or she were too fearful to leave home 13 are also rated on the basis of observed behavior.
to shop or go to the physician’s office. Items 15 to 24 are rated on the basis of observed
behavior and speech. Then, sum the total of the 24
• There are limits on the evaluator’s ability to assess
BPRS symptom construct scores, and find the BPRS
patient concentration in a one-time interview. In
impairment score in Table 14-9.
the aggregate, an estimate of the patient’s ability
to concentrate may rely more on the collateral
14.6b Step 2: GAF Impairment Score
sources of information as well as the employment
Determine the GAF impairment score based on Table
history. A person who appears to concentrate
14-10. The GAF is based only to psychological, social,
adequately during a mental status examination or
and occupational functioning. Do not include impair-
a psychological test may not do so in other settings
ment in functioning due to physical or environmental
(eg, reading, watching movies).
limitations. It may be useful to consider previous GAF
• Limitations in the 6 domains listed in Table 14-5, scores recorded in the medical record.
which are due to physical impairments, should not be
included. For example, if a patient cannot carry out 14.6c Step 3: PIRS Impairment Score
ADLs because of a spinal cord injury, no impairment The first step in determining the PIRS impairment
should be generated in the M&BD ratings. score is to grade the patient from 1 to 5 in Tables
14-11 through Table 14-16.
• To measure the impairment caused by a work-
related injury or incident, the evaluator must The steps for rating with the PIRS then are as
determine whether a ratable preexisting mental follows:
and behavioral impairment existed. If so, by
1. Patients should receive a score from 1 to 5 in
definition the current impairment is a sum of both
each of the 6 impairment domains (Tables 14-11
the preexisting impairment and the impairment
to 14-16).
resulting from the work injury/incident. Calculate
the current permanent impairment using the 2. Arrange the 6 scores from lowest to highest, for
methods described in Section 14.6. Calculate example, 1 2 2 4 4 5.
a second impairment rating based only on the
3. Select the middle 2 scores from the arrangement
preexisting condition. The impairment rating due
of 6 scores. In the example “1 2 2 4 4 5,” the
to the work-related injury or incident will be the
Chapter 14
middle 2 scores are “2” and “4.”

difference between the 2 scores.
4. Sum the middle 2 scores. In the example above,
• Impairment scores do not, in themselves, indicate
the sum of the middle 2 scores would be “6.” (The
whether a patient can work or not. This is an indepen-
sum of the middle scores is used to avoid outliers
dent assessment that must be made during the evalu-
in the 6 impairment domains. For example, sup-
ation. For example, a patient with a 40% impairment
pose a patient had very poor hygiene but was an
may be 100% disabled from employment.
effective landscaper, the patient might still func-
tion well in this chosen occupation. Conversely,
a patient with panic disorder who may be well
groomed and well spoken, may still never be able
14.6 Method of Impairment Rating to leave the house. Whereas impairment in 1 area
is not equivalent or interchangable with another,
14.6a Step 1: BPRS Impairment Score the “middle” offers a median score.)
The BPRS form consists of 24 symptom constructs,
5. Determine the PIRS impairment score from
each to be rated on a 7-point scale of severity ranging
Table 14-17.
from “not present” to “extremely severe” (Table 14-8).
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TA B L E 14 - 8
BPRS Forma
Symptom Constructb Scoringc
1. Somatic concern 1 2 3 4 5 6 7
2. Anxiety 1 2 3 4 5 6 7
3. Depression 1 2 3 4 5 6 7
4. Suicidality 1 2 3 4 5 6 7
5. Guilt 1 2 3 4 5 6 7
6. Hostility 1 2 3 4 5 6 7
7. Elevated mood 1 2 3 4 5 6 7
8. Grandiosity 1 2 3 4 5 6 7
9. Suspiciousness 1 2 3 4 5 6 7
10. Hallucinations 1 2 3 4 5 6 7
11. Unusual thought content 1 2 3 4 5 6 7
12. Bizarre behavior 1 2 3 4 5 6 7
13. Self-neglect 1 2 3 4 5 6 7
14. Disorientation 1 2 3 4 5 6 7
15. Conceptual disorganization 1 2 3 4 5 6 7
16. Blunted affect 1 2 3 4 5 6 7
17. Emotional withdrawal 1 2 3 4 5 6 7
18. Motor retardation 1 2 3 4 5 6 7
19. Tension 1 2 3 4 5 6 7
20. Uncooperativeness 1 2 3 4 5 6 7
21. Excitement 1 2 3 4 5 6 7
22. Distractability 1 2 3 4 5 6 7
23. Motor hyperactivity 1 2 3 4 5 6 7
24. Mannerisms and posturing 1 2 3 4 5 6 7
a
BPRS indicates Brief Psychiatric Rating Scale.
b
Construct items 1 to 14 are rated on the basis of the individual’s self-report; items 5 to 24, on the basis of observed behavior and speech.
Sum the total of the 24 scores.
c
1 indicates not present; 2, very mild; 3, mild; 4, moderate; 5, moderately severe; 6, severe; and 7, extremely severe.
Chapter 14
TA B L E 14 -9
14.6d Step 4: List BPRS, GAF, and PIRS
Impairment Score of Brief Psychiatric Rating Impairment Scores
Scale (BPRS) Based on the work in steps 1 to 3, list the BPRS,
BPRS Summed Score BPRS Impairment Score GAF, and PIRS impairment scores above in the
24–30 0% blanks below.
31–35 5% BPRS impairment score
36–40 10%
GAF impairment score
41–45 15%
46–50 20% PIRS impairment score
51–60 30% Of the 3 impairment scores listed in step 4, the M&BD
61–70 40% impairment rating is the median (middle) value of the
71–168 50% BPRS, GAF, and PIRS impairment scores.
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TA B L E 14 -1 0
Impairment Score of Global Assessment of Functioning Scale (GAF)
GAF Impairment
GAF Description Score
91–100 No symptoms; superior functioning in a wide range of activities, life’s problems never seem 0%
to get out of hand, is sought out by others because of his or her many positive qualities
81–90 Absent or minimal symptoms (eg, mild anxiety before an exam); good functioning in all 0%
areas, interested and involved in a wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or concerns (eg, an occasional
argument with family members)
71–80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors 0%
(eg, difficulty concentrating after family argument); no more than slight impairment in social,
occupational, or school functioning (eg, temporarily falling behind in school work)
61–70 Some mild symptoms (eg, depressed mood and mild insomnia) 5%
or
some difficulty in social, occupational, or school functioning (eg, occasional truancy, or
theft within the household), but generally functioning pretty well, has some meaningful
interpersonal relationships
51–60 Moderate symptoms (eg, flat affect and circumstantial speech, occasional panic attacks) 10%
or
moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts
with coworkers)
41–50 Serious symptoms (eg, suicidal ideation, severe obsessional rituals, frequent shoplifting) 15%
or
any serious impairment in social, occupational, or school functioning (eg, no friends,
unable to keep a job)
31–40 Some impairment in reality testing or communication (eg, speech is at times illogical, 20%
obscure, or irrelevant)
or
major impairment in several areas, such as work or school, family relations, judgment,
thinking, or mood (eg, depressed adult avoids friends, neglects family, and is unable to work;
child frequently beats up younger children, is defiant at home, and is failing at school)
21–30 Behavior is considerably influenced by delusions or hallucinations 30%
or
serious impairment in communication or judgment (eg, sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation)
or
inability to function in almost all areas (eg, stays in bed all day; no job, home, or friends)
11–20 Some danger of hurting self or others (eg, suicide attempts without clear expectation of 40%
death, frequently violent, manic excitement)
or
occasionally fails to maintain minimal personal hygiene (eg, smears feces)
or
Chapter 14
gross impairment in communication (eg, largely incoherent or mute)

1–10 Persistent danger of severely hurting self or others (eg, recurrent violence) 50%
or
persistent inability to maintain minimal personal hygiene
or
serious suicidal act with clear expectation of death
TA B L E 14 -11
Self-Care, Personal Hygiene, and Activities of Daily Living
1 No deficit, or minor deficit attributable to the normal variation in the general population.
2 Mild impairment. Able to live independently; looks after self adequately, although may look unkempt occa-
sionally; sometimes misses a meal or relies on take-out food.
3 Moderate impairment. Can’t live independently without regular support. Needs prompting to shower daily
and wear clean clothes. Does not prepare own meals, frequently misses meals. Family member or community
nurse visits (or should visit) 2–3 times per week to ensure minimum level of hygiene and nutrition.
4 Severe impairment. Needs supervised residential care.
5 Totally impaired. Needs assistance with basic functions, such as feeding and toileting.
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TA B L E 14 -12 TA B L E 14 -14
Role Functioning, Social and Recreational Interpersonal Relationships
Activities
1 No deficit, or minor deficit attributable
1 No deficit, or minor deficit attributable to to the normal variation in the general
the normal variation in the general popu- population. No difficulty in forming and
lation. Regularly participates in social sustaining relationships (eg, partner, close
activities that are age, sex, and cultur- friendships lasting years).
ally appropriate. May belong to clubs or
2 Mild impairment. Existing relationships
associations and is actively involved with
strained. Tension and arguments with
these.
partner or close family member, loss of
2 Mild impairment. Occasionally goes out some friendships.
to such events without needing a sup-
3 Moderate impairment. Previously estab-
port person but does not become actively
lished relationships severely strained,
involved (eg, dancing, cheering favorite
evidenced by periods of separation or
team).
domestic violence. Spouse, relatives, or
3 Moderate impairment. Rarely goes out to community services looking after children.
such events, and mostly when prompted
4 Severe impairment. Unable to form or sus-
by family or close friend. Will not go out
tain long term relationships. Preexisting
without a support person. Not actively
relationships ended (eg, lost partner, close
involved, remains quiet and withdrawn.
friends). Unable to care for dependents
4 Severe impairment. Never leaves place of (eg, own children, elderly parent).
residence. Tolerates the company of fam-
5 Totally impaired. Unable to function in
ily member or close friend but will go to a
society. Living away from populated areas,
different room or place when others come
actively avoiding social contact.
to visit family or flat mate/roommate.
5 Totally impaired. Cannot tolerate living
with anybody, extremely uncomfortable
when visited by close family member.
TA B L E 14 -13 TA B L E 14 -15
Travel Concentration, Persistence, and Pace
1 No deficit, or minor deficit attributable to 1 No deficit, or minor deficit attributable
the normal variation in the general popu- to the normal variation in the general
lation. Can travel to new environments population.
without supervision.
2 Mild impairment. Can undertake a basic
2 Mild impairment. Can travel without sup- retraining course or a standard course of
port person but only in a familiar area education or training at a slower pace.
such as local shops or a neighbor. Can focus on intellectually demanding
tasks for up to 30 minutes, then feels
3 Moderate impairment. Cannot travel
Chapter 14
fatigued or develops headache.
away from own residence without sup-
port person. Problems may be due to 3 Moderate impairment. Unable to read
excessive anxiety or cognitive impairment. more than newspaper articles. Finds it dif-
ficult to follow complex instructions.
4 Severe impairment. Finds it extremely
uncomfortable to leave own residence 4 Severe impairment. Can read only a
even with trusted person. few lines before losing concentration.
Difficulties following simple instructions.
5 Totally impaired. May require 2 or more
Concentration deficits obvious even dur-
persons to supervise when traveling.
ing brief conversation. Unable to live
alone or needs regular assistance from
relatives or community services.
5 Totally impaired. Needs constant super-
vision and assistance in an institutional
setting.
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TA B L E 14 -16 work was not worth the effort because of the futil-
Resilience and Employability ity of life. He withdrew into his home and began to
1 No deficit, or minor deficit attributable to stay in bed. He had no interest in his usual activities.
the normal variation in the general popu- When asked if he were depressed, he would answer
lation. Can work full time. Duties and per- “yes” but state that he really had no “feelings at all.”
formance are consistent with the injured
worker’s education and training. Able to
He felt excessive fatigue and at times stated that he
cope with the normal demands of the job. would be better off dead. These symptoms were
2 Mild impairment. Can work full time but consistently present most of the day over the month
with modifications, or can work in the before evaluation.
same position a reduced number of hours
per week. He had no past history of mood instability, signifi-
3 Moderate impairment. Cannot work at all
cant medical problems, or alcohol or substance use.
in same position. May be able to work in a There was no history of personality problems or
less stressful occupation. work difficulties. He was happily married and had
4 Severe impairment. Cannot sustain work raised 3 successful children. He had a first cousin
over time in any position. with depression onset in midlife.
5 Totally impaired. Cannot work at all.
The patient sought psychiatric evaluation, and medi-
cal consultation revealed no medical cause. He was
diagnosed with major depression. He was started
on antidepressant therapy and had only a partial
14.7 Examples of Impairment response. He underwent several antidepressant trials
Ratings due to Mental and of sufficient length, appropriate dosages, different
Behavioral Disorders classes, and augmentive strategies. His response to
medication was only partial or inadequate or was
limited by side effects. His medication compli-
The case examples are for illustrative purposes.
ance was good and there was no discerned second-
Every pertinent detail of a patient’s presentation may
ary gain. He would not consider electroconvulsive
not be included in these concise vignettes.
therapy, but did participate in cognitive behavioral
therapy. After more than 1 year of various medi-
cine trials, his symptoms seemed to stabilize and
EXAMPLE 14 -1: IMPAIRMENT DUE TO MAJOR
he was thought to have reached Maximum Medical
DEPRESSIVE EPISODE
Improvement (MMI).
A 55-year-old high-functioning real estate developer
After the reported treatment course, he reported
noted a change in his normal outlook where the “sky
he slept fairly well with only occasional insomia
was no longer blue but gray.” He said that food had
(1 night per month). He returned to within 10% of
no taste, and he could not concentrate on reading or
his preillness body weight. He still had episodic
television. Terminal insomnia and feelings of hope-
feelings of hopelessness and helplessness, but they
lessness and helplessness had developed. He felt his
Chapter 14
were brief. He felt his mood was generally good and

he had no passive death wishes. He had returned to
work on a half-time basis several months earlier and
TA B L E 14 -17
recently had increased to full time.
Impairment Score of Psychiatric Impairment
Rating Scale (PIRS) His ongoing psychiatric difficulties were three-
Sum of PIRS Middle Scores PIRS Impairment Score fold. First, his ability to concentrate had not fully
recovered. The patient estimated that his ablilties to
2 0%
concentrate on reading, hobbies, and work projects
3 5%
remained significantly diminished. He felt that his
4 10% ability to focus at work was diminished by 50%. His
5 15% work efficiency was approximately two thirds of his
6 20% premorbid level. Second, he continued to have some
7 30% anhedonia. He had only minor interest in sexual rela-
tions with his wife and minimal interest in social
8 40%
activities that had been a major part of their life
9–10 50%
together. If his wife pushed him, he would go out
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reluctantly. Third, he continued to have trouble with Table 14-14: 2

fatigue. He reported he could start out strong in the Table 14-15: 2
morning but by noon he would have to sit and relax Table 14-16: 2
almost to the point of needing a nap. Afterward he
Arrange the scores: 1, 1, 2, 2, 2, 2.
would feel good until about 3 PM, when he would
Select the middle 2 scores: 2, 2.
again feel the need to rest. He had arranged his
Sum of middle 2 scores: 4.
schedule around his needs for rest.
PIRS impairment score (Table 14-17): 10%.
Diagnosis: Axis I: Major depressive disorder, in
Step 4: List BPRS, GAF, and PIRS impairment scores
partial remission.
Axis II: None. BPRS impairment score: 0%.
Axis III: None. GAF impairment score: 5%.
PIRS impairment score: 10%.
M&BD Impairment Rating: 5%, calculated
according to the following 4 steps. Of the 3 impairment scores, the M&BD impairment
rating is the middle value: 5%.
Step 1: BPRS impairment score
Somatic concern: 1
EXAMPLE 14 -2: IMPAIRMENT DUE
Anxiety: 1
TO SCHIZOPHRENIA
Depression: 3
Suicidality: 1 A 32-year-old woman had her first psychotic break
Guilt: 1 at age 19 years, when she required hospitalization.
Hostility: 1 Organic workup revealed no medical cause for the
Elevated mood: 1 psychosis. Subsequent follow-up supported a diagno-
Grandiosity: 1 sis of schizophrenia, chronic undifferentiated type.
Suspiciousness: 1 Over the years of treatment her “positive” symptoms
Hallucinations: 1 of schizophrenia subsided, and she required lower
Unusual thought content: 1 doses of long-acting neuroleptics. She stopped taking
Bizarre behavior: 1 her medications on several occasions and had an
Self-neglect: 1 exacerbation of auditory hallucinations and thought
Disorientation: 1 disorder. She continued to live with her parents with-
Conceptual disorganization: 1 out trouble. She had no history of substance abuse.
Blunted affect: 1
On evaluation she seemed very organized and well
Emotional withdrawal: 2
put-together, reporting that over the last year she had
Motor retardation: 1
not suffered from any delusions, hallucinations, or
Tension: 1
thought flow difficulties. She stated that she was able
Uncooperativeness: 1
to complete her ADLs, including feeding, bathing,
Excitement: 1
dressing, and grooming. She described her appetite
Distractability: 1
Chapter 14
as good and sleep as restful. However, her affect
Motor hyperactivity: 1
appeared flat during most of the interview. When
Mannerisms and posturing: 1
asked about ADLs and social roles outside the home,
Sum the total of the 24 BPRS symptom construct she looked surprised and stated she did not think she
scores: 27. could function outside her home. When questioned
Find the BPRS impairment score in Table 14-9: 0%. about social interaction, she indicated she got along
very well with family and people that she was meet-
Step 2: Determine GAF impairment at MMI
ing for the first time. When questioned whether she
A GAF test score of 61 to 70 (mild symptoms or went out in public and interacted with new people, she
some difficulty in social, occupational, or school stated “no” but she did meet new people at her parents
functioning) elicits an impairment score of 5% house. When asked about concentration, she stated
(Table 14-10). that she enjoyed working out detailed problems, read-
ing mysteries, and working puzzles. She admitted that
Step 3: PIRS rating score
she did not feel she would do well in a highly struc-
Table 14-11: 1 tured setting where any “stress” was involved.
Table 14-12: 2
Because of possible variance among the appearance,
Table 14-13: 1
statements, and typical course of schizophrenia,
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permission was obtained to speak with her family. Disorientation: 2

The family supported some of her statements but Conceptual disorganization: 2
placed many in a different light. They agreed that Blunted affect: 4
she had not had symptoms of psychosis in the last Emotional withdrawal: 3
year. They also indicated that while she was able to Motor retardation: 1
meet her basic needs, she required a checklist in her Tension: 1
room, which she reviewed before leaving. She also Uncooperativeness: 1
had to have reminders about her appearance. When Excitement: 1
questioned whether she left the home, her mother Distractability: 1
indicated it would take 2 weeks to prepare her to Motor hyperactivity: 1
leave the house for a physician’s appointment, and Mannerisms and posturing: 1
she required accompaniment by a parent whenever
Sum the total of the 24 BPRS symptom construct
she went out.
scores: 39.
When asked about meeting new people in the home, Find the BPRS impairment score in Table 14-9: 10%.
the mother indicated her daughter would meet peo-
ple but left the room shortly after the introduction.
When questioned about concentration, the mother A GAF test score of 41 to 50 (serious symptoms or
stated that her daughter did seem to be interested in serious impairment in social, occupational, or school
“problems, mysteries, and puzzles” but she did not functioning) elicits an impairment score of 15%
offer solutions. When questioned about structured (Table 14-10).
situations and stress, she indicated her daughter
could not tolerate forced organization, timetables,
or conflict of any type in the home. Her mother felt Table 14-11: 3
one of the main problems was lack of motivation. Table 14-12: 3
Apparently, the family needed to keep her moving Table 14-13: 3
toward her basic activities. Her mother indicated Table 14-14: 4
that this was in contrast to her teen years, when she Table 14-15: 3
was focused and motivated. Her personality style Table 14-16: 4
had continued for the first 5 years of the illness, but
over the last 7 she seemed a different person. Several
temporary employment positions through a mental
health vocational agency were unsuccessful.
Diagnosis: Axis I: Schizophrenia, undifferentiated
type, with prominent negative symptoms.
Axis II: None. BPRS impairment score: 15%.
Axis III: None. GAF impairment score: 15%.
Chapter 14
Impairment Rating: 15%, calculated according to

the following 4 steps. Of the 3 impairment scores, the M&BD impairment
Somatic concern: 1
EXAMPLE 14 -3: POSTTRAUMATIC STRESS
Anxiety: 4
DISORDER
Depression: 2
Suicidality: 1 A 23-year-old carpenter had recently returned from
Guilt: 1 active military duty, where he participated in opera-
Hostility: 1 tions under fire. As an infantryman, he participated
Elevated mood: 1 in killing enemy combatants, and he witnessed
Grandiosity: 1 several platoon members suffering severe injury or
Suspiciousness: 1 death. He felt he could have saved one of them.
Hallucinations: 1
He returned home after his tour of duty, and returned
Unusual thought content: 2
to his premorbid occupation. He noted he “wanted
Bizarre behavior: 2
his old life back.” He became increasingly depressed
Self-neglect: 3
and declared his “nerves were shot.” He wondered if
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it would have been better if he had perished in armed Self-neglect: 2

conflict. He began to complain increasingly about Disorientation: 1
recurrent and intrusive recollections of the death of Conceptual disorganization: 1
a fellow soldier and about frequent nightmares about Blunted affect: 2
his experiences in Iraq. He became more avoidant Emotional withdrawal: 4
of friends and social contacts, and had decreasing Motor retardation: 1
interest in social activities. He became increasingly Tension: 3
irritable and hypervigilant. Uncooperativeness: 1
Excitement: 1
Upon return to his family, he remained emotion-
Distractability: 2
ally distant from his wife and children, describing a
psychological numbness. He was surprised that he
argued more frequently with his wife. He did not
socialize spontaneously, although he would see old Sum the total of the 24 BPRS symptom construct
friends if they sought him out. He returned to his scores: 43.
former job as a carpenter, but with markedly reduced Find the BPRS impairment score in Table 14-9: 20%.
productivity. He would sometimes become tearful or
anxious for no apparent reason and would leave work
on those occasions. A GAF test score of 51 to 60 (moderate symptoms or
moderate difficulty in social, occupational, or school
Several medication trials and combinations with
functioning) elicits an impairment score of 10%
an additional course of psychotherapy improved
(Table 14-10).
the symptom picture moderately. A portion of his
depressive complaints resolved. Some depressive fea- Step 3: PIRS rating score
tures were present, not meeting diagnostic threshold.
Table 14-11: 2
There was no evidence of substance abuse or depen-
Table 14-12: 3
dence before or after combat, and work and relation-
Table 14-13: 1
ship history did not suggest personality disorder.
Table 14-14: 2
On presentation, he was unshaven, seemed tense and Table 14-15: 2
anxious, and volunteered little spontaneously. He Table 14-16: 2
acknowledged he had not felt like himself for many
months. He reported vividly reliving combat epi-
sodes with some frequency. He was glad to be alive.
He reported the inability to feel close to his loved
ones.
Diagnosis: Axis I: Posttraumatic stress disorder,
partial remission. BPRS impairment score: 20%.
Axis II: None. GAF impairment score: 10%.
Chapter 14
Axis III: None. PIRS impairment score: 10%.
M&BD Impairment Rating: 10%, according to the Of the 3 impairment scores, the M&BD impairment
following 4 steps. rating is the middle value: 10%.
Somatic concern: 3 EXAMPLE 14 - 4: LOW BACK PAIN ASSOCIATED
Anxiety: 4 WITH ADJUSTMENT DISORDER
Depression: 3
A 49-year-old welder suffered a torn right medial
Suicidality: 2
meniscus and low back pain after a fall into a 2.4-m
Guilt: 3
(8-ft) hole. He had extensive bruising of the buttocks
Hostility: 2
and thigh. He continued to complain of left groin pain,
Elevated mood: 1
which was recalcitrant to aggressive conservative
Grandiosity: 1
management of low back pain. Neuroimaging was
Suspiciousness: 1
inconclusive. High-resolution magnetic resonance
Hallucinations: 1
imaging (MRI) revealed a free fragment of herniated
disk material at L2-3, which was not previously
Bizarre behavior: 1
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appreciated. He underwent microdiskectomy with Suicidality: 1

general improvement over the next few months, and Guilt: 1
his medial meniscus was repaired, with a favorable Hostility: 1
rehabilitation course. Yet his low back pain took a Elevated mood: 1
turn for the worse. Grandiosity: 1
Suspiciousness: 1
During the course of his low back rehabilitation his
Hallucinations: 1
mood declined and he became anxious. He partially
responded to a selective serotonin reuptake inhibi-
Bizarre behavior: 1
tor (SSRI) with moderate dosages of diazepam,
Self-neglect: 1
but improvement was short-lived. His anxiety and
Disorientation: 1
depression increased as his back pain worsened. His
Conceptual disorganization: 1
failure to improve prompted a change to mirtazapine
Blunted affect: 1
(Remeron), with a marked positive response. Again,
the improvement was short-lived.
Past medical history did not include a history of sub- Tension: 1
stance abuse, conduct disorder, or criminal history. Uncooperativeness: 1
There was a solid work history and a successful mili- Excitement: 1
tary history, demonstrating healthy preinjury adjust- Distractability: 1
ment. He had no mental health history. Records Motor hyperactivity: 1
indicated a stable weight. He denied any change in Mannerisms and posturing: 1
his sex life. He denied crying spells and continued
Sum the total of the 24 BPRS symptom construct
his wood-working projects in his garage.
scores: 31.
Repeated imaging showed an incompetent L2-3 disk Find the BPRS impairment score in Table 14-9: 10%.
with recurrent disk herniation, and he underwent
Step 2: Determine GAF Impairment at MMI
anterior fusion at L2-3 with instrumentation. After
fusion surgery he improved functionally and pain A GAF test score of 61 to 70 (mild symptoms or
improved to a point where he was receiving minimal some difficulty in social, occupational, or school
pain medications. He was able to return to full-time functioning) elicits an impairment score of 5%
light-duty work with minimal vegetative signs. He (Table 14-10).
had continued complaints of low mood and anxiety
2 months after return to work. Despite patient edu-
cation in regard to psychiatric treatment options, Table 14-11: 1
he refused additional medication adjustments or Table 14-12: 2
psychotherapy. Table 14-13: 1
Table 14-14: 1
On mental status examination he was clean, neat,
Table 14-15: 2
and cooperative. His psychomotor activity was
Chapter 14
Table 14-16: 2
within the normal range. He described his mood as
“not bad.” He was visibly anxious. There was no sui- Arrange the scores: 1, 1, 1, 2, 2, 2.
cidal thinking or psychosis. There was no evidence Select the middle 2 scores: 1, 2.
of cognitive impairment or slowing. Sum of middle 2 scores: 3.
Diagnosis: Axis I: Adjustment disorder with depres-
sion and anxiety. Step 4: List BPRS, GAF, and PIRS impairment
Axis II: None. scores
Axis III: Meniscal tear, herniated nucleus pulposa
BPRS impairment score: 10%.
requiring fusion.
GAF impairment score: 5%.
M&BD Impairment Rating: 0%, according to the PIRS impairment score: 5%.
following 4 steps.
In most cases of an MBD accompanying a physical
Step 1: BPRS impairment score impairment, the psychological issues are encom-
passed within the rating for the physical impairment,
Somatic concern: 3
and the MBD chapter should not be used.
Anxiety: 4
Depression: 3
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EXAMPLE 14 -5: COMPLEX ISSUES Medical history was pertinent for severe menstrual
pain in her teens, leading to missed school days
A 40-year-old, twice-divorced white woman was
and taking prescription pain medications. Both her
struck about the head and neck by a teenage resident
appendix and gallbladder were removed because of
at a treatment facility for adolescent behavior disor-
recurrent complaints of abdominal pain. She under-
ders. She sustained a scalp laceration without loss
went hysterectomy because of “an ovarian cyst” after
of consciousness. She inisted a photograph be taken
many years of unexplained pelvic pain. She had been
of the scene. Staff quickly came to her aid, and she
seen by a GI specialist for a variety of stomach com-
was taken to the emergency room where her lacera-
plaints, and a neurologist for “chronic migraines,”
tion was sutured. Radiographs of the cervical spine
although true migraine had never been diagnosed.
and computed tomography (CT) scan of the head
were negative. She had some mild musculoskeletal Her work history was pertinent for short-lived, low-
complaints. She was kept off work for several days, pay, low-skill jobs. She had been terminated from 2
and was prescribed a nonsteroidal anti-inflammatory positions after “going off” on her boss. Work atten-
drug and rest. dance had also been problematic.
She was seen for 2 visits by an Employee Assistance Other psychosocial stressors included the incarcera-
Program counselor. She reported anxiety and dif- tion of her 20-year-old son for drug trafficking. Her
ficulty sleeping, with frequent thoughts of the event. 22-year-old daughter had completed 10th grade but
The counselor informed her she had posttraumatic had never obtained a general equivalency diploma
stress disorder within 10 days of the event, and the (GED). The daughter went on to beauty school but had
documented history was scanty. Within 10 days she never worked in the field. Her daughter had 2 children
was released to work in the office, without exposure out of wedlock, received no assistance from either
to the adolescent residents. father of the children, and was receiving public aid.
She reported ongoing musculoskeletal complaints. A review of the primary care doctor’s records
Physical therapy and a variety of conservative inter- showed she had been prescribed several antidepres-
ventions decreased her complaints minimally. She sants over the years for vague complaints of anxiety,
reported becoming panicky when venturing out in and a smattering of vague somatic complaints.
public and described becoming more withdrawn and
Physical therapists noted her subjective complaints
reclusive. She was referred for psychiatric evaluation,
were out of proportion with her objective perfor-
at which time she was diagnosed with an adjustment
mance. Symptom exaggeration was suspected. She
disorder with anxiety and depressed mood. An SSRI
failed 7 of 10 validity indicators on a functional
was initiated at a low dose, and trazodone was pre-
capacity evaluation, which placed her performance
scribed for sleep.
in the “sedentary” category. She reported to thera-
She underwent an MMPI-2, which did not support pists she had traveled distances for vacations, which
posttraumatic stress disorder. she enjoyed. Medical records established essentially
stable weight over the past 10 years.
Her sleep, mood, and anxiety improved somewhat.
Chapter 14
Attempts to return her to work with adolescent Family history was pertinent for an alcoholic father, a
residents were met with resistance and claims of mother who had always been “sickly” and took diaz-
increasing anxiety. She would not participate in a epam for years, an incarcerated son, and a daughter
carefully designed graded exposure/desensitization who had a history of several suicide gestures.
protocol. During the day, she visited nearby friends
The patient reported drinking 4 to 5 shots of alcohol
and helped her aging mother run errands.
plus a 6-pack of beer on weekend nights, a history
It was learned that her live-in boyfriend was receiv- of 2 convictions for driving while intoxicated, and
ing social security disability for a work-related back intermittent use of marijuana and methamphet-
injury. She reported that taking his chronic opioid amine. Primary care physician notes reveal several
pain medications was helpful for her condition. reports of “lost” opioid prescriptions with requests
for replacements, as well as a history of requesting
Legal history revealed she had received a substantial
“nerve” pills with some regularity, both before and
financial settlement after a car accident several years
after the accident.
earlier, and she reported sustaining back and neck
injuries. She was receiving no ongoing treatment for She was independent in all ADLs and managed her
these conditions, conservative or surgical. She had home, grocery shopping, and bill-paying indepen-
obtained legal representation for the current work- dently. Her car was recently repossessed. She had
related incident.
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declared bankruptcy 5 years earlier, acknowledging Motor hyperactivity: 2

a debt of $50,000, mostly in unpaid credit card debts. Mannerisms and posturing: 1
On exam, she was markedly overweight with fair Sum the total of the 24 BPRS symptom construct
grooming, long hair and no makeup. Her boyfriend scores: 36.
accompanied her. He ambulated with a cane. Find the BPRS impairment score in Table 14-9: 15%.
Physical therapy records invariably revealed she was Step 2: Determine GAF impairment at MMI
pleasant and talkative with staff with no obvious
A GAF test score of 61 to 70 (mild symptoms or
signs of depression or anxiety. She reported a good
some difficulty in social, occupational, or school
relationship with her boyfriend. She denied a signifi-
functioning) elicits an impairment score of 5%
cant change thereof since the assault. She was able
(Table 14-10).
to describe their future plans: buying a new home in
the country. Step 3: PIRS rating score
There were minimal objective findings on mental Table 14-11: 2
status and physical exams, yet complaints of dis- Table 14-12: 2
abling anxiety and physical discomfort continued. Table 14-13: 1
Various treatment modalities—both physical and Table 14-14: 1
psychiatric—did little to decrease her subjective Table 14-15: 2
complaints over 12 months, so she was deemed to be Table 14-16: 2
at MMI.
Diagnosis: Axis I: Adjustment disorder with Select the middle 2 scores: 2, 2.
depression and anxiety, partially resolved; symp- Sum of middle 2 scores: 4.
tom exaggeration; secondary gain; somatization PIRS impairment score (Table 14-17): 10%.
disorder, preexisting; mixed substance abuse, R/O
dependence.
Axis II: Histrionic/somatoform (cluster B) features. BPRS impairment score: 15%.
Axis III: History of cervical strain. GAF impairment score: 5%.
M&BD Impairment Rating: 10%, according to the
following 4 steps. Of the 3 impairment scores, the M&BD impairment
Somatic concern: 4
Anxiety: 4 EXAMPLE 14 -6: ANTISOCIAL PERSONALITY
Depression: 2 DISORDER AND SUBSTANCE ABUSE
Suicidality: 1
A 32-year-old, twice-divorced white man presented
Guilt: 1
with the chief complaint, “It’s my nerves, Doc.” He
Chapter 14
Hostility: 1
was requesting diazepam (Valium). He complained
Elevated mood: 1
of chronic anxiety, temper flares, brief periods of
Grandiosity: 1
low moods associated with external stressors, diffi-
Suspiciousness: 1
culty getting along with people, and “panic attacks,”
Hallucinations: 1
described as periods of nervousness without other
associated physical symptoms.
Bizarre behavior: 1
Self-neglect: 2 Records showed he had received a variety of ben-
Disorientation: 1 zodiazepines from several sources, including emer-
Conceptual disorganization: 1 gency room physicians, family doctors, and company
Blunted affect: 1 doctors through numerous short employments. He
Emotional withdrawal: 2 reported several work injuries consistent with lumbar
Motor retardation: 1 strains, yet had been maintained on substantial dos-
Tension: 2 ages of opioids from various sources. He reported
Uncooperativeness: 1 taking various nerve and pain medicines belonging
Excitement: 1 to his girlfriend and other friends.
Distractability: 2
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He was 2 months into a 4-month employment as a With aggressive pharmacotherapy his positive symp-
roofer. Additional history revealed a stable weight and toms were diminished by approximately half. His med-
good appetite, sleep, and sex drive. He did not appear ications did not improve his insight, which was nil.
anxious. On exam he had long hair, multiple tattoos
Soon after hospital discharge he would inevitably
with violent imagery, and several self-applied tattoos.
discontinue his medications. When ill, he would
He reported an incarceration for assault and drug roam the streets, creating occasional altercations
trafficking. He stated he was abstinent from drink- with perceived attackers. More than once he had
ing but had had periods of heavy drinking with a been arrested for assault, which often precipitated
capacity for 0.95 L (1 qt) of hard liquor a day. He had his admissions. Conditional releases with mandated
received several summons for driving while intoxi- depot antipsychotics still did not improve his clinical
cated and had undergone two 30-day drug rehabilita- status sufficiently for stable independent living.
tion stays for alcohol, opioid, and cocaine abuse.
He would periodically abuse cocaine, usually just
His early history showed he met criteria for conduct after his social security check arrived. The cocaine
disorder with a history of physical fighting, repeated invariably caused a flare of his psychosis. Substance
truancy, stealing, and lying before the age of 15 abuse treatment proved fruitless. His drug use was
years. He repeatedly left short-lived job opportu- minimized by his having a state-appointed payee
nities due to “butting heads” with coworkers and supervise his spending.
bosses. He had lived in 10 different cities, stating he
On exam he was disheveled with poor dentition and
wanted to “see the country.” He had fathered 3 chil-
prominent body odor. His affect was blunted, and his
dren but had never consistently paid child support.
flow of thought was tangential. He was delusional
His explanation was that his wives were “ignorant.”
and hallucinating. He was paranoid, agitated, and
His family history was consistent with substance hostile and could tolerate only a brief interview.
abuse in multiple relatives. His father was incarcer-
His continuing paranoia made group home living
ated for violent crimes.
intolerable for him. He lived in a small state-sup-
He was noted to be superficially charming with female ported apartment. A community support worker
staff, initially ingratiating with the physician, and sub- ensured there was food in the house and took him to
sequently demanding and hostile when requests for the doctor’s appointments. The apartment was dirty and
benzodiazepine were not granted. He refused labora- in disarray, and he totally neglected his grooming.
tory tests or a toxicology screen and declined referral to Any layperson could easily identify the patient as
an outpatient substance abuse program. severely disturbed. He could be seen talking to him-
self and rummaging through garbage. He had never
Diagnosis: Axis I: Mixed substance dependence.
successfully maintained a job, and he had failed
Axis II: Antisocial personality disorder.
numerous temporary employee placements.
Axis III: No diagnosis.
There was no evidence for antisocial personality
No calculation of the BPRS, GAF, or PIRS score is
disorder. The severity of his illness interfered with
required. Mixed substance dependence and antiso-
Chapter 14
the development of a positive therapeutic alliance
cial personality disorder are not ratable in this chap-
with a psychiatrist. He refused medical and dental
ter. Disorders that are not ratable in this chapter are
care. Because he subsisted largely on fast food, he
listed in Section 14.1c.
was becoming obese. His parents were deceased and
he would have nothing to do with his sister, who was
herself reclusive. He spent most of his time wander-
EXAMPLE 14 -7: SCHIZOPHRENIA, SEVERE
ing the streets and required hospitalization on occa-
A 35-year-old African-American man had always sion due to exposure and dehydration.
been described as a loner. In his early 20s he became
Diagnosis: Axis I: Schizophrenia: chronic undiffer-
progressively more withdrawn and experienced mul-
entiated type, severe.
tiple paranoid delusions. He experienced auditory
Axis II: No diagnosis.
hallucinations—multiple voices delivering a run-
Axis III: No diagnosis.
ning commentary on his activities. He had a formal
thought disorder. He was psychiatrically hospitalized
on a number of occasions. The organic workup was
“negative.”
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M&BD Impairment Rating: 50%, according to the Sum the total of the 24 BPRS symptom construct
following 4 steps. scores: 91.
Find the BPRS impairment score in Table 14-9: 50%.
Somatic concern: 1
Anxiety: 4 A GAF test score of 1 to 10 (persistent danger of
Depression: 2 severely hurting self or others, persistent inability
Suicidality: 1 to maintain minimal personal hygiene, or serious
Guilt: 1 suicidal act with clear expectation of death) elicits an
Hostility: 7 impairment score of 50% (Table 14-10).
Elevated mood: 1
Grandiosity: 1
Suspiciousness: 7 Table 14-11: 4
Hallucinations: 6 Table 14-12: 5
Unusual thought content: 7 Table 14-13: 3
Bizarre behavior: 6 Table 14-14: 5
Self-neglect: 6 Table 14-15: 4
Disorientation: 1 Table 14-16: 5
Conceptual disorganization: 4
Blunted affect: 4
Tension: 5
Uncooperativeness: 6 Step 4: List BPRS, GAF, and PRIS impairment scores
Excitement: 3
BPRS impairment score: 50%.
Distractability: 5
GAF impairment score: 50%.
Of the 3 impairment scores, the M&BD impairment
Chapter 14
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14.8 Appendix: Brief Psychiatric 5. Moderately severe Frequent expressions of

somatic concern or exaggera-
Rating Scale (Expanded Version) tions of existing ills
or
some preoccupation and
This section reproduces an interview schedule, symp-
moderate impairment of
tom definitions, and specific anchor points for rating functioning. Not delusional.
symptoms on the BPRS. Clinicians intending to use 6. Severe Preoccupation with somatic
the BPRS should also consult the detailed guidelines complaints with much
for administration contained in Ventura et al.19 Rate impairment in functioning
construct items 1 to 14 on the basis of individual’s or
somatic delusions without
self-report. Note that items 7, 12, and 13 are also rated acting on them or disclosing
on the basis of observed behavior. Items 15–24 are to others
rated on the basis of observed behavior and speech. 7. Extremely severe Preoccupation with somatic
(See also Table 14-8.) complaints with severe
impairment in functioning
1. Somatic Concern or
somatic delusions that tend
Degree of Concern Over Present Bodily Health to be acted on or disclosed to
others
Rate the degree to which physical health is perceived
as a problem by the individual, whether complaints
Sample Questions
have realistic bases or not. Somatic delusions should
• Have you been concerned about your physical
be rated in the severe range with or without somatic
health?
concern. Note: Be sure to assess the degree of
impairment due to somatic concerns only, and not • Have you had any physical illness or seen a
other symptoms, such as depression. In addition, if medical doctor lately? (What does your doctor
the individual rates 6 or 7 due to somatic delusions, say is wrong? How serious is it?)
then you must rate Unusual Thought Content (symp-
• Has anything changed regarding your
tom 11) at least 4 or above.
appearance?
Symptom Severity Symptom • Has it interfered with your ability to perform
1. Not present
your usual activities and/or work?
2. Very mild Occasional somatic concerns • Did you ever feel that parts of your body had
that tend to be kept to self changed or stopped working?
3. Mild Occasional somatic concerns
that tend to be voiced to • [If individual reports any somatic concerns/
others (eg, family, doctor) delusions, ask the following] How often are you
4. Moderate Frequent expressions of concerned about [use individual’s description]?
somatic concern or exaggera-
tions of existing ills • Have you expressed any of these concerns to
Chapter 14
or others?
some preoccupation, but no
impairment in functioning.
Not delusional.
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2. Anxiety 3. Depression
Reported apprehension, tension, fear, panic, or Include sadness, unhappiness, anhedonia and pre-
worry. Rate only the individual’s statements, not occupation with depressing topics (can’t attend to
observed anxiety, which is rated under Tension. TV or conversations due to depression), hopeless,
loss of self-esteem (dissatisfied or disgusted with
Symptom Severity Symptom self or feelings of worthlessness). Do not include
1. Not present
vegetative symptoms (eg, motor retardation, early
waking, or the amotivation that accompanies the
2. Very mild Reports some discomfort due
to worry deficit syndrome).
or
infrequent worries that occur Symptom Severity Symptom
more than usual for most
normal individuals 1. Not present
3. Mild Worried frequently but can 2. Very mild Occasionally feels sad, unhappy,
readily turn attention to other or depressed
things 3. Mild Frequently feels sad or unhappy
4. Moderate Worried most of the time and but can readily turn attention
cannot turn attention to other to other things
things easily but no impairment 4. Moderate Frequent periods of feeling
in functioning very sad, unhappy, moderately
or depressed, but able to function
occasional anxiety with auto- with extra effort
nomic accompaniment but no
impairment in functioning 5. Moderately severe Frequent, but not daily, periods
of deep depression
5. Moderately severe Frequent, but not daily, periods or
of anxiety with autonomic some areas of functioning are
accompaniment disrupted by depression
or
some areas of functioning are 6. Severe Deeply depressed daily but not
disrupted by anxiety or worry persisting throughout the day
or
6. Severe Anxiety with autonomic many areas of functioning are
accompaniment daily but not disrupted by depression.
persisting throughout the day
or 7. Extremely severe Deeply depressed daily
many areas of functioning are or
disrupted by anxiety or constant most areas of functioning are
worry disrupted by depression
7. Extremely severe Anxiety with autonomic

Sample Questions
accompaniment persisting
throughout the day • How has your mood been recently? Have you felt
or depressed (sad, down, unhappy, as if you didn’t
most areas of functioning are care)?
disrupted by anxiety or constant
Chapter 14
worry • Are you able to switch your attention to more

pleasant topics when you want to?
Sample Questions
• Have you been worried a lot during [mention time • Do you find that you have lost interest in or get
frame]? Have you been nervous or apprehensive? less pleasure from things you used to enjoy, like
(What do you worry about?) family, friends, hobbies, watching TV, eating?
• Are you concerned about anything? How about [If individual reports feelings of depression, ask the
finances or the future? following]:
• When you are feeling nervous, do your palms • How long do these feelings last?
sweat or does your heart beat fast (or shortness of
• Has it interfered with your ability to perform
breath, trembling, choking)?
your usual activities?
• [If individual reports anxiety or autonomic
accompaniment, ask the following] How much
of the time have you been [use individual’s
description]?
• Has it interfered with your ability to perform
your usual activities/work?
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4. Suicidality 5. Guilt
Expressed desire, intent, or actions to harm or Overconcern or remorse for past behavior. Rate only
kill self. individual’s statements. Do not infer guilt feelings
from depression, anxiety, or neurotic defenses. Note:
Symptom Severity Symptom if the individual rates 6 or 7 due to delusions of guilt,
1. Not present
then you must rate Unusual Thought Content at least
4 or above, depending on level of impairment.
2. Very mild Occasional feelings of being
tired of living. No overt suicidal
thoughts. Symptom Severity Symptom
3. Mild Occasional suicidal thoughts 1. Not present
without intent or specific plan
2. Very mild Concerned about having failed
or
someone, or at something,
he or she feels he or she would
but not preoccupied. Can shift
be better off dead
thoughts to other matters easily.
4. Moderate Suicidal thoughts frequent
3. Mild Concerned about having failed
without intent or plan
someone, or at something, with
5. Moderately severe Many fantasies of suicide by some preoccupation. Tends to
various methods. May seriously voice guilt to others
consider making an attempt
4. Moderate Disproportionate preoccupa-
with specific time and plan
tion with guilt, having done
or
wrong, injured others by doing
impulsive suicide attempt using
or failing to do something, but
nonlethal method or in full view
can readily turn attention to
of potential saviors
other things
6. Severe Clearly wants to kill self.
5. Moderately severe Preoccupation with guilt,
Searches for appropriate means
having failed someone or at
and time
something, can turn attention
or
to other things, but only with
potentially serious suicide
great effort. Not delusional.
attempt with individual
knowledge of possible rescue 6. Severe Delusional guilt
or
7. Extremely severe Specific suicidal plan and intent
unreasonable self-reproach
(eg, as soon as , I will
very out of proportion to
do it by doing X)
circumstances. Moderate
or
preoccupation present.
suicide attempt characterized
by plan, individual thought was 7. Extremely severe Delusional guilt
lethal, or attempt in secluded or
environment unreasonable self-reproach
grossly out of proportion to
Sample Questions circumstances. Individual is very
preoccupied with guilt and is
• Have you felt that life wasn’t worth living?
likely to disclose to others or
Chapter 14
• Have you thought about harming or killing act on delusions.
yourself?
Sample Questions
• Have you felt tired of living or as though you • Is there anything you feel guilty about?
would be better off dead?
• Have you been thinking about past problems?
• Have you ever felt like ending it all?
• Do you tend to blame yourself for things that
[If individual reports suicidal ideation, ask the have happened?
following]:
• Have you done anything you’re still ashamed of?
• How often have you thought about [use
[If individual reports guilt/remorse/delusions, ask
individual’s description]?
the following]:
• Did you (Do you) have a specific plan?
• How often have you been thinking about [use
• Have you disclosed your feelings of guilt to
others?
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6. Hostility 7. Elevated Mood

Animosity, contempt, belligerence, threats, A pervasive, sustained, and exaggerated feeling of
arguments, tantrums, property destruction, fights, well-being, cheerfulness, euphoria (implying a patho-
and any other expression of hostile attitudes logical mood), optimism that is out of proportion to
or actions. Do not infer hostility from neurotic the circumstances. Do not infer elation from increased
defenses, anxiety, or somatic complaints. Do not activity or from grandiose statements alone.
include incidents of appropriate anger or obvious
self-defense. Symptom Severity Symptom
1. Not present
Symptom Severity Symptom 2. Very mild Seems to be very happy,
1. Not present cheerful without much reason
2. Very mild Irritable or grumpy, but not 3. Mild Some unaccountable feelings
overtly expressed of well-being that persist
3. Mild Argumentative or sarcastic 4. Moderate Reports excessive or unreal-
istic feelings of well-being,
4. Moderate Overtly angry on several
cheerfulness, confidence, or
occasions
optimism inappropriate to cir-
or
cumstances, some of the time
yelled at others excessively
May frequently joke, smile, be
5. Moderately severe Has threatened, slammed
giddy or overly enthusiastic
about or thrown things
or
6. Severe Has assaulted others but with few instances of marked
no harm likely, eg, slapped or elevated mood with euphoria
pushed
5. Moderately severe Reports excessive or unreal-
or istic feelings of well-being,
destroyed property, eg, confidence, or optimism inap-
knocked over furniture, propriate to circumstances,
broken windows much of the time. May
describe feeling “on top of
7. Extremely severe Has attacked others with
the world,” like “everything is
definite possibility of harming
falling into place,” or “better
them or with actual harm,
than ever before”
eg, assault with hammer or
or
weapon
several instances of marked
elevated mood with euphoria
Sample Questions
6. Severe Reports many instances of
• How have you been getting along with people marked elevated mood with
(family, coworkers, etc)? euphoria
or
• Have you been irritable or grumpy lately? mood definitely elevated
almost constantly throughout
• How do you show it? Do you keep it to yourself? interview and inappropriate
Chapter 14
to content
• Were you ever so irritable that you would shout at
people or start fights or arguments? 7. Extremely severe Individual reports being
elated or appears almost
• Have you found yourself yelling at people you intoxicated, laughing, joking,
giggling, constantly euphoric,
didn’t know? feeling invulnerable, all
inappropriate to immediate
• Have you hit anyone recently?
circumstances
Sample Questions
• Have you felt so good or high that other people
thought that you were not your normal self?
• Have you been feeling cheerful and “on top of the
world” without any reason?
[If individual reports elevated mood/euphoria, ask
the following]:
• Did it seem like more than just feeling good?
• How long did that last?
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8. Grandiosity 9. Suspiciousness
Exaggerated self-opinion, self-enhancing conviction Expressed or apparent belief that other persons have
of special abilities or powers, or identity as someone acted maliciously or with discriminatory intent.
rich or famous. Rate only individual’s statements Include persecution by supernatural or other nonhu-
about himself or herself, not his or her demeanor. man agencies (eg, the devil). Note: Ratings of 3 or
Note: If the individual rates 6 or 7 due to grandiose above should also be rated under Unusual Thought
delusions, you must rate Unusual Thought Content at Content.
least 4 or above.
Symptom Severity Symptom
1. Not present
1. Not present
2. Very mild Seems on guard. Reluctant to
2. Very mild Feels great and denies respond to some “personal”
obvious problems, but not questions. Reports being
unrealistic overly self-conscious in public.
3. Mild Exaggerated self-opinion 3. Mild Describes incidents in
beyond abilities and training which others have harmed
4. Moderate Inappropriate boastfulness, or wanted to harm him or
eg, claims to be brilliant, her that sound plausible.
insightful, or gifted beyond Individual feels as if others
realistic proportions, but are watching, laughing,
rarely self-discloses or acts on or criticizing him or her in
these inflated self-concepts. public, but this occurs only
Does not claim that grandiose occasionally or rarely. Little or
accomplishments have no preoccupation.
actually occurred. 4. Moderate Says other persons are talking
5. Moderately severe Same as 4 but often self- about him or her maliciously,
discloses and acts on these have negative intentions, or
grandiose ideas. May have may harm him or her. Beyond
doubts about the reality of the likelihood of plausibility,
the grandiose ideas. Not but not delusional. Incidents
delusional. of suspected persecution
occur occasionally (less than
6. Severe Delusional—claims to have once per week) with some
special powers like extrasen- preoccupation.
sory perception (ESP), to have
millions of dollars, invented 5. Moderately severe Same as 4, but incidents occur
new machines, worked at jobs frequently, such as more than
when it is known that he or once per week.
she was never employed in Individual is moderately
these capacities, or be Jesus preoccupied with ideas of
Christ or the US president. persecution
Individual may not be very or
preoccupied. individual reports persecutory
Chapter 14
7. Extremely severe Delusional—same as 6 but delusions expressed with
individual seems very preoc- much doubt (eg, partial
cupied and tends to disclose delusion)
or act on grandiose delusions. 6. Severe Delusional—speaks of Mafia
plots, the Federal Bureau of
Sample Questions Investigation (FBI), or others
• Is there anything special about you? poisoning his or her food,
persecution by supernatural
• Do you have any special abilities or powers? forces
• Have you thought that you might be somebody 7. Extremely severe Same as 6, but the beliefs are
bizarre or more preoccupying.
rich or famous? Individual tends to disclose or
act on delusions.
[If the individual reports any grandiose ideas/
delusions, ask the following]:
Sample Questions
• How often have you been thinking about [use • Do you ever feel uncomfortable in public?
• Does it seem as though others are watching you?
• Have you told anyone about what you have been
• Are you concerned about anyone’s intentions
thinking?
toward you?
• Have you acted on any of these ideas?
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6. Severe Experiences verbal or visual

• Is anyone going out of their way to give you a hallucinations several times
hard time, or trying to hurt you? a day
or
• Do you feel in any danger? many areas of functioning
are disrupted by these
[If individual reports any persecutory ideas/delu- hallucinations
sions, ask the following]: 7. Extremely Persistent verbal or visual
severe hallucinations throughout the
• How often have you been concerned that [use day
individual’s description]? or
most areas of functioning
• Have you told anyone about these experiences? are disrupted by these
hallucinations
10. Hallucinations
Sample Questions
Reports of perceptual experiences in the absence of
• Do you ever seem to hear your name being
relevant external stimuli. When rating degree to which
called?
functioning is disrupted by hallucinations, include
preoccupation with the content and experience of the • Have you heard any sounds or people talking to
hallucinations, as well as functioning disrupted by you or about you when there has been nobody
acting out on the hallucinatory content (eg, engaging around?
in deviant behavior due to command hallucinations).
[If hears voices, ask the following]:
Include thoughts aloud (“Gedenkenlautwerden”) or
pseudohallucinations (eg, hears a voice inside head) if • What does/do the voice/voices say?
a voice quality is present.
• Did it have a voice quality?
Symptom Severity Symptom • Do you ever have visions or see things that others
1. Not present
do not see?
2. Very mild While resting or going to • Do you smell odors that others do not smell?
sleep, sees visions, smells
odors, or hears voices, sounds, [If the individual reports hallucinations, ask the
or whispers in the absence of following]:
external stimulation, but no
impairment in functioning • Have these experiences interfered with your
3. Mild While in a clear state of ability to perform your usual activities/work?
consciousness, hears a voice
calling the individual’s name, • How do you explain them?
experiences nonverbal audi-
tory hallucinations (eg, sounds • How often do they occur?
or whispers), formless visual
hallucinations or has sensory 11. Unusual Thought Content
experiences in the presence of Unusual, odd, strange, or bizarre thought content.
a modality-relevant stimulus
Chapter 14
(eg, visual illusions) infre- Rate the degree of unusualness, not the degree of
quently (eg, 1–2 times per disorganization of speech. Delusions are patently
week) and with no functional absurd, clearly false, or bizarre ideas that are
impairment
expressed with full conviction. Consider the
4. Moderate Occasional verbal, visual, individual to have full conviction if he or she has
gustatory, olfactory, or
tactile hallucinations with no
acted as though the delusional belief was true. Ideas
functional impairment of reference or persecution can be differentiated
or from delusions in that ideas are expressed with much
nonverbal auditory doubt and contain more elements of reality. Include
hallucinations/visual illusions
more than infrequently or with
thought insertion, withdrawal, and broadcast. Include
impairment grandiose, somatic, and persecutory delusions even
5. Moderately severe Experiences daily if rated elsewhere. Note: If Somatic Concern, Guilt,
hallucinations Suspiciousness, or Grandiosity are rated 6 or 7 due
or to delusions, then Unusual Thought Content must be
some areas of functioning are rated 4 or above.
disrupted by hallucinations
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1. Not present
• Have you felt that you were under the control of
another person or force?
2. Very mild Ideas of reference (people
may stare or may laugh at [If individual reports any odd ideas/delusions, ask
him), ideas of persecution
the following]:
(people may mistreat him).
Unusual beliefs in psychic • How often do you think about [use individual’s
powers, spirits, unidentified
flying objects (UFOs), or description]?
unrealistic beliefs in one’s
own abilities. Not strongly
• Have you told anyone about these experiences?
held. Some doubt. How do you explain the things that have been
3. Mild Same as 2, but degree of
happening [specify]?
reality distortion is more
Rate items 12 to 13 on the basis of individual’s self-
severe as indicated by highly
unusual ideas or greater report and observed behavior.
conviction. Content may be
typical of delusions (even 12. Bizarre Behavior
bizarre), but without full
conviction. The delusion
Reports of behaviors which are odd, unusual, or
does not seem to have fully psychotically criminal. Not limited to interview
formed, but is considered as period. Include inappropriate sexual behavior and
one possible explanation for inappropriate affect.
an unusual experience.
4. Moderate Delusion present but no
preoccupation or functional
impairment. May be an 1. Not present
encapsulated delusion or
2. Very mild Slightly odd or eccentric pub-
a firmly endorsed absurd
lic behavior (eg, occasionally
belief about past delusional
giggles to self, fails to make
circumstances.
appropriate eye contact) that
5. Moderately severe Full delusion(s) present with does not seem to attract the
some preoccupation attention of others
or or
some areas of functioning dis- unusual behavior conducted
rupted by delusional thinking in private, eg, innocuous ritu-
als, that would not attract the
6. Severe Full delusion(s) present with
attention of others
much preoccupation
or 3. Mild Noticeably peculiar public
many areas of functioning behavior, eg, inappropriately
are disrupted by delusional loud talking, makes inappro-
thinking priate eye contact,
or
7. Extremely severe Full delusion(s) present with
private behavior that occa-
almost total preoccupation
sionally, but not always,
or
attracts the attention of oth-
Chapter 14
most areas of functioning dis-
ers, eg, hoards food, conducts
rupted by delusional thinking
unusual rituals, wears gloves
indoors
Sample Questions
• Have you been receiving any special messages 4. Moderate Clearly bizarre behavior that
attracts or (if done privately)
from people or from the way things are arranged would attract the attention
around you? or concern of others, but with
no corrective intervention
• Have you seen any references to yourself on TV necessary. Behavior occurs
or in the newspapers? occasionally, eg, fixated
staring into space for several
• Can anyone read your mind? minutes, talks back to voices
once, inappropriate giggling/
• Do you have a special relationship with God? laughter on 1–2 occasions,
talking loudly to self.
• Is anything like electricity, X rays, or radio waves
affecting you?
• Are thoughts put into your head that are not your
own?
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5. Moderately severe Clearly bizarre behavior that 4. Moderate Hygiene/appearance is notice-

attracts or (if done privately) ably below usual community
would attract the attention standards, eg, fails to bathe
of others or the authorities, or change clothes, clothing
eg, fixated staring in a socially very soiled, hair unkempt,
disruptive way, frequent inap- needs prompting, noticeable
propriate giggling/laughter, by others
occasionally responds to or
voices, or eats non-foods irregular eating and drinking
with minimal medical con-
6. Severe Bizarre behavior that attracts
cerns and consequences
attention of others and
intervention by authorities, 5. Moderately Several areas of hygiene/
eg, directing traffic, public severe appearance are below usual
nudity, staring into space for community standards
long periods, carrying on a or
conversation with hallucina- poor grooming draws criti-
tions, frequent inappropriate cism by others and requires
giggling/laughter regular prompting. Eating
or hydration is irregular and
7. Extremely Serious crimes committed in
poor, causing some medical
severe a bizarre way that attract the
problems.
attention of others and the
control of authorities, eg, sets 6. Severe Many areas of hygiene/
fires and stares at flames appearance are below usual
or community standards, does
almost constant bizarre not always bathe or change
behavior, eg, inappropriate clothes even if prompted.
giggling/laughter, responds Poor grooming has caused
only to hallucinations and can- social ostracism at school/
not be engaged in interaction residence/work or required
intervention. Eating erratic
Sample Questions and poor, may require
medical intervention.
• Have you done anything that has attracted the
attention of others? 7. Extremely Most areas of hygiene/
severe appearance/nutrition are
• Have you done anything that could have gotten extremely poor and easily
noticed as below usual com-
you into trouble with the police? munity standards
or
• Have you done anything that seemed unusual or hygiene/appearance/nutrition
disturbing to others? require urgent and immediate
medical intervention
13. Self-neglect
Hygiene, appearance, or eating behavior below usual Sample Questions
expectations, below socially acceptable standards, or • How has your grooming been lately?
life-threatening.
• How often do you change your clothes?
Chapter 14
Symptom Severity Symptom • How often do you take showers?

1. Not present • Has anyone (parents/staff) complained about
2. Very mild Hygiene/appearance slightly your grooming or dress?
below usual community stan-
dards, eg, shirt out of pants, • Do you eat regular meals?
buttons unbuttoned, shoe
laces untied, but no social or 14. Disorientation
medical consequences
Does not comprehend situations or communications,
3. Mild Hygiene/appearance occasion-
such as questions asked during the entire BPRS
ally below usual community
standards, eg, irregular bath- interview. Confusion regarding person, place, or
ing, clothing is stained, hair time. Do not rate if incorrect responses are due to
uncombed, occasionally skips delusions.
an important meal. No social
or medical consequences.
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1. Not present
15. Conceptual Disorganization
Degree to which speech is confused, disconnected,
2. Very mild Seems muddled or mildly
confused 1–2 times during
vague, or disorganized. Rate tangentiality, sud-
interview. Oriented to person, den topic shifts, incoherence, derailment, blocking,
place, and time. neologisms, and other speech disorders. Do not rate
3. Mild Occasionally muddled or content of speech.
mildly confused 3–4 times
during interview. Minor inac-
curacies in person, place, or Symptom Severity Symptom
time, eg, date off by more 1. Not present
than 2 days, or gives wrong
2. Very mild Peculiar use of words or
division of hospital or com-
rambling but speech is
munity center.
comprehensible
4. Moderate Frequently confused during
3. Mild Speech a bit hard to under-
interview. Minor inaccura-
stand or make sense of due to
cies in person, place, or time
tangentiality, or sudden topic
are noted, as in 3 above. In
shifts
addition, may have difficulty
remembering general infor- 4. Moderate Speech difficult to under-
mation, eg, name of the US stand due to tangentiality,
president. circumstantiality, idiosyncratic
speech, or topic shifts on
5. Moderately severe Markedly confused during
many occasions
interview, or to person, place,
or
or time. Significant inaccura-
1–2 instances of incoherent
cies are noted, eg, date off by
phrases
more than 1 week, or cannot
give correct name of hospital. 5. Moderately severe Speech difficult to understand
Has difficulty remembering due to circumstantiality,
personal information, eg, tangentiality, neologisms,
where he or she was born or blocking or topic shifts most
recognizing familiar people. of the time
or
6. Severe Disoriented as to person,
3–5 instances of incoherent
place, or time, eg, cannot
phrases
give correct month and year.
Disoriented in 2 of 3 spheres. 6. Severe Speech is incomprehensible
due to severe impairment
7. Extremely severe Grossly disoriented as to per-
most of the time. Many BPRS
son, place, or time, eg, cannot
items cannot be rated by self-
give name or age. Disoriented
report alone.
in all 3 spheres.
7. Extremely severe Speech is incomprehensible
Sample Questions throughout interview
• May I ask you some standard questions we ask
everybody?
Chapter 14
• How old are you?
• What is the date? [allow 2 days]
• What is this place called?
• What year were you born?
• Who is the US president?
Rate items 15 to 24 on the basis of observed behavior
and speech.
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16. Blunted Affect 17. Emotional Withdrawal

Restricted range in emotional expressiveness of face, Deficiency in individual’s ability to relate emotion-
voice, and gestures. Marked indifference even when ally during interview situation. Use your own feeling
discussing distressing topics. In the case of euphoric as to the presence of an “invisible barrier” between
or dysphoric individuals, rate Blunted Affect if a flat individual and interviewer. Include withdrawal
quality is also clearly present. apparently due to psychotic processes.
Symptom Severity Symptom Symptom Severity Symptom

1. Not present 1. Not present
2. Very mild Emotional range is slightly 2. Very mild Lack of emotional involve-
subdued or reserved but ment shown by occasional
displays appropriate facial failure to make reciprocal
expressions and tone of voice comments, appearing preoc-
that are within normal limits cupied, or smiling in a stilted
manner, but spontaneously
3. Mild Emotional range overall is
engages the interviewer most
diminished, subdued, or
of the time
reserved, without many
spontaneous and appropriate 3. Mild Lack of emotional involve-
emotional responses. Voice ment shown by noticeable
tone is slightly monotonous. failure to make reciprocal
comments, appearing preoc-
4. Moderate Emotional range is noticeably
cupied, or lacking in warmth,
diminished, individual doesn’t
but responds to interviewer
show emotion, smile, or react
when approached
to distressing topics except
infrequently. Voice tone 4. Moderate Emotional contact not
is monotonous or there is present much of the interview
noticeable decrease in spon- because individual does not
taneous movements. Displays elaborate responses, fails to
of emotion or gestures are make eye contact, doesn’t
usually followed by a return seem to care if interviewer
to flattened affect. is listening, or may be
preoccupied with psychotic
5. Moderately severe Emotional range very dimin-
material
ished, individual doesn’t
show emotion, smile, or react 5. Moderately severe Same as 4, but emotional
to distressing topics except contact not present most of
minimally, few gestures, the interview
facial expression does not
6. Severe Actively avoids emotional
change very often. Voice tone
participation. Frequently
is monotonous much of the
unresponsive or responds
time.
with yes/no answers (not
6. Severe Very little emotional range solely due to persecutory
or expression. Mechanical delusions). Responds with
in speech and gestures most only minimal affect.
Chapter 14
of the time. Unchanging

7. Extremely severe Consistently avoids emotional
facial expression. Voice tone
participation. Unresponsive or
is monotonous most of the
responds with yes/no answers
time.
(not solely due to persecutory
7. Extremely severe Virtually no emotional delusions). May leave during
range or expressiveness, stiff interview or just not respond
movements. Voice tone is at all.
monotonous all of the time.
Use the following probes at end of interview to

assess emotional responsivity:
• Have you heard any good jokes lately?
• Would you like to hear a joke?
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4. Moderate Many and frequent signs of

18. Motor Retardation motor tension, with 1 or more
Reduction in energy level evidenced by slowed signs sometimes occurring
simultaneously, eg, wagging
movements and speech, reduced body tone, one’s foot while wringing
decreased number of spontaneous body movements. hands together. There are
Rate on the basis of observed behavior of the times when no signs of
individual. Do not rate on the basis of individual’s tension are present.
subjective impression of his own energy level. Rate 5. Moderately severe Many and frequent signs
regardless of medication effects. of motor tension, with 1 or
more signs often occurring
simultaneously. There are still
Symptom Severity Symptom rare times when no signs of
tension are present.
1. Not present
6. Severe Same as 5, but signs of
2. Very mild Slightly slowed or reduced tension are continuous
movements or speech
compared to most people 7. Extremely severe Multiple motor manifestations
of tension are continuously
3. Mild Noticeably slowed or reduced present, eg, continuous
movements or speech pacing and hand wringing
compared to most people
4. Moderate Large reduction or slowness
in movements or speech 20. Uncooperativeness
5. Moderately severe Seldom moves or speaks Resistance and lack of willingness to cooperate with
spontaneously the interview. The uncooperativeness might result
or
very mechanical or stiff
from suspiciousness. Rate only uncooperativeness
movements in relation to the interview, not behaviors involving
6. Severe Does not move or speak peers and relatives.
unless prodded or urged
7. Extremely severe Frozen, catatonic Symptom Severity Symptom
1. Not present
2. Very mild Shows nonverbal signs of
19. Tension reluctance, but does not
Observable physical and motor manifestations of complain or argue
tension, nervousness, and agitation. Self-reported 3. Mild Gripes or tries to avoid
experiences of tension should be rated under the complying, but goes ahead
item on anxiety. Do not rate if restlessness is solely without argument
akathisia, but do rate if akathisia is exacerbated by 4. Moderate Verbally resists but eventually
tension. complies after questions are
rephrased or repeated
5. Moderately severe Same as 4, but some informa-
tion necessary for accurate
Chapter 14
1. Not present ratings is withheld
2. Very mild More fidgety than most but 6. Severe Refuses to cooperate with
within normal range. A few interview, but remains in
transient signs of tension, interview situation
eg, picking at fingernails,
7. Extremely severe Same as 6, with active efforts
foot wagging, scratching
to escape the interview
scalp several times, or finger
tapping.
3. Mild Same as 2, but with more
frequent or exaggerated signs
of tension
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21. Excitement 22. Distractibility

Heightened emotional tone or increased emotional Degree to which observed sequences of speech and
reactivity to interviewer or topics being discussed, actions are interrupted by stimuli unrelated to the
as evidenced by increased intensity of facial expres- interview. Distractibility is rated when the individual
sions, voice tone, expressive gestures, or increase in shows a change in the focus of attention as charac-
speech quantity and speed. terized by a pause in speech or a marked shift in
gaze. Individual’s attention may be drawn to noise
Symptom Severity Symptom in adjoining room, books on a shelf, interviewer’s
1. Not present
clothing, and so on. Do not rate circumstantiality,
tangentiality, or flight of ideas. Also, do not rate
2. Very mild Subtle and fleeting or ques-
tionable increase in emo- rumination with delusional material. Rate even if the
tional intensity. For example, distracting stimulus cannot be identified.
at times seems keyed-up or
overly alert.
3. Mild Subtle but persistent increase
in emotional intensity. 1. Not present
For example, lively use of 2. Very mild Generally can focus on inter-
gestures and variation in viewer’s questions with only
voice tone. 1 distraction or inappropri-
4. Moderate Definite but occasional ate shift of attention of brief
increase in emotional inten- duration
sity. For example, reacts to 3. Mild Individual shifts focus
interviewer or topics that are of attention to matters
discussed with noticeable unrelated to the interview
emotional intensity. Some 2–3 times
pressured speech.
4. Moderate Often responsive to irrelevant
5. Moderately severe Definite and persistent stimuli in the room, eg, averts
increase in emotional inten- gaze from the interviewer
sity. For example, reacts to
5. Moderately severe Same as above, but now
many stimuli, whether rele-
distractibility clearly
vant or not, with considerable
interferes with the flow of
emotional intensity. Frequent
the interview
pressured speech.
6. Severe Extremely difficult to conduct
6. Severe Marked increase in emotional
interview or pursue a topic
intensity. For example, reacts
due to preoccupation with
to most stimuli with inap-
irrelevant stimuli
propriate emotional intensity.
Has difficulty settling down 7. Extremely severe Impossible to conduct inter-
or staying on task. Often rest- view due to preoccupation
less or impulsive, or speech is with irrelevant stimuli
often pressured.
7. Extremely severe Marked and persistent
Chapter 14
increase in emotional inten-

sity. Reacts to all stimuli
with inappropriate intensity,
impulsiveness. Cannot settle
down or stay on task. Very
restless and impulsive most of
the time. Constant pressured
speech.
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23. Motor Hyperactivity 24. Mannerisms and Posturing

Increase in energy level evidenced in more frequent Unusual and bizarre behavior, stylized movements
movement and/or rapid speech. Do not rate if rest- or acts, or any postures which are clearly
lessness is due to akathisia. uncomfortable or inappropriate. Exclude obvious
manifestations of medication side effects. Do not
Symptom Severity Symptom include nervous mannerisms that are not odd or
1. Not present unusual.
2. Very mild Some restlessness, diffi-
culty sitting still, lively facial
expressions, or somewhat
talkative 1. Not present
3. Mild Occasionally very restless, 2. Very mild Eccentric or odd mannerisms
definite increase in motor or activity that ordinary
activity, lively gestures, 1–3 persons would have difficulty
brief instances of pressured explaining, eg, grimacing,
speech picking. Observed once for a
brief period.
4. Moderate Very restless, fidgety, exces-
sive facial expressions, or non- 3. Mild Same as 2, but occurring on
productive and repetitious 2 occasions of brief duration
motor movements. Much 4. Moderate Mannerisms or posturing,
pressured speech, up to one eg, stylized movements
third of the interview. or acts, rocking, nodding,
5. Moderately severe Frequently restless, fidgety. rubbing, or grimacing,
Many instances of excessive observed on several
nonproductive and repeti- occasions for brief periods or
tious motor movements. On infrequently but very odd.
the move most of the time. For example, uncomfortable
Frequent pressured speech, posture maintained for 5
difficult to interrupt. Rises on seconds more than twice.
1–2 occasions to pace. 5. Moderately severe Same as 4, but occurring
6. Severe Excessive motor activity, rest- often, or several examples
lessness, fidgety, loud tap- of very odd mannerisms
ping, noisy, etc, throughout or posturing that are
most of the interview. Speech idiosyncratic to the individual
can only be interrupted with 6. Severe Frequent stereotyped
much effort. Rises on 3–4 behavior, assumes and
occasions to pace. maintains uncomfortable
7. Extremely severe Constant excessive motor or inappropriate postures,
activity throughout entire intense rocking, smearing,
interview, eg, constant strange rituals, or fetal
pacing, constant pressured posturing. Individual can
speech with no pauses, interact with people and the
individual can only be environment for brief periods
Chapter 14
interrupted briefly and only despite these behaviors.
small amounts of relevant 7. Extremely severe Same as 6, but individual
information can be obtained cannot interact with people
or the environment due to
these behaviors
Guides6e_14_347-382.indd 381 2/17/09 2:55:09 PM

10. Lezak MD, Howieson DB, Loring DW, with Hannay

References HJ, Fischer JS. Neuropsychological Assessment. 4th ed.
Oxford, NY: Oxford University Press Inc; 2004.
1. American Psychiatric Association. Diagnostic and 11. American Academy of Neurology. Assessment:
Statistical Manual of Mental Disorders. Fourth neuropsychological testing of adults. Neurology.
Edition, Text Revision. Washington, DC: American 1996;47:592–599.
Psychiatric Association;2000.
12. Martelli MF, ed. Controversies in neuropsychology.
2. Feigner JP, Robins E, Guze S, et al. Diagnostic criteria Neurorehabilitation. 2001;16(4).
for use in psychiatric research. Arch Gen Psychiatry.
13. Strasburger LH, Gutheil TG, Brodsky A. On
1972;26:27–63.
wearing two hats: role conflict in serving as both
3. McHugh PR. Striving for coherence: psychiatry’s efforts psychotherapist and expert witness. Am J Physicatry.
over classification. JAMA. 2005;293:2526–2528. 1997;154:448–456.
4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas 14. Meyerson A. Malingering. In: Sadock BJ, Sadock VA,
KR, Walters EE. Lifetime prevalence and age-of-onset eds. Kaplan & Sadock’s Comprehensive Textbook of
distributions of DSM-IV disorders in the national Psychiatry. Vol 1. 7th ed. Philadelphia, Pa: Williams &
comorbidity survey replication. Arch Gen Psychiatry. Wilkins; 2000.
2005;62:593–602.
15. Rogers R, ed. Clinical Assessment of Malingering
5. Carey B. Snake phobias, moodiness, and a battle in and Deception. 2nd ed. New York, NY: Guilford
psychiatry. New York Times. June 14, 2005. Publications; 1997.
6. Atlas SJ, Nardin RA. Evaluation and treatment of low 16. Overall JE, Gorham DR. Brief Psychiatric Rating Scale.
back pain: an evidence-based aproach to clinical care. Psychol Rep. 1962;10:799–812.
Muscle Nerve. 2003;27:265–284.
17. Overall JE, Gorham DR. Brief Psychiatric Rating Scale:
7. Glass RM. Is grief a disease? Sometimes. JAMA. recent developments in ascertainment and scaling.
2005;293:2658–2660. Psychopharmacol Bull. 1988;24:97–99.
8. Leon RL, Bowden CL, Faber RA. Psychiatric interview, 18. Hedlund JL, Vieweg BW. Brief Psychiatric Rating
history, and mental status examination. In: Kaplan HI, Scale: comprehensive review. J Operational Psychiatry.
Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 1980;11:48–65.
Baltimore, Md: Williams & Wilkins; 1989.
19. Ventura MA, Green MF, Shaner A, Liberman
9. Anastasi A, Urbina S. Psychological Testing, 7th ed. RP. Training and quality assurance with the brief
Upper Saddle River, NJ: Prentice Hall; 1996. psychiatric rating scale: the drift buster. Int J Methods
Psychiatr Res. 1993;3:221–244.
Chapter 14
Guides6e_14_347-382.indd 382 3/4/09 10:29:40 AM

CHAPTER 15
The Upper
Extremities
Introduction
15.2 Diagnosis-Based Impairment
15.3 Adjustment Grid and Grade Modifiers: Non-

Key Factors
15.4 Peripheral Nerve Impairment

Impairment
Introduction
15.6 Amputation Impairment
nent impairment due to impairments of the upper
extremities (upper limbs). For evaluation purposes,
15.7 Range of Motion Impairment
as illustrated in Figure 15-1, the upper extremity is
divided into 4 regions (distal to proximal):
15.8 Summary
• Digits/Hand: including carpometacarpal (CMC),
15.9 Appendix metacarpophalangeal (MCP), and interphalangeal
Appendix 15-A Functional Assessment (IP) joints.
Inventories
• Wrist: including distal radioulnar, radiocarpal, and
Appendix 15-B Electrodiagnostic
ulnocarpal joints.
Evaluation of Entrapment Syndromes
• Elbow: including humeroulnar and proximal radio-
ulnar joints.
• Shoulder: including scapulothoracic, scapulocla-
Chapter 15
vicular, sternoclavicular, and glenohumeral joints.

In prior editions of the Guides, the upper limb was
referred to as the upper extremity, and this usage has
become standardized. However, proper use of ter-
minology would require that the structure from the
shoulder to the hand be called the upper limb. In the
Sixth Edition both terms are used synonymously.
383
Guides6e_15_383-492.indd 383 2/17/09 2:56:08 PM

F I G U R E 15 -1 This chapter has been updated with informa-

Upper Extremity Regions tion and research provided by the state and
medical specialty societies listed in the preface.
Impairment evaluations of the upper extremity
must be performed within the context of the
directives in Chapters 1 and 2 and only performed
when conditions have reached Maximum Medical
Improvement (MMI).
This chapter incorporates the following changes:
Shoulder (1) International Classification of Functioning,
Disability, and Health (ICF) Model is used to
provide a common basis for the description of
human functioning and impairments; (2) principles
of assessment have been simplified and clarified;
(3) specific diagnosis-based rating tables for the
most common injuries and diagnoses have been
added; (4) physical examination has been simpli-
Elbow fied; (5) functional assessment is provided through
focused history-taking, including information
about Activities of Daily Living (ADLs) and a
functional assessment tool; (6) criteria for diagnosis
of complex regional pain syndrome (CRPS) have
Wrist
been updated for consistency with current stan-
Digits / hands
dards and other chapters of the Guides; and (7) an
Upper Extremity Impairment Evaluation Record is
provided as a template to simplify recording of the
evaluation. As appropriate, impairment values from
prior editions are retained; some adjustments were
necessary to more appropriately reflect the impair-
Assessment of the upper extremities requires evalu- ment or were required because of changes in the
ation of soft tissue, skeletal structure, joints, and the methodology.
peripheral nervous system; vascular conditions are
rated per Section 4.8, Vascular Diseases Affecting The authors have made every effort to provide the
the Extremities. most current and comprehensive information for
the impairment scenarios likely to be encountered.
In clinical situations and discussions regarding the Although the chapter and the impairment rating
potential functional severity of an injury, there are method may seem complex at first, the chapter pres-
typically 4 considerations: (1) what is the problem ents information that is useful and necessary for
(diagnosis), (2) what difficulties does the patient impairment assessments. The reader is encouraged
report, (3) what are the examination findings, and to read the entire chapter and review case examples
(4) what are the results of clinical studies. In a simi- before performing an assessment. The impairment
lar manner, these are the steps used to assess most rating process has been simplified by providing a
cases of musculoskeletal impairment. congruent rating method among the 3 musculoskele-
Musculoskeletal impairment rating is based primar- tal chapters. Once the examiner masters the method-
ily on a specific diagnosis, which, in the current ology in one chapter, that same methodology applies
method, results in assignment to an impairment to other chapters.
Chapter 15
class using grids designed for this purpose. The The authors of this chapter recognize that the pro-
impairment value within a class is further refined by cess described is still far from perfect with respect
considering information related to functional status, to defining impairment or the complexities of
physical examination findings, and the results of human function; however, the authors’ intention is
clinical testing. The rationale for this change from to simplify the rating process, to improve interrater
previous rating methods is to standardize and sim- reliability, and to provide a solid basis for future edi-
plify the rating process, to improve content validity, tions of the Guides.
and to provide a more uniform method that promotes
greater interrater reliability and agreement.
Guides6e_15_383-492.indd 384 2/17/09 2:56:09 PM

15.1 Principles of Assessment Diagnoses for the upper extremity are defined in
3 major categories:
• Soft tissue.
Guides’ user must become familiar with Chapters 1
and 2 and the Glossary. Chapters 1 and 2 discuss the • Muscle/tendon.
• Ligament/bone/joint.
Glossary provides definitions of common terms used In the event that a specific diagnosis is not included
in impairment evaluation. in the diagnosis-based regional grid, the examiner
should use a similar listed condition as a guide to
The impairment evaluation and report should include a
determining an impairment value. In the report, the
comprehensive, accurate medical history; a review and
examiner must fully explain the rationale for the
summary of all pertinent records; and a comprehen-
analogy.
sive description of the individual’s current symptoms
and their relationship to daily activities. The examiner
should perform a careful and thorough physical exami-
and Signs
nation and review all findings of relevant laboratory,
The medical history must describe the chief com-
radiographic (imaging), and ancillary tests.
plaint and discuss the quality, frequency, and duration
Anatomic, diagnostic, and functional bases for of symptoms such as pain, numbness, paresthesias,
determining impairment are part of the ICF Model. and weakness; functional difficulties; and any inter-
Diagnosis-based impairments are provided for each ference with daily activities. The evaluation report
of the 4 regions of the upper limb (digits/hand, wrist, should include the individual’s description of how the
elbow, and shoulder). These regional grids include symptoms and condition developed and the assumed
5 columns containing impairment classes, numbered cause. The evaluator should ask the patient about any
from 0 to 5. These classes are designed to reflect the perceived relationship between the current condi-
degree of impairment, and numerical ranges of impair- tion and any other musculoskeletal problems. The
ment have been assigned to each class as described in examiner should also clarify, to the extent possible,
Table 15-1, Definition of Impairment Classes. causation and apportionment; that is, document the
mechanism of injury for the condition being evalu-
Most impairment values for the upper extremity are
ated, and any prior problems. A complete report will
calculated using the diagnosis-based impairment
include discussion of previous evaluations and thera-
(DBI) method. Impairment class is determined by
peutic interventions as described in medical records,
the diagnosis and specific criteria, considered the
past medical history, review of systems, and personal
“key factor,” and then adjusted by grade modifiers
and social history and family history. Available
or “non-key factors” that may include functional
X rays and other imaging studies or reports should be
history, physical examination, and relevant clinical
reviewed and commented on in the report.
studies. Therefore, the first step is defining the diag-
nosis. The grade modifiers, or “non-key” factors, are Case history is based on information presented by
considered only if they are determined by the exam- the patient and available in medical records. The
iner to be reliable and associated with the diagnosis. evaluating physician or physicians should obtain
The process for calculating impairment values is objective data through physical examination and
described in detail in Section 15.3d. appropriate clinical studies. If information provided
by the patient or noted in previous medical records,
TA B L E 15 -1 or findings on physical examination, are incon-
sistent, the evaluator’s report should reference the
Definition of Impairment Classes
inconsistencies. The diagnosis used for placement
Impairment Range
Chapter 15
in an impairment class must be based on reliable

Upper Whole findings reflective of the impairment that is being
Class Problem Extremity (UEI) Person (WPI)
assessed and supported by the clinical history, cur-
0 No objective 0% 0% rent examination, and clinical studies. Objective
findings findings are always given the greater weight of evi-
1 Mild 1%–13% 1%–8% dence over subjective complaints.
2 Moderate 14%–25% 8%–15% Functional history, physical examination, and clini-
3 Severe 26%–49% 16%–29% cal tests all contribute to better understanding of
4 Very severe 50%–100% 30%–60% the patient’s diagnosis and condition. Each of these
Guides6e_15_383-492.indd 385 3/6/09 11:38:12 AM

“non-key factors” is described below. Adjustment extremity–related physical findings, such as limb
grids related to each of these factors, and for use in deformity, instability, motion deficits, and neurologic
the impairment calculation, are provided in Sections findings, including sensory and motor deficits. The
15.3a to 15.3c. examiner should remove splints or other external
devices as appropriate, to permit adequate and thor-
Functional History ough examination. The examiner should consider
A proper functional history enables the physician to the patient’s diagnosis, the reliability of findings on
help determine the impact of a given condition on examination, and the results of previous examina-
basic functioning of the limb for ADLs. The physi- tions and observations as recorded in the medical
cian is expected to grade this impact in 1 of 5 broad records documenting previous treatment.
categories of incremental impairment. For a given
Positive (abnormal), negative (normal), and nonphys-
diagnosis or condition, the impact is defined as:
iological findings must be assessed bilaterally and
documented. If the opposite extremity is uninvolved
• Grade modifier 0: no demonstrable interference
and not previously injured, it should be used to
with function.
define normal for that individual. Whenever possible,
• Grade modifier 1: interference with the vigorous quantitative findings should be reported, as opposed
or extreme use of the limb only. to general descriptions (ie, document specific mea-
surements of upper limb girth as opposed to report-
• Grade modifier 2: interference with regular use of
ing extent of atrophy). More objective findings, such
the limb for ADLs but helper assistance (ie, assis-
as atrophy, are given greater relative weight over
tance of another person) is not required.
findings that require patient participation, such as
• Grade modifier 3: interference with minimal use demonstration of active range of motion or strength,
of the limb for ADLs and some helper assistance and reports of tenderness. Inconsistencies and dis-
(ie, assistance of another person) is required. crepancies between what is observed, what has been
previously reported, and what is otherwise expected
• Grade modifier 4: interference with all use of the
should be noted. Examination findings that differ
limb precludes activity or requires total assistance
significantly from previously recorded observations
for some or all ADLs.
after the probable date of MMI should be reported,
with comments noting the discrepancy; these find-
Cross-validation can occur by observing the patient
ings may be excluded from the impairment calcula-
perform simple routine activities (eg, writing, open-
tion, as described later in this chapter.
ing a jar, buttoning a shirt, tying shoes, or ability to
change into a hospital gown or dress after the exami- It is important to ensure that upper extremity impair-
nation). The physician should note inconsistencies ment discussed in this chapter is not due to underlying
and lack of congruence when evident. A functional cervical spine pathology. If the neurologic exam points
assessment tool may be used in addition, to further to an underlying spine disorder, the upper extremity
evaluate this parameter. One example of a func- impairment would, in most cases, be accounted for in
tional assessment tool, the QuickDASH, is included the spine impairment rating (Chapter 17), assuming
in Appendix 15-A of this chapter. The physician is that there are no other primary upper extremity diag-
expected to weigh the patient’s subjective complaints noses requiring a concomitant rating.
and score on the functional assessment tool, relative
to the expected severity for a given condition. The Clinical Studies
grade modifier that reflects this analysis may be The physician needs to review and document actual
accepted or not as a variable in the impairment cal- studies and findings from relevant diagnostic studies,
culation depending on consistency with other objec- including laboratory tests, roentgenographic (X ray)
tive clinical parameters used to assess the severity of studies, computed tomographic (CT) scans, magnetic
Chapter 15
the condition. resonance images (MRIs), nuclear medicine scans,

ultrasound examinations, and electrodiagnostic test-
If multiple diagnoses or regions are being rated,
ing. In some cases, only reports may be available,
the examiner should consider the relative contribu-
and this should be noted in the record. Although
tion of each of these diagnoses to the functional
imaging and other studies may assist physicians in
complaints.
making a diagnosis, they are not the sole determi-
nants of a diagnosis. Clinical test results that do not
Physical Examination
correlate with the patient’s symptoms or support the
Guided by the history, an appropriate physical
diagnosis should be commented on by the examiner.
examination is performed, documenting upper
Guides6e_15_383-492.indd 386 2/17/09 2:56:10 PM

15.2 Diagnosis-Based Impairment physical examination, and clinical studies. The grade
modifiers are used in the Net Adjustment Formula
Most impairments are based on the diagnosis- described in the box in Section 15.3d, to calculate a
based impairments (DBI), in which impairment net adjustment. The final impairment grade is deter-
class is determined by the diagnosis and specific mined by adjusting the grade up or down from the
criteria; this is then adjusted by “non-key” factors default value C by the calculated net adjustment.
(grade modifiers) that may include functional his- The lowest possible grade is A, and adjustments less
tory (FH), physical examination (PE), and clinical than 2 from the default value C will automatically
studies (CS). The grade modifiers, or “non-key” be considered A; the highest possible grade is E, and
factors, are considered only if they are determined adjustments greater than 2 will automatically be
by the examiner to be reliable and associated with considered E. The regional grid is then consulted
the diagnosis. Typically, these other factors will again to determine the appropriate impairment value
support the class and default grade assignment; for the selected class and grade. Grade modifiers
however, in some circumstances a lower or higher allow movement within a class but do not allow
grade may be assigned, depending on the specifics movement into a different class.
of the case.
The regional grid is used for 2 purposes: (1) to
Alternative approaches are also provided for bas- determine the most appropriate class for a specific
ing impairment on peripheral nerve deficits, CRPS, regional diagnosis and (2) to determine the final
amputation, and range of motion. Range of motion impairment after appropriate adjustments are made
is used primarily as a physical examination adjust- using the grade modifiers.
ment factor and only to determine actual impair-
There are 5 classes in the DBI grid:
ment values when a grid permits its use as an
option; this is a significant change from prior edi-
• Class 0: no objective problem.
tions. Range of motion ratings cannot be combined
with other approaches, with the exception of amputa- • Class 1: mild problem.
tion. Complex regional pain syndrome ratings cannot
• Class 2: moderate problem.
be combined with other approaches.
• Class 3: severe problem.
Figure 15-2, Upper Extremity Impairment
Evaluation Record, should be completed, or all • Class 4: very severe problem approaching total
information on that record should be provided in function loss.
the impairment rating report. The terms Class,
Default Impairment, Adjustments, and Assigned Subjective complaints without objective physi-
Grade Modifier used in the Evaluation Record cal findings or significant clinical abnormalities
are described in detail in the sections that fol- are assigned class 0 and have usually no ratable
low. An example of a completed Upper Extremity impairment.
Impairment Evaluation Record (Figure 15-31) is pro-
This process is repeated for each separate diagnosis
vided at the end of this chapter.
in each limb involved. In most cases only one diag-
Diagnosis-based impairment is the primary method nosis will be appropriate. If a patient has 2 signifi-
of evaluation for the upper limb. Four regional cant diagnoses, for instance, rotator cuff tear and
grids, listing relevant diagnoses, are provided in biceps tendonitis, the examiner should use the diag-
this section, 1 for each region of the upper extrem- nosis with the highest causally-related impairment
ity (digits/hand, wrist, elbow, and shoulder). An rating for the impairment calculation. Thus, when
impairment will be defined by class and grade. The rating rotator cuff injury/impingement or
impairment class is determined first, by using the glenohumeral pathology/surgery, incidental
Chapter 15
corresponding diagnosis-based regional grid. The resection arthroplasty of the AC joint is not rated.
grade is then determined using the adjustment grids
Vascular conditions are rated per Section 4.8,
provided in Section 15.3.
Vascular Diseases Affecting the Extremities.
Once the impairment class has been determined, The diagnosis of CRPS—CRPS type I, previously
based on the diagnosis, the grade is initially assigned known as reflex sympathetic dystrophy (RSD), and
the default value, “C.” The final impairment grade CRPS type II, previously known as causalgia—must
within the class is calculated using the grade modi- be supported by consistent, objective findings, as
fiers, or non-key factors, as described in Section explained in Section 15.5.
15.3. Grade modifiers include functional history,
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FIGURE 15 -2
Upper Extremity Impairment Evaluation
Name: Exam Date:

ID Number: Sex: F M Side: R L Birth Date:
Diagnosis: Injury Date:
Diagnosis-Based Impairments
Gride Diagnosis / Criteria Assigned Class Grade Modifier Adjustments Assigned Dx Grade Final UEI
Digit (D) 0 1 2 3 4 Net

Wrist (W) GMFH 0 1 2 3 4 2 1 0 1 ≥2
Elbow (E)
GMPE 0 1 2 3 4 A B C D E
Shoulder(S)
GMCS 0 1 2 3 4
(Optional: QuickDASH Score: )
Net Adjustment (GMFH CDX)
(GMPE CDX) + (GMCS CDX)
D 0 1 2 3 4 Net
W GMFH 0 1 2 3 4 2 1 0 1 ≥2
E
GMPE 0 1 2 3 4 A B C D E
S
GMCS 0 1 2 3 4
(GMPE CDX) (GMCS CDX)
D 0 1 2 3 4 Net
W GMFH 0 1 2 3 4 2 1 0 1 ≥2
E
GMPE 0 1 2 3 4 A B C D E
S
GMCS 0 1 2 3 4
Combined UEI
Peripheral
Nerve/
Entrapments
Nerve Sensory and Motor Grading Assigned Class Grade Modifier Adjustments Assigned Dx Grade Combined UEI
Sensory Deficit Sensory Deficit GMFH 0 1 2 3 4 n/a Sensory:
A B C D E
0 1 2 3 4 n/a 0 1 2 3 4 GMCS 0 1 2 3 4 n/a
Motor Deficit Motor Deficit GMFH 0 1 2 3 4 n/a Motor:
0 1 2 3 4 n/a 0 1 2 3 4 n/a GMCS 0 1 2 3 4 n/a A B C D E
Entrapment
Electrodiagnostics: Test 0 1 2 3 4 n/a Average:
History 0 1 2 3 4 n/a Functional Grade:
Normal Mild
Physical 0 1 2 3 4 n/a
Moderate Severe
CRPS I Adjustment
Impairment Abbreviations
Points Assigned Class Adjustments Assigned Grade Final UEI S - Shoulder
E = Elbow
0 1 2 3 4 FH 0 1 2 3 4 n/a A B C D E W = Wrist
PE 0 1 2 3 4 n/a H = Hand
D = Digit
CS 0 1 2 3 4 n/a
GMFH = Grade Modifier Functional History
GMPE = Grade Modifier Physical Examination
Amputation GMCS = Grade Modifier Clinical Studies
Chapter 15
Level Assigned Class Adjustments Assigned Grade Final UEI
0 1 2 3 4 FH 0 1 2 3 4 n/a A B C D E
Summary Final UEI
PE 0 1 2 3 4 n/a
CS 0 1 2 3 4 n/a Diagnosis-Based Impairment
Peripheral Nerve
Motion Entrapment
Joint Total UEI Assigned Class
CRPS (Stand-alone)
0 1 2 3 4
Amputation
0 1 2 3 4 Range of Motion (Stand-alone)
0 1 2 3 4 Final Combined Impairment
Combined ÜEI Whole Person Impairment
Regional Impairments
Signed: Name (Print): Date:
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Steps in Performing an Impairment Rating undergone surgery does not result in an “add-
on” value or additional impairment percentage.
1. Perform history and examination, and deter-
Impairment ratings are based on the patient’s condi-
mine if individual is at MMI.
tion at the time of the rating.
2. Establish the reliable diagnosis for each part
Selection of the optimal diagnosis requires judg-
of the upper limb to be rated.
ment and experience. If more than 1 diagnosis can
3. Use the regional grid in the appropriate region be used, the highest causally-related impairment rat-
to determine the associated class. ing should be used; this will generally be the more
specific diagnosis. Typically, 1 diagnosis will ade-
4. Use the adjustment grid and the grade modi-
quately characterize the impairment and its impact
fiers, including functional history, physical exam,
on ADLs. Certain diagnoses may span more than 1
and clinical tests, to determine what grade of
class; therefore, these diagnoses are associated with
associated impairment should be chosen within
specific objective findings on physical examination
the class defined by the regional grid.
or clinical studies to ensure placement in the appro-
5. Use the regional grid to identify the appropri- priate class. Painful disorders in a regional grid are
ate impairment rating for any allowable diagno- rated only once; it is duplicative to rate in both “soft
sis, impairment class, and grade. tissue” and “muscle tendon.”
6. Combine upper extremity percentages using In the event that a specific diagnosis is not listed in
the Combined Values Chart (in the Appendix the DBI grid, the examiner should identify a similar
at the end of the book) in the same extremity, listed condition to be used as a guide to the impair-
as appropriate. If both upper extremities are ment calculation. The rationale for this decision
involved, convert impairments to whole person should be described.
and combine.
The regional grids have 1 column that includes diag-
noses and 5 columns reflecting impairment classes.
Identify the applicable diagnosis in the left-most col-
15.2a Diagnosis-Based Impairment Class umn. The permissible class assignments (0 to 4) are
Assignment: Regional Grids specified in the horizontal rows. Reference the spe-
The first step in determining an impairment rating cific criteria in the row for that diagnosis to determine
is to choose the diagnosis that is most applicable for which class is appropriate. Above the criteria in each
the region being assessed. Diagnoses are divided cell are 5 numbers reflecting the range of impairment
into 3 categories: soft tissue, muscle/tendon, and associated with those specific diagnostic criteria.
ligament/bone/joint. Typically, soft-tissue diagnoses Each of these numbers corresponds to grades A, B, C,
are assigned the lowest impairments and ligament/ D, and E, with A the mildest and E the most severe.
bone/joint diagnoses the highest impairments. As The middle value is grade C and represents a default
much as possible, impairment values from prior edi- impairment value, which typically corresponds with
tions of the Guides were retained, unless adjustments the impairment value assigned in prior editions of the
were necessary to more appropriately reflect the Guides. Grades and the corresponding final impair-
impairment or were required because of changes in ment value are modified by the use of the adjustment
the methodology. On the basis of the diagnosis and grid and the Net Adjustment Formula, as discussed
other specific differentiators that may be associated earlier. The formula and impairment calculation pro-
with that diagnosis, the condition is assigned to a cess are described in detail in Section 15.3d.
specific class in the regional grid.
General Considerations
Reliability of the diagnosis is essential, and the Instructions for using the DBI grid are provided in
diagnosis must be consistent with the clinical history
Chapter 15
Section 15.2, Diagnosis-Based Impairment. The

and findings at the time of impairment assessment. evaluator should select the most accurate diagnosis
Surgery does not necessarily result in an impairment and identify the class containing that diagnosis. As
rating, unless it is a factor that contributes to placing previously described, the numerical value of the
a diagnosis within a class. Surgical intervention is impairment associated with that diagnosis, located
only relevant if it alters the functional status of the above each diagnosis, may be increased or decreased
condition evaluated at MMI. For example, surgical within an impairment class based on grade modi-
repair of a torn carpal ligament can decrease the fiers, as determined using the adjustment grids
instability from a higher class to class 0 if the described in Section 15.3.
instability is resolved. The fact that the joint has
Guides6e_15_383-492.indd 389 3/3/09 6:58:31 PM

Diagnoses must be objectively based and modified structures. Instructions are provided in Section
by reliable findings using the adjustment grids. The 15.1, Principles of Assessment, and Section 15.3,
examiner must utilize the classification of severity Adjustment Grid and Grade Modifiers: Non-Key
of findings as defined in Tables 15-7 through 15-9. If Factors, and involve the use of Table 15-2, Digit
a physical examination or clinical studies finding is Regional Grid, and the Table 15-6 adjustment grid
used to define the DBI, it cannot also be used as an (and associated Tables 15-7 to 15-9).
adjustment.
15.2c Wrist
Range of motion may under specific circumstances,
The wrist region is defined as the region from car-
be selected as an alternative approach to rating
palmetacarpal joints to the midforearm, including
impairment. Diagnoses in the grid that may be rated
all the bones (trapezoid, trapezium, capitate, hamate,
using range of motion are followed by an asterisk (*).
scaphoid, lunate, triquetrum, and pisiform), joints,
An impairment rating that is calculated using range
ligamentous, and soft-tissue structures encompassing
of motion may not be combined with the DBI; it
the wrist joint. Instructions are provided in Sections
stands alone as a rating.
15.1 and 15.3 and involve the use of Table 15-3,
All impairments in the digit regional grid are Wrist Regional Grid, and the Table 15-6 adjustment
expressed as digit impairment. In the rare case when grid (and associated Tables 15-7 to 15-9).
there are multiple DBIs involving the same digit and
these impairments are not duplicative, the values 15.2d Elbow
are combined at the digit level. Digit impairments The elbow region is defined as the region midfore-
are then converted to hand impairments. If there are arm to midhumerus, including all the bone, joint,
multiple digits involved, the digit impairments at ligamentous, and soft-tissue structures encompassing
the hand level are added. Impairment cannot exceed the wrist joint. Instructions are provided in Sections
100% of digit. If a whole person permanent impair- 15.1 and 15.3 and involve the use of Table 15-3,
ment is necessary, the hand impairment is converted Wrist Regional Grid, and the Table 15-6 adjustment
to upper extremity impairment and ultimately to grid (and associated Tables 15-7 to 15-9).
15.2e Shoulder
All impairments in the wrist, elbow, and shoulder
The shoulder is defined as the region from the mid-
regional grids are expressed as upper extremity
humerus to the scapulothoracic region, including all
impairment. In the rare case when there are mul-
the bone, joint, ligamentous, and soft-tissue struc-
tiple DBIs, the values are combined. As required
tures encompassing the shoulder joint. Instructions
by the jurisdiction, the upper extremity impairment
are provided in Sections 15.1 and 15.3 and involve
may be converted to whole person impairment or
the use of Table 15-5, Shoulder Regional Grid, and
to hand impairment using Table 15-11, Impairment
the Table 15-6 adjustment grid (and associated
Values Calculated From Upper Extremity
Tables 15-7 to 15-9).
Impairment.
In the shoulder, it is not uncommon for rotator cuff
Clinical examples are provided in Section 15.3e.
tears, a superior labrum from anterior to posterior
The Guides’ user is encouraged to read the entire
(SLAP) lesion or other labral lesions, and biceps
chapter for a complete understanding of the impair-
tendon pathology to all be present simultaneously.
ment rating method before interpreting the ratings
The evaluator is expected to choose the most signifi-
or performing the calculations that accompany the
cant diagnosis and to rate only that diagnosis using
examples.
the DBI method that has been described. If clinical
studies confirm more than 1 of the following symp-
15.2b Thumb/Finger/Hand
tomatic diagnoses—rotator cuff tear, SLAP or other
The thumb/finger/hand is defined as the region from
Chapter 15
labral lesion, or biceps tendon pathology—the grade

the carpalmetacarpal joints to the fingertips, includ-
can be modified according to the Clinical Studies
ing all the bone, joint, ligamentous and soft-tissue
Adjustment Table (Table 15-9).
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TA B L E 15 -2 Digit Regional Grid: Digit Impairments
Digit Regional Grid

IMPAIRMENT
IMPAIRMENT
RANGES (digit) 0 1%–13% Digit 14%–25% Digit 26%–49% Digit 50%–100% Digit
GRADE A B C D E A B C D E A B C D E A B C D E
SOFT TISSUE
Pain in digit* 0 0 0 1 1 1
nonspecific hand
No significant History of painful
pain post acute
symptoms or injury, residual
injury or surgery
signs at MMI symptoms with-
(not otherwise
out consistent
specified)
objective findings
(this impairment
can only be given
once per digit in
an individual’s
lifetime)
Healed minor 0 2 3 4 5 6
soft-tissue or
Healed with no Residual symp-
skin injury,*
residual symptoms and con-
including digit
toms or findings sistent objective
pain despite
other than skin findings at MMI
full motion, no
scarring (eg, painful post-
instability, and
traumatic joint
no pulp loss
enlargement, nail
deformity involv-
ing 50% of a
nail, tender scar,
retained foreign
body of 3 mm
in size, retained
ganglion cyst or
mucous cyst)*
Healed with 0 6 7 8 9 10 16 18 20 22 24
more significant
Healed with no Loss of 50% of Loss of 50%
soft tissue or skin
residual symp- pulp, nail abnor- of pulp; com-
injury,* includ-
toms or findings malities involving plications of
ing nail abnor-
other than skin 50% of a nail osteomyelitis
malities involving
scarring secondary to
50% of a nail
trauma, retained
secondary to
foreign body
trauma, residual
3 mm
distal pha-
lanx pulp loss,
retained foreign
body 3 mm*
Chapter 15
MUSCLE/TENDON
Pain in digit* 0 0 0 1 1 1
nonspecific hand
pain post acute
consistent objec- injury, residual
injury or surgery
tive findings at symptoms with-
(not otherwise
MMI out consistent
specified)
objective findings
(this impairment
can only be given
once per digit in
an individual’s
lifetime)
(continued)
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TA B L E 15 -2 (C O N TI N U E D) Digit Regional Grid: Digit Impairments

IMPAIRMENT
IMPAIRMENT
RANGES 0 1%–13% Digit 14%–25% Digit 26%–49% Digit 50%–100% Digit
MUSCLE/TENDON
Sprain/strain* 0 4 5 6 7 8
includes initial
No residual find- Residual pain
diagnoses of
ings: No pain and and/or functional
first-, second-,
no residuals loss with normal
and third-degree
motion
sprain, now at
MMI*
Digital stenosing 0 4 5 6 7 8
tenosynovitis*
No residual find- Symptomatic
(trigger digit)
ings: / surgical trigger finger
treatment / surgery.
Persistent trigger-
ing with normal
motion
Extensor tendon 0 4 5 6 7 8
rupture/lacera-
No residual find- Residual loss
tion* (commonly
ings: / surgical / symptoms;
described as
treatment functional with
mallet finger;
normal motion
extensor digito-
rum communis,
or extensor
indicis)
Flexor tendon 0 4 5 6 7 8
rupture/lac-
No residual find- Residual loss
eration* (flexor
ings: / surgical / symptoms;
digitorum pro-
treatment functional with
fundus or sub-
normal motion
limis; or flexor
pollicis longus)
LIGAMENT/BONE/JOINT
Posttraumatic 0 4 5 6 7 8
degenerative
No residual Residual pain
joint disease*
findings and/or functional
loss with normal
range of motion
Joint dislocation or sprain*
Thumb MCP* 0 1 2 3 4 5
No residual 10º Instability
findings
3 4 5 6 7
10º–20º Instability
Chapter 15
8 9 10 11 12
20º Instability
Thumb IP* 0 3 4 5 6 7 14 14 15 16 17
No residual 10º Instability 20º Instability
findings
8 9 10 11 12
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TA B L E 15 -2 Digit Regional Grid: Digit Impairments
IMPAIRMENT
IMPAIRMENT
Joint dislocation or sprain*
Thumb CMC* 0 14 14 15 16 17 29 32 35 38 41
findings
21 23 25 25 25
Finger DIP* 0 3 4 5 6 7 14 14 15 16 17
findings
8 9 10 11 12
Finger PIP* 0 8 9 10 11 12 14 14 15 16 17
10º Instability
No residual 10º–20º Instability
findings
21 23 25 25 25
20º Instability
Finger MCP* 0 14 14 15 16 17
No residual 10º Instability
findings
16 18 20 22 24
21 23 25 25 25
20º Instability
Fractures*
Thumb 0 8 9 10 11 12
metacarpal,
No residual Residual symp-
intra-articular*
findings toms, consistent
objective findings
and/or functional
loss, with normal
motion
Distal phalanx* 0 2 3 4 5 6
objective findings
and/or functional
loss, with normal
motion
Proximal pha- 0 4 5 6 7 8
lanx, middle
phalanx,
Chapter 15
metacarpal*
objective findings
and/or functional
loss, with normal
motion
Metacarpal 0 6 7 8 9 10
head*
objective findings
and/or functional
loss, with normal
motion
(continued)
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TA B L E 15 -2 (C O N TI N U E D) Digit Regional Grid: Digit Impairments

IMPAIRMENT
IMPAIRMENT
Ankylosis/arthrodesis*
Rate per Section 15.7, Range of Motion Impairment
Arthroplasty*
Thumb CMC* 26 28 30 32 34
Residual symp-
toms, consistent
objective findings
and/or functional
loss, with normal
motion
Finger DIP* 3 4 5 6 7
Residual symp-
toms, consistent
objective findings
and/or functional
loss, with normal
motion
Finger PIP* 8 9 10 11 12
Residual symp-
toms, consistent
objective findings
and/or functional
loss, with normal
motion
Finger MP* 16 18 20 22 24
Residual symp-
toms, consistent
objective findings
and/or functional
loss, with normal
motion
Note: indicates Maximum Medical Improvement; IP, interphalangeal; MCP, metacarpophalangeal; CMC, carpometacarpal; DIP, distal
interphalangeal; PIP, proximal interphalangeal
* If motion loss is present, this impairment may alternatively be assessed using Section 15.7, Range of Motion Impairment. A
range of motion impairment stands alone and is not combined with diagnosis impairment.
Chapter 15
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TA B L E 15 -3 Wrist Regional Grid: Upper Extremity Impairments
Wrist Regional Grid

IMPAIRMENT
IMPAIRMENT
RANGES (upper
extremity %) 0 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
SOFT TISSUE*
Wrist pain* 0 0 0 1 1 1
nonspecific wrist
pain post acute
injury or surgery
(not otherwise
out consistent
specified)
objective findings
Wrist contusion (this impairment
or crush injury* can only be given
with healed once in an indi-
minor soft tissue vidual’s lifetime)
or skin injury
Wrist mass or 1 2 2 2 3
ganglion cyst*
Residual symp-
toms and con-
sistent objective
findings at MMI
MUSCLE/TENDON*
Wrist pain*: 0 0 0 1 1 1
nonspecific wrist
pain post acute
injury or surgery
(not otherwise
out consistent
specified)
objective findings
(this impairment
can only be given
once in an indi-
vidual’s lifetime)
Wrist sprain/ 0 0 1 1 2 2
strain* includes
initial diagnoses
objective abnor- injury, residual
of first-, second-,
mal findings of symptoms with-
and third-degree
muscle or tendon out consistent
sprain. No resi-
injury at MMI objective findings
dual instability
(this impairment
or loss of motion
can only be given
but persisting
once in an indi-
pain at MMI (eg,
Chapter 15
de Quervain’s
disease, intersec-
tion syndrome,
nonspecific
tendonitis)
Wrist 0 3 4 5 6 7
laceration
No residual find- Residual loss,
or ruptured
ings: / surgical functional with
muscle/tendon*
treatment normal motion
(continued)
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TA B L E 15 -3 (C O N TI N U E D) Wrist Regional Grid: Upper Extremity Impairments
IMPAIRMENT
IMPAIRMENT
RANGES (upper
LIGAMENT/BONE/JOINT*
Wrist sprain/h/o 0 6 7 8 9 10 14 15 16 17 18
dislocation*
No residual find- Mild instability Moderate insta-
including carpal
ings: / surgical (grade modifier 1 bility (grade
instability
treatment per radiographic modifier 2 per
studies and crite- radiographic
ria in Table 15-9) studies and crite-
ria in Table 15-9)
(clinical studies
excluded from 20 22 24 25 25
adjustment
Severe instability
process)
(grade modifier 3
per radiographic
studies and crite-
ria in Table 15-9)
(clinical studies
excluded from
adjustment
process)
Triangular 0 6 7 8 9 10
fibrocartilage
No residual find- Documented
complex (TFCC)
ings: / surgical TFCC injury /
tear*
treatment surgery with
residual findings
Fracture* 0 1 2 3 4 5
No residual find- Residual symp-
ings: / surgical toms, consistent
treatment objective findings
and/or functional
loss, with normal
motion
Avascular necro- 1 2 2 3 4 14 15 16 17 18
sis (AVN) of
Stage 1 normal Stage 3 abnormal
lunate
bone architecture bone architecture
Kienbock’s
on plain X rays, on plain X rays
disease*
MRI may be nor- or MRI with
mal or show early lunate collapse or
stages fragmentation
3 4 5 6 7 17 19 22 23 25
Stage 2 abnormal Stage 4 abnormal
bone architecture bone architecture
on plain X rays or on plain X rays
MRI but no carpal or MRI with
Chapter 15
lunate collapse lunate collapse

or fragmentation
and adjoining
bones affected.
If treated surgi-
cally, wait until
MMI and rate by
type of surgical
treatment
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TA B L E 15 -3 Wrist Regional Grid: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
RANGES (upper
Posttraumatic Posttraumatic, 1 3 5 7 9 If motion loss,

degenerative No residual find- may assess per
Posttraumatic
joint disease* ings: / surgical Section 15.7,
DJD with docu-
(DJD) treatment Range of Motion
mented specific
Impairment
injury, asym-
(not combined
metric arthritic
with diagnosis
changes noted on
impairment)
imaging
Arthrodesis 8 9 10 11 12 If nonoptimal
(fusion) positioning,
Successful fusion
Intercarpal assess per
fusion* Section 15.7,
Scaphoid- Range of Motion
capitate Impairment
Capitate-hamate
Hamate-
triquetrum
Wrist arthrod- 26 28 30 32 34 If nonoptimal

esis (fusion)* positioning assess
Wrist arthrod-
per Section 15.7,
esis in functional
Range of Motion
position (10º
Impairment
extension to 10º
flexion, radial 5º
to ulnar 10º)
Arthroplasty 20 22 24 25 25 26 28 30 32 34
Wrist (total)
Normal motion Complicated,
arthroplasty*
unstable, or
infected
Radiocarpal 14 15 16 17 18
arthroplasty*
Normal motion
17 19 21 23 25
Complicated,
unstable, or
infected
Ulnar head iso- 8 9 10 11 12 14 14 15 16 17

lated, proximal
Normal motion Complicated,
row carpec-
unstable, or
tomy, or carpal
infected
bone (isolated)
Chapter 15
arthroplasty*
Radial sty- 3 4 5 6 7
loid (isolated)
Normal motion
arthroplasty*
8 9 10 11 12
Complicated,
unstable, or
infected
Note: UE indicates upper extremity; MMI, Maximum Medical Improvement; and MRI, magnetic resonance image.
* If motion loss is present, this impairment may alternatively be assessed using Section 15.7, Range of Motion Impairment.
A range of motion impairment stands alone and is not combined with diagnosis impairment.
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TA B L E 15 - 4 Elbow Regional Grid: Upper Extremity Impairments
Elbow Regional Grid

IMPAIRMENT
IMPAIRMENT
RANGES (upper
SOFT TISSUE*
Elbow pain* 0 0 0 1 1 1
Nonspecific
elbow pain fol-
lowing injury
or occupational
out consistent
exposure
objective findings
(this impairment
can only be given
once in an indi-
Elbow contusion 1 2 2 2 3
or crush injury*
Residual symp-
with healed
toms and con-
minor soft tissue
sistent objective
or skin injury
findings at MMI
Olecranon 1 2 2 2 3
bursitis*
Residual symp-
toms and con-
sistent objective
findings at MMI
MUSCLE/TENDON*
Elbow pain*: 0 0 0 1 1 1
nonspecific
elbow pain post
acute injury or
surgery (not
out consistent
otherwise
objective findings
specified)
(this impairment
can only be given
once in an indi-
Sprain/strain*: 0 0 1 1 2 2
No residual
instability or loss
of motion but
persisting pain
Chapter 15
at MMI
(this impairment
can only be given
once in an indi-
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TA B L E 15 - 4 Elbow Regional Grid: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
RANGES (upper
MUSCLE/TENDON*
Epicondylitis: 0 0 1 1 2 2
Lateral or
medial*
mal findings at symptoms with-
MMI out consistent
objective findings
(this impairment
can only be given
once in an indi-
3 4 5 6 7
s/p surgical
release of flexor
or extensor ori-
gins with residual
symptoms
Distal biceps 0 3 4 5 6 7
tendon rupture*
No residual find- Residual loss of
ings: / surgical strength, func-
treatment tional with nor-
mal motion
Collateral 0 3 4 5 6 7
ligament injury:
No residual find- Recurrent insta-
medial, ulnar or
ings: / surgical bility: occasional
lateral*
treatment
8 9 10 11 12
Recurrent insta-
bility: frequent;
resulting in func-
tional limitation
Persistent elbow 0 8 9 10 11 12 16 18 20 22 24 34 37 40 43 46
subluxation or
No residual find- Mild: can be com- Moderate: cannot Severe: cannot be
dislocation*
ings: / surgical pletely reduced be completely reduced
treatment manually reduced manually
Fracture* 0 1 2 3 4 5
and/or functional
Chapter 15
loss, with normal

motion
Loose bodies or 0 3 4 5 6 7
osteochondral
lesions*
(continued)
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TA B L E 15 - 4 (C O N TI N U E D) Elbow Regional Grid: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
RANGES (upper
Posttraumatic Posttraumatic, 1 3 5 7 9
degenerative No residual find-
Posttraumatic
joint disease(DJD)* ings: / surgical
DJD with
treatment
documented
specific injury,
asymmetric
arthritic changes
noted on imaging
(fusion)* positioning,
Elbow arthrod-
assess per
esis in functional
Section 15.7,
position (70º to
Range of Motion
80º flexion, 20º
Impairment
to 30º pronation)
Total elbow 26 28 30 32 34
arthroplasty*
Normal motion
34 37 40 43 46
Complicated,
unstable, or
infected
Radial head 6 7 8 9 10
(isolated)
Normal motion
arthroplasty*
9 10 11 12 13
Complicated,
unstable, or
infected
Note: UE indicates upper extremity; MMI, Maximum Medical Improvement.
Chapter 15
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TA B L E 15 - 5 Shoulder Regional Grid: Upper Extremity Impairments
Shoulder Regional Grid

IMPAIRMENT
IMPAIRMENT
RANGES (upper
SOFT TISSUE*
Shoulder pain,* 0 0 0 1 1 1
nonspecific
shoulder pain
following injury
or occupational
out consistent
exposure
objective findings
(this impairment
can only be given
once in an indi-
Shoulder contu- 1 2 2 2 3
sion or crush
Residual symp-
injury* with
toms and con-
healed minor
sistent objective
soft tissue or
findings at MMI
skin injury
Shoulder
bursitis
MUSCLE/TENDON*
Shoulder pain* 0 0 0 1 1 1
nonspecific
shoulder pain
post acute
injury or surgery
out consistent
(not otherwise
objective findings
specified)
(this impairment
can only be given
once in an indi-
Sprain/strain*: 0 0 1 1 2 2
No residual
instability or loss
of motion but
persisting pain
at MMI
(this impairment
Chapter 15
can only be given

once in an indi-
(continued)
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TA B L E 15 - 5 (C O N TI N U E D) Shoulder Regional Grid: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
RANGES (upper
Tendinitis* 0 0 1 1 2 2
objective abnor- injury, or occupa-
mal findings at tional exposure,
MMI residual symp-
toms without
consistent objec-
tive findings (this
impairment can
only be given
once in an indi-
1 2 3 4 5
Residual loss,
functional with
normal motion
Impingement 0 0 1 1 2 2
syndrome*
MMI out consistent
objective findings
(this impairment
can only be given
once in an indi-
1 2 3 4 5
Residual loss,
functional with
normal motion
Rotator cuff 0 0 1 1 2 2
injury, partial-
thickness tear*
MMI out consistent
objective findings
(this impairment
can only be given
once in an indi-
1 2 3 4 5
Residual loss,
Chapter 15
functional with
normal motion
(continued)
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IMPAIRMENT
IMPAIRMENT
RANGES (upper
Rotator cuff 0 1 2 3 4 5
injury, full-
thickness tear*
MMI out consistent
objective findings
(this impairment
can only be given
once in an indi-
3 4 5 6 7
Residual loss,
functional with
normal motion
Acromiocla- 0 1 2 3 4 5 16 18 20 22 24
vicular (AC)
No significant History of painful AC separation
joint injury or
objective abnor- injury, residual type IV (com-
disease*
mal findings at symptoms with- plete disruption
MMI out consistent AC joint capsule
objective findings and coracocla-
(this impairment vicular ligaments
can only be given and avulsion of
once in an indi- coracoclavicular
vidual’s lifetime) ligament from
clavicle) or higher
1 2 3 4 5
severity
Residual loss,
functional with
normal motion
8 9 10 11 12
s/p Distal clavicle
resection or AC
separation type
III (complete
disruption AC
joint capsule and
coracoclavicular
ligaments)
(continued)
Chapter 15
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TA B L E 15 - 5 (C O N TI N U E D) Shoulder Regional Grid: Upper Extremity Impairments
IMPAIRMENT
IMPAIRMENT
RANGES (upper
Unidirectional 0 4 5 6 7 8 20 22 24 25 25
shoulder
No residual find- Occult (consis- Dislocating
instability*
ings: / surgical tent relationship humeral head
treatment of symptoms (confirmed his-
with activities tory of acute
and grade 1 trauma, consis-
instability) tent relationship
of symptoms with
9 10 11 12 13
activities, grade 3
Subluxing or 4 instability)
humeral head
(confirmed his-
tory of acute
trauma, consis-
tent relationship
of symptoms with
activities, grade 2
instability)
Multidirectional 0 9 10 11 12 13 22 23 24 25 25
shoulder insta-
No significant History of trau- Dislocating
bility (excluding
objective abnor- matic episode humeral head
patients with
mal findings of and shoulder (confirmed his-
bilateral multidi-
soft-tissue injury instability dem- tory of acute
rectional shoul-
at MMI onstrated in 2 or trauma, consis-
der instability)*
more directions tent relationship
of symptoms with
Post op patients
activities, grade 3
with persistent
or 4 instability)
symptoms with
no instability may
be rated with
ROM. If ROM is
normal rate by
nonspecific shoul-
der pain*
Multidirectional 0 0 0 1 1 1
shoulder insta-
No significant History of trau-
bility bilateral
objective abnor- matic episode
with complaints
mal findings of or occupational
following injury
soft-tissue injury exposure
at MMI
Labral lesions, 0 1 2 3 4 5
including SLAP
tears*
and/or functional
Chapter 15
loss, with normal

motion
Biceps tendon 0 1 2 3 4 5
dislocation/sub-
luxation*
and/or functional
loss, with normal
motion
(continued)
Guides6e_15_383-492.indd 404 2/17/09 2:56:20 PM

IMPAIRMENT
IMPAIRMENT
RANGES (upper
Fracture* 0 1 2 3 4 5
and/or functional
loss, with normal
motion
Loose bodies or 0 3 4 5 6 7
osteochondral
lesions*
Posttraumatic Posttraumatic, 1 3 5 7 9
degenerative No residual find-
Posttraumatic
joint disease ings: / surgical
DJD with docu-
(DJD)* treatment
mented specific
injury, asym-
metric arthritic
changes noted on
imaging
(fusion) positioning assess
Shoulder arthrod-
per Section 15.7,
esis in functional
Range of Motion
position (20º to
Impairment
40º flexion, 20º
to 40ºabduction,
20º to 50º inter-
nal rotation)
Shoulder 20 22 24 25 25 26 28 30 32 34
arthroplasty*
Implant with Resection with
normal motion normal motion
34 37 40 43 46
Complicated,
unstable, or
infected
Note: UE indicates upper extremity; MMI, Maximum Medical Improvement; s/p, status post; and SLAP, superior labrum from
anterior to posterior.
15.3Adjustment Grid and Grade example, X-ray findings in the case of carpal instabil-
Chapter 15
ity, that same specific finding may not be used again to

Modifiers: Non-Key Factors determine the grade modifier.
The adjustment grid, as described in the introduction, The grade modifiers associated with functional
is used to assign a grade within the class defined by history, physical examination, and clinical studies
the regional grid. The grade for a given class is deter- will be used to calculate a net adjustment, according
mined by considering functional history, physical to Section 15.3d, that permits modification of
examination findings, and the results of relevant clini- the default value, grade C, up or down within a
cal studies. If a non-key factor or grade modifier was given class. When determining the grade modifier,
used for primary placement in the regional grid as, for assess each of the components of the adjustment
Guides6e_15_383-492.indd 405 2/17/09 2:56:20 PM

TA B L E 15 - 6
Adjustment Grid: Summary
Specific Grade Grade Grade Grade Grade
Adjustment Modifier 0 Modifier 1 Modifier 2 Modifier 3 Modifier 4
Grid
Functional Table 15-7 No problem Mild problem Moderate Severe Very severe
History problem problem problem
Physical Table 15-8 No problem Mild problem Moderate Severe Very severe
Examination problem problem problem
Clinical Studies Table 15-9 No problem Mild problem Moderate Severe Very severe
problem problem problem
(eg, soft-tissue findings, stability, and alignment) modifier 0, and those with constant symptoms that
that are attributable to the condition being rated persist despite treatment and are unable to perform
and use the highest class modifier as the value for self-care activities, will be assigned grade modifier 4.
that adjustment in the Net Adjustment Calculation.
For example, on physical examination, soft-tissue Functional history grade modifier should be applied
findings may be characterized as grade modifier only to the single, highest diagnosis-based impairment
0 and stability findings may be grade modifier 2. (DBI). Specific jurisdictions may modify this process
The class modifier for physical examination would such that functional history adjustment is considered for
then be grade modifier 2, because it is the higher each DBI or not considered at all as a grade modifier.
of the 2 grades. If any of these factors are deter-
The evaluating physician may use the QuickDASH
mined by the examiner to be unreliable or incon-
functional assessment outcome questionnaire as part
sistent, they should be disregarded in the grading
of the process of evaluating functional symptoms;
adjustment. The examiner should explain the basis
the QuickDASH and functional assessment measures
for grade assignment or discounting of a specific
are provided in Appendix 15-A to this chapter. The
adjustment for lack of reliability in the evaluation
inventory is used only to assist the examiner in defin-
report.
ing the grade modifier for functional history and does
not serve as a basis for defining further impairment,
15.3a Adjustment Grid: Functional History
nor does the score reflect an impairment percentage.
Grade assignment for functional symptoms is based
on subjective reports that are attributable to the The examiner must assess the reliability of the func-
impairment. Grading is based on the extent to which tional reports, recognizing the potential influence of
functional symptoms interfere with different level of behavioral and psychosocial factors. If the grade for
activities, as summarized in Table 15-7, Functional functional history differs by 2 or more grades from
History Adjustment. As explained in Section 1.8e, that described by physical examination or clinical
History of Clinical Presentation, in general, individ- studies, the functional history should be assumed to
uals with no symptoms will be assigned grade be unreliable. If the functional history is determined
TA B L E 15 -7
Functional History Adjustment: Upper Extremities
Grade Modifier 0 Grade Modifier 1 Grade Modifier 2 Grade Modifier 3 Grade Modifier 4
Class No problem Mild problem Moderate problem Severe problem Very severe
Definitions problem
Asymptomatic Pain/symptoms with Pain/ symptoms Pain/symptoms Pain/symptoms
strenuous/vigor- with normal with less than at rest; /
Chapter 15
ous activity; / activity; / normal activity medications to

medication to control medications to con- (minimal); / control symptoms
symptoms trol symptoms medications to
control symptoms
AND able to perform AND able to per- AND requires assis- AND unable to
self-care activities form self-care tance to perform perform self-care
independently activities with self-care activities activities
modification but
unassisted
QuickDASH 0–20 21–40 41–60 61–80 81–100
Score
Guides6e_15_383-492.indd 406 3/3/09 6:58:32 PM

to be unreliable or inconsistent with other documen- criteria in Table 15-8 to define the range of motion
tation, it is excluded from the grading process. grade modifier. Range of motion impairment is not
combined with the DBI.
15.3b Adjustment Grid: Physical
The evaluation of neurologic deficits is explained in
Examination
Section 15.4, Peripheral Nerve Impairments. In evaluat-
When performing a physical examination, the cli-
ing muscle atrophy, the arm circumference should be
nician needs to determine the significance of the
measured and compared with the opposite arm at equal
findings related to the impairment being evaluated.
distances from either the joint line or another palpable
For the purposes of this evaluation, greater weight is
anatomic structure. Neither limb should have swelling
given to those findings that are more objective. Some
or varicosities that would invalidate the measurements.
parameters described in the adjustment grid may be
region-specific. If a physical examination finding is used in place-
ment of a diagnosis within a specific class in a DBI
If multiple diagnoses are rated, the examiner should
grid, that same finding cannot also be used as a
determine the appropriate impairment class for
grade modifier.
each diagnosis, and the examiner must distinguish
whether certain physical examination findings are
15.3c Adjustment Grid: Clinical Studies
associated with each specific ratable condition. If a
The patient may have undergone a variety of special
physical finding has been used to determine class
tests, including imaging studies and electrodiagnostic
placement, that specific finding should not be con-
(EMG/NCV) studies. The physician should review
sidered again, for example, range of motion in the
these studies, the findings, and note their interpre-
upper extremity. If physical examination findings are
tations. Whenever possible, the physician should
determined to be unreliable or inconsistent, or they
personally review the studies and report agreement
are for conditions unrelated to the condition being
or disagreement with previous interpretations. If a
rated, they are excluded from the grading process.
finding is used for placement of a diagnosis within a
The physician must explain, in the report, the ratio-
specific class in a DBI grid, that same finding can-
nale for the choice of grade.
not also be used as a grade modifier. Studies must be
The classification for motion deficits is based on reliable and pertinent to the condition being rated.
assessment according to the parameters in Section
Although imaging and other studies may assist physi-
15.7, Range of Motion Impairment. Table 15-8,
cians in making a diagnosis, it is important to note
Physical Examination Adjustment, summarizes the
that a positive imaging study in and of itself does not
grading process. Specific parameters are provided in
make the diagnosis. For imaging studies to be of diag-
the adjustment grid for the appropriate region.
nostic value, clinical symptoms and signs resulting
Stability, alignment, and deformity are determined from an injury must correlate with the imaging find-
clinically and/or on the basis of radiographic studies; ings. In other words, an imaging test is useful to con-
specific parameters may vary by region. firm a diagnosis, but the result of an imaging study
alone is insufficient to qualify for an impairment. In
Range of motion deficits are determined according to
cases in which the abnormalities present on imaging
the process and the criteria specified in Section 15.7
studies and are known (or assumed) to have preexisted
and may be used only when specified by the regional
an injury being rated, evaluators should acknowledge
grid, or in the rare case when DBIs are not applicable.
these antecedent conditions in the report.
Upper extremity impairment can be evaluated by
assessing the range of motion of joints, recognizing Wrist stability is based on radiographic findings.
that pain and motivation may affect the measure- Radiographic studies must be of adequate quality to
ments. If it is clear to the evaluator that a restricted permit measurement of the appropriate angles. The
range of motion has an organic basis, 3 measurements scapholunate and radiolunate angles are measured
Chapter 15
should be obtained and the greatest range measured on a lateral radiograph taken with the fist forcefully
should be used for the determination of impairment. If clenched (stressed view) and the wrist in neutral
multiple previous evaluations have been documented flexion/extension and lateral deviation. Lines are
and there is inconsistency in a rating class between the drawn on the film parallel to the long axis of the
findings of 2 observers, or in the findings on separate radius, through the long axis of the scaphoid (palmar
occasions by the same observer, the results are con- surface), and a line representing the long axis of the
sidered invalid and cannot be used to rate impairment. lunate (a line perpendicular to the line connecting
Range of motion restrictions in multiple directions the 2 distal poles, Figure 15-3). The angles between
do increase the impairment. The total values for the these lines are measured. The normal radiolunate
digit, wrist, elbow, or shoulder are compared with the relationship should be less than 10° of either volar
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TA B L E 15 - 8
Physical Examination Adjustment: Upper Extremities
Class No problem Mild problem Moderate problem Severe problem Very severe problem
Definitions
Observed No consistent Minimal palpatory Moderate palpa- Severe palpatory Very severe palpa-
and Palpatory findings findings, consis- tory findings, findings, consis- tory findings, consis-
Findings tently documented, consistently docu- tently documented, tently documented,
(tenderness, without observed mented, and sup- and supported by and supported by
swelling, mass, abnormalities ported by observed observed moder- observed severe
or crepitance) abnormalities ate or greater abnormalities
abnormalities
Stability Stable Grade 1 (slight) Grade 2 (moderate) Grade 3 (serious) Gross instability
instability instability instability
Hand/finger/ Pain with stressing Pain and slight Pain and 5 mm of Severe instability
thumb of ligament, but opening joint opening with
no opening of joint stress
with stress
Wrist Clicking or clunking Clicking or clunk-
by history, but not ing by history,
reproducible and reproduc-
ible on physical
examination
Wrist excessive 10º passive 10º–20º passive 20º passive
passive/active 20º active 20º–30º active 30º active
mediolateral
joint devia-
tion degrees
compared to
normal
Shoulder Grade 1 (slight) Grade 2 (moderate) Grade 3 (serious)
instability; instability; easily instability; dislocat-
subluxable subluxable able with anesthesia
or sedation
Alignment/ Normal for Mild Moderate Severe Very severe
Deformity individual with
symmetry to
opposite side
Range of None Mild decrease from Moderate decrease Severe decrease Very severe decrease
Motion normal or uninjured from normal or from normal or from normal or unin-
(reference opposite side uninjured opposite uninjured opposite jured opposite side
Section 15.7) side side
For digit impair- For digit impair-
ments only, this For digit impairments For digit impairments ments only, this
reflects a total digit only, this reflects a only, this reflects a reflects a total digit
impairment 20% total digit impair- total digit impair- impairment 70%
digit impairment. ment of 20% to 39% ment of 40% to 70% digit impairment.
For wrist, elbow, digit impairment. digit impairment. For wrist, elbow,
and shoulder this For wrist, elbow, and For wrist, elbow, and and shoulder this
reflects a total joint shoulder this reflects shoulder this reflects reflects a total joint
impairment of 12% a total joint impair- a total joint impair- impairment 42%
upper extremity ment of 12% to 23% ment of 24% to 42% upper extremity
impairment. upper extremity upper extremity impairment.
impairment. impairment.
Chapter 15
Muscle Atrophy 1 cm 1.0–1.9 cm 2.0–2.9 cm 3.0 cm–3.9 cm 4.0 cm

(asymmetry
compared
to opposite
normal)
Note: ROM indicates range of motion; GH indicates Glenohumeral.
Guides6e_15_383-492.indd 408 2/17/09 2:56:22 PM

or dorsal lunate angulation. The scapholunate for that diagnosis and those criteria; the last grade (E)
angle ranges from 30° to 60° (average of 47°). The is the highest. For most impairment rating scenarios,
triquetrolunate stepoff is measured on the neutral the middle grade (C) and the correlating numerical
posteroanterior (PA) view and represents proximal or impairment value in that class will serve as the initial
ulnar translation of the triquetrum. The scapholunate (default) rating, as described in Table 15-10.
gap is best profiled on a neutral PA view with the
Once the class is determined, the grade should ini-
ulnar aspect of the hand elevated 10° to 15° or on a
tially be assigned to the default (C) rating. This initial
neutral anteroposterior (AP) view. Ulnar translation
default value may be modified up or down within a
may occur secondary to injury or arthritis. It is
class by using the grade modifiers. These are designed
measured on the neutral PA view with the fist force-
to reflect specific functional, physical examination,
fully clenched. Normally, greater than 50% of the
and clinical findings specific to the patient. Using
lunate overlies the ulnar border of the distal radius.
the Net Adjustment Formula, the assigned value
As ulnar translation becomes more severe, progres-
for each grade modifier (0 to 4) is compared with
sively less of the lunate overlies the radius.
the number of the impairment class (0 to 4) using
In the shoulder, it is not uncommon for rotator cuff the Net Adjustment Formula, described in the box
tears, SLAP or other labral lesions, and biceps ten- entitled: Net Adjustment Formula: Mathematical
don pathology to all be present simultaneously. The Explanation. The net adjustment value is used to move
evaluator is expected to choose the most significant up a grade ( Net Adjustment Value) or down a grade
diagnosis and to rate only that diagnosis using the ( Net Adjustment Value) within a class. If all of the
DBI method that has been described. If clinical grade modifier numbers are the same as the impair-
studies confirm more than 1 of the following symp- ment class number, the net adjustment will be 0 and the
tomatic diagnoses—rotator cuff tear, SLAP or other default value (C) will be the impairment rating value
labral lesion, or biceps tendon pathology—the grade for that diagnosis. A change in class is not permitted,
can be modified according to the Clinical Studies regardless of the magnitude of the net adjustment.
Adjustment Table (Table 15-9). Grade adjustments do not permit a change in class.
Electrodiagnostic studies should be performed by
FIGURE 15 -3
a licensed physician who is qualified by educa-
tion, training, and experience in these procedures. Techniques for Measuring the Scaphoid (S),
Lunate Axis (L), and Long Axis of the Radius (R)
Typically, these studies are performed by board and Corresponding Angles
certified neurologists and physical medicine special-
ists. Some jurisdictions allow others to perform such
studies. The studies must be performed in accor-
dance with established standards.
15.3d Impairment Calculation

Methodology
As described in the preceding parts of this chapter,
impairment is calculated by identifying an impair-
ment class that reflects the diagnosis and a grade that
considers functional, physical and clinical facets of
the condition. The impairment class is determined
first, by using the corresponding diagnosis-based
regional grid. The grades are then determined using
the adjustment grids.
Chapter 15
Each regional grid provides a range of impairment

values for each specific diagnosis. Each cell within a
regional grid contains a range of impairment values,
represented as a series of 5 numbers that correspond S
to grades A through E. Once the impairment class is
determined according to diagnostic criteria, the final
30°–60° L
impairment grade within a particular class is deter- R
mined by the non-key factors, or grade modifiers, (av. 47°)
identified in the adjustment grids. The first grade (A)
is the lowest impairment rating that could be assigned Source: David M. Lichtman, Fort Worth, Texas.
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TA B L E 15 -9
Clinical Studies Adjustment: Upper Extremities
Class Definitions No problem Mild problem Moderate problem Severe problem Very severe
problem
Imaging Studies No available Clinical studies con- Clinical studies con- Clinical studies Clinical studies
clinical studies or firm diagnosis, mild firm diagnosis, mod- confirm diagnosis, confirm diagno-
relevant findings pathology erate pathology severe pathology sis, very severe
pathology
Shoulder Clinical studies con- Clinical studies
firm one of the fol- confirm more than
lowing symptomatic one of the follow-
diagnoses: rotator ing symptomatic
cuff tear, SLAP or diagnoses: rotator
other labral lesion, cuff tear, SLAP or
biceps tendon other labral lesion,
pathology biceps tendon
pathology. The
most significant
diagnosis is the
only one rated.
X rays
Arthritis Cartilage interval Cartilage interval: Cartilage interval No cartilage inter-
normal or mild joint moderate joint space severe joint space val; radiographic
space narrowing narrowing with cystic narrowing with evidence of severe
and/or osteophytes changes on 1 or both cystic changes posttraumatic
sides of joint and/or on both sides arthrosis
osteophytes; radio- of joint and/or
graphic evidence of osteophytes; or
mild posttraumatic avascular necrosis
arthrosis; avascular with bony collapse/
necrosis without fragmentation
collapse
Stability
Joint laxity 10º Instability 10º–20º Instability 20º–30º Instability 30º Instability
(based on stress
testing)
Wrist (see text Radiolunate angle Radiolunate angle Radiolunate angle
for explanation) 11º–20º 21º–30º 30º
Scapholunate angle Scapholunate angle Scapholunate
61º–70º 71º–80º angle 80º
Scapholunate gap Scapholunate gap Scapholunate gap
3–5 mm 6–8 mm 8 mm
Triquetrolunate ste- Triquetrolunate ste- Triquetrolunate
poff 1 mm poff 2 mm stepoff 3 mm
Ulnar translation Ulnar translation Ulnar translation
mild moderate severe
Nerve Normal Conduction delay Motor conduction Partial axonal loss Total axonal
Conduction (sensory and/or block loss/denervation
Testing motor)
Chapter 15
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TA B L E 15 -9 (C O N TI N U E D)
Clinical Studies Adjustment: Upper Extremities
Electrodiagnostic Normal Needle EMG done Needle EMG done Needle EMG done Needle EMG done
Testing at least 3 wk but at least 3 wk but less at least 3 wk but at least 3 wk but
less than 9 mo after than 9 mo after injury less than 9 mo less than 9 mo
Note: If the EMG injury shows at shows at least 2 after injury shows after injury shows
test results meet least 1 fibrillation fibrillation potentials at least 3 fibrilla- at least 4 fibrilla-
some of, but not potentials and posi- and positive waves tion potentials and tion potentials and
all of, the crite- tive waves in at least in at least 2 muscles positive waves in positive waves in
ria for a specific 2 muscles innervated innervated by the at least 3 muscles at least 3 muscles
class, the next by the injured nerve. injured nerve. If the innervated by the innervated by the
lower class is the If the EMG study is EMG study is first injured nerve. If injured nerve. If
class to be used first done more than done more than 9 mo the EMG study is the EMG study is
in rating the 9 mo post injury, the post injury, the exam first done more first done more
impairment exam shows high- shows high-amplitude than 9 mo post than 9 mo post
amplitude polypha- polyphasic muscle injury, the exam injury, the exam
sic muscle potentials potentials in at least shows high-ampli- shows no motor
in at least 1 muscle 2 muscles and recruit- tude polyphasic units (fibrofatty
and recruitment ment in those muscles muscle potentials replacement of
in that muscle is at is at least moderately in at least 3 muscles muscle) in at least
least mildly reduced. decreased. and recruitment 2 muscles.
in those muscles is
severely decreased.
Note: SLAP indicates superior labrum from anterior to posterior; EMG, electromyogram.
Net Adjustment Formula: Method

Mathematical Explanation 1. Determine the class first, using the relevant regional
Net adjustment may be obtained by a mathemati- grid, by choosing the appropriate diagnosis for the
cal formula and then use of the resultant value to condition, in the leftmost column. Select the appro-
define the grade. The following abbreviations are priate class for that diagnosis, based on the criteria
used: specified in the columns for classes 0 to 4.
CDX Class of Diagnosis (Regional Grid) 2. Using the adjustment grids for functional history,
GMFH Grade Modifier for Functional History physical examination, and clinical tests, identify
GMPE Grade Modifier for Physical the appropriate grade using grade modifiers:
Examination a. If there are multiple components to a grade
GMCS Grade Modifier for Clinical Studies modifier, such as physical examination (which
Net Adjustment (GMFH CDX) (GMPE may include palpatory findings, alignment,
CDX) (GMCS CDX) and instability), choose the highest grade
modifier that is objective and associated with
Grade Assignments the diagnosis being rated. If a grade modifier
Net Adjustment Grade is found to be unreliable or inconsistent, it
(from default C) should be disregarded and eliminated from
2 A the calculation.
1 B b. If a particular criterion, such as range of
0 C motion, was used to determine impairment
1 D
Chapter 15
class, it may not be used again to determine

2 E the grade and is disregarded in the impair-
For example, if the diagnosis is in impairment ment calculation.
class 2, then CDX = 2. If net adjustment value is c. The functional history grade modifier should
2, then the Grade is A. be applied only to the highest DBI. Specific
jurisdictions may modify this process so that
functional history adjustment is considered for
each DBI or not considered at all as a grade
modifier.
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TA B L E 15 -1 0 Methodology for Determining the Grade in an Impairment Class
DIAGNOSTIC
CRITERIA (KEY
FACTOR) CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4
IMPAIRMENT
RANGES (UPPER
EXTREMITY %) 0 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
EXAMPLE 3 4 5 6 7 16 18 20 22 24 26 28 30 32 34 50 52 54 56 58
RATING
3. Applying the Net Adjustment Formula, as To further illustrate this process, if the key factor
shown in the box, “Mathematical Explanation,” identifies class 3, and non-key factors identify grade
calculate the net adjustment value by subtracting modifier 1 and grade modifier 4 with the third non-key
the numerical value of the class (CDX) from the factor determined to be unreliable, this would produce
numerical value of the grade modifier for each differences of 2 (1 3)and 1 (4 3), respectively.
component (functional history, physical exami- These (2 1) add to a net adjustment of 1, mov-
nation, and clinical tests) and add those values. ing the rating to 1 lower grade within that class (ie, 1
That net adjustment value will determine how position to the left) and the corresponding impairment
many places up or down from the default value percentage. In this example, if the non-key factors both
“C” the rating should move and the correspond- identified grade modifier 1, the differences would total
ing numerical value for the impairment. to 4 [Net Adjustment (1 3) (1 3) 4].
Since this procedure does not allow jumping from 1
Example: Triangular Fibrocartilage class to a lower (or higher) class, the rating would move
Complex Tear to the lowest grade within a class. In this example, if all
non-key factors identified class 3, impairment would
The use of the grid process can be illustrated by the
remain at the default midposition.
rating of a triangular fibrocartilage complex tear,
treated surgically, with mild problems reported and As explained in other chapters, a modification of
normal examination. According to the wrist regional this process is required for class 4 impairments;
grid, this results in class 1 impairment. If use of these impairments are uncommon. If the key
the adjustment table for non-key factors resulted factor is class 4, and both non-key factors were
in a functional history grade modifier 1 (“mild grade modifier 4, the differences would sum-
problem”), Physical Examination grade modifier 0 mate to zero, and placement in a grade above the
(normal examination), and Clinical Studies grade default value C in class 4 would not be possible.
modifier 1 (“clinical studies confirm diagnosis, mild To correct this deficiency, if the key factor iden-
Chapter 15
pathology”), the net adjustment is calculated as NA tifies class 4, automatically add 1 to the value
(GMFH CDX) (GMPE CDX) (GMCS of each non-key factor. For example, if the key
CDX) or (1 1) (0 1) (1 1) 1, and factor identifies class 4, and the first non-key fac-
it moves the grade within the class 1 position to the tor was grade 3, the second was grade 4, the dif-
left of the default value (8% upper extremity), result- ferences are 1 and 0. Adding 1 to each of the
ing in 7% upper extremity impairment. non-key factor grades yields differences of 0 and
1, which summates to 1. The default value C is
then adjusted up 1 grade to D. Consequently, the
final class and grade is 4D.
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15.3e Upper Extremity Diagnosis-based fruit fell on his hand while he was stocking shelves
Impairment Examples in the grocery store. He was treated surgically and
after surgery continued to have some mild deformity
Finger/Hand Examples
of his metacarpal with pain to palpation. He was able
to return to work without restrictions.
CLASS 0
Current Symptoms: Mildly painful, minimal inter-
0% Impairment of the Digit
ference with ADLs.
Physical Exam: Minimal tenderness was noted to
EXAMPLE 15-1: STENOSING TENOSYNOVITIS,
palpation; otherwise unremarkable.
RESOLVED WITH SURGERY
Clinical Studies: X rays of the hand confirmed
healing of metacarpal fracture (not involving the
History: The patient worked on an assembly line metacarpal head).
and developed a trigger finger (stenosing tenosy-
Diagnosis: Fracture metacarpal.
novitis) of the ring finger. At the time of initial
evaluation, she had swelling over the flexor tendon Impairment Rating: Regional Impairments:
with pain to palpation. She was treated with nonste- Diagnosis “fractures—proximal phalanx, middle
roidal anti-inflammatory drugs (NSAIDs), a splint phalanx, metacarpal” and per criteria of “Residual
and local injections of corticosteroids but failed to symptoms, consistent objective findings and/or
note improvement. Surgical release was performed. functional loss, with normal motion” assigned to
Several weeks later, the patient had complete resolu- class 1 with midrange default value of 6% digit.
tion of her symptoms and returned to her usual job. Adjustment Grids: Functional History: Grade modi-
fier 1, Physical Examination: Grade modifier 1,
based on “minimal palpatory findings, consistently
Physical Exam: Well-healed incision was noted. The documented, without observed abnormalities”,
patient had no tenderness or swelling on examination Clinical Tests: Grade Modifier 1 based on “clini-
and full, painless range of motion of the ring finger cal studies confirm diagnosis, mild pathology”. Net
was noted. The patient denied pain with gripping. adjustment compared with diagnostic class is 0 and
remains at default. Therefore, 6% impairment of the
Clinical Studies: X rays of the hand were normal.
digit. Converts by Table 15-12, Impairment Values
Diagnosis: Stenosing tenosynovitis, resolved with Calculated From Digit Impairment, to 2% hand
surgery. impairment (HI), 1% UEI and 1% WPI.
Impairment Rating: Regional Impairments: Class 1 Example Calculation: Default for
Diagnosis “digital stenosing tenosynovitis (trigger Diagnosis 6% Digita
digit)” and per criteria of “No residual findings: CDX GMFH GMPE GMCS
/ surgical treatment” assigned to class 0 with no
1 1 1 1
ratable impairment. 0% digit, 0% hand, 0% upper
extremity impairment (UEI), 0% whole person Net adjustment
impairment (WPI). (GMFH CDX) (1 1) 0
Comment: The patient noted resolution of symp- (GMPE CDX) (1 1) 0
toms and findings with surgery. Surgical intervention (GMCS CDX) (1 1) 0
does not, by itself, warrant impairment.
Net adjustment 0
Result is class 1 adjustment 0, which equals class 1
grade C 6% digit
Chapter 15
a
CDX indicates class of diagnosis; GMFH, grade modifier
CLASS 1
for functional history; GMPE, grade modifier for physical
6% Impairment of the Digit examination and GMCS, grade modifier for clinical studies.
EXAMPLE 15-2: FRACTURE METACARPAL

History: The patient sustained a fracture of the mid-
dle finger metacarpal when a heavy box of canned
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CLASS 1 CLASS 2
8% Impairment of the Digit 14% Impairment of the digit
EXAMPLE 15-3: STENOSING TENOSYNOVITIS, EXAMPLE 15- 4: DISTAL INTERPHALANGEAL

SYMPTOMATIC, IMPAIRMENT RATING JOINT DISLOCATION, REDUCED
Subject: 24-year-old man. Subject: 50-year-old woman.

History: The patient sustained an injury to his right History: The patient sustained a dislocation of the
index finger while operating a nail gun at work. Six distal interphalangeal (DIP) joint of her middle fin-
months after surgical treatment, he has moderately ger when she tried to catch some files falling off a
severe persisting pain and swelling near the flexor desk. Treated without surgery.
tendon of the A1 pulley.
Current Symptoms: Problems with stiffness and
Current Symptoms: He has reported difficulty with feeling of instability occurring with normal activi-
handwriting, zipping clothing, and turning a key ties, although cautious with digit.
with his dominant (right) hand.
Physical Exam: Instability of 25° at the DIP joint
Functional assessment: The QuickDASH score with ligament testing medially and laterally at the
is 62. In-office observation of his handwriting and distal phalanx. DIP flexion 50° with 20° extension
dressing abilities confirms this. lag (for definition, see Section 15.7).
Physical Exam: Pain with minimal trigger phenom- Clinical Studies: X rays confirmed relocation of the
enon on active range of motion. Full motion. distal phalanx to the anatomic position and 25° of
joint space opening with stress testing.
Diagnosis: Reduced DIP joint dislocation, treated
Diagnosis: Trigger finger of right index finger.
without surgery, with residual moderate DIP joint
Impairment Rating: Regional Impairments: stiffness and moderate loss of joint motion.
Diagnosis “digital stenosing tenosynovitis (trigger
Impairment Rating: Regional Impairments:
digit)” and per criteria of “Symptomatic trigger fin-
Diagnosis “joint dislocation or sprain” and per cri-
ger / surgery. “Persistent triggering with normal
teria of “20° instability” assigned to class 2 with
motion” assigned to class 1 with midrange default
midrange default value of 15% digit. Adjustment
value of 6% digit. Adjustment Grids: Functional
Grids: Functional History: Grade modifier 2 (moder-
History: Grade modifier 2; Physical examination:
ate problem), Physical Examination: Grade modifier
Grade modifier 2; Clinical tests: Grade modifier
1 (based on motion, see comment in this example),
not applicable (n/a). Net adjustment compared with
Clinical Tests: n/a (component of defining DBI). Net
diagnostic class is 2, assigned to grade E (high-
adjustment compared with diagnostic class is 1,
est assignment). Therefore, 8% digit impairment.
assigned grade B, 14% digit. Converts by Table 15-
Converts by Table 15-12 to 2% HI, 1% UEI, and 1%
12 to 3% HI, 3% UEI, and 2% WPI.
WPI.
Class 2 Example Calculation: Default for
Class 1 Example Calculation: Default for Diagnosis 15% Digita
Diagnosis 6% Digita
CDX GMFH GMPE GMCS
CDX GMFH GMPE GMCS
2 2 1 n/a
1 2 2 n/a
Net adjustment
Net adjustment
(GMFH CDX) (2 2) 0
(GMFH CDX) (2 1) 1
Chapter 15
(GMPE CDX) (1 2) 1
(GMPE CDX) (2 1) 1
(GMCS CDX) n/a
(GMCS CDX) n/a
Net adjustment 1
Net adjustment 2
Result is class 1 adjustment 2, which equals class 1 grade B 14% digit impairment
grade E 8% digit
a
a
UEI indicates upper extremity impairment; CDX, class of
CDX indicates class of diagnosis; GMFH, grade modifier diagnosis; GMFH, grade modifier for functional history;
for functional history; GMPE, grade modifier for physical GMPE, grade modifier for physical examination; GMCS,
examination; GMCS, grade modifier for clinical studies; and grade modifier for clinical studies; and n/a, not applicable.
n/a, not applicable.
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Comment: Instability is part of the class determina- CLASS 1

tion in this case, and therefore is not used as a physi- 1% to 13% Impairment of the Upper Extremity
cal examination adjustment. Per Table 15-31, Finger
Range of Motion, her range of motion findings of
EXAMPLE 15-6: GANGLION CYST
DIP flexion 50° result in a 10% digit impairment
(grade modifier 1) and her 20° extension lag results Subject: 34-year-old woman.
in 2% digit impairment (also grade modifier 1); this
History: A clerical assistant had a 6-month his-
totals 12% digit impairment. Per Table 15-8, Physical
tory of intermittent right wrist tenderness along the
Examination Adjustment, a 12% digit impairment is
extensor surface. Treatment has included intermittent
consistent with grade modifier 1. If rated by range of
NSAIDs in prescription doses; use of wrist cock-up
motion, the impairment would have been 12% digit
splint as needed; cold applications and local injection
with no adjustments for functional history since it
with steroids on 2 occasions.
was the same as the impairment class for range of
motion. Current Symptoms: She is fully independent in
ADLs. Ergonomic accommodation at her desk and
Wrist Examples computer terminal has been made. Her productivity
drops off during symptomatic flare-ups but is other-
CLASS 0
wise maintained.
0% Impairment of the Upper Extremity
Functional Assessment: The QuickDASH score is 53.
EXAMPLE 15-5: CONTUSION Physical Exam: Soft-tissue swelling on dorsum of
wrist approximately 2-cm diameter; nonfluctuant;
active and passive range of motion maintained.
History: The man’s hand and wrist were struck by a
Clinical Studies: Wrist films reveal soft-tissue
brick 6 months ago, which was diagnosed as “contu-
swelling but no bone or joint pathology; MRI con-
sion” and treated conservatively. Due to the patient’s
firms a dorsal ganglion cyst.
ongoing pain complaints, an MRI was performed
and this was normal. Diagnosis: Wrist ganglion cyst.
Physical Exam: Complains of severe, incapacitating Impairment Rating: Regional Impairments:
pain. Reports marked tenderness. During examina- Diagnosis “wrist mass or ganglion cyst” and per cri-
tion demonstrated reduced motion; however, when teria of “Residual symptoms and consistent objective
casually observed during the visit, normal motion findings at MMI,” assigned to class 1 with midrange
was noted. No objective findings on examination. default value of 2% UEI. Adjustment Grids: Functional
History: Grade modifier 2 (QuickDASH in range of 41
Functional Assessment: Reports marked interference
to 60), Physical Examination: Grade modifier 2 based
in nearly all ADLs. The QuickDASH score is 50.
on “moderate palpatory findings, consistently docu-
Clinical Studies: Hand and wrist films reveal no mented, and supported by observed abnormalities.”
abnormality. The MRI is normal. Clinical Tests: Grade modifier 1 based on “clinical
studies confirm diagnosis, mild pathology.” Net adjust-
Diagnosis: History of contusion with no objective
ment compared with diagnostic class is +2, resulting in
findings.
grade E and 3% UEI. Converts to 2% WPI.
Diagnosis “wrist contusion or crush injury with
healed minor soft tissue or skin injury” and per cri-
teria of “No significant consistent objective findings
Chapter 15
at MMI,” assigned to class 0 with no ratable impair-

ment. 0% UEI or 0% WPI.
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Class 1 Example Calculation: Default for arthrosis, however these were prior to fusion. Studies
Diagnosis 2% UEIa support Diagnosis criteria.). Net adjustment com-
CDX GMFH GMPE GMCS
pared with diagnostic class is 1 and 28% UEI.
Converts to 17% WPI.
1 2 2 1
Net adjustment Class 3 Example Calculation: Default for

Diagnosis 30% UEIa
(GMFH CDX) (2 1) 1
CDX GMFH GMPE GMCS
(GMPE CDX) (2 1) 1
3 2 n/a n/a
(GMCS CDX) (1 1) 0
Net adjustment
Net adjustment 2
(GMFH CDX) (2 3) 1
default grade E 3% UEI (GMPE CDX) n/a
a
UEI indicates upper extremity impairment; CDX, class of (GMCS CDX) n/a
diagnosis; GMFH, grade modifier for functional history;
GMPE, grade modifier for physical examination; GMCS, Net adjustment 1
grade modifier for clinical studies; and n/a, not applicable.
Result is class 3 adjustment 1, which results in class 3
grade B 28% UEI
a
CLASS 3 diagnosis; GMFH, grade modifier for Functional History;
GMPE, grade modifier for physical examination; GMCS,
26% to 49% Impairment of the Upper Extremity grade modifier for clinical studies; and n/a, not applicable.
EXAMPLE 15-7: STATUS POST WRIST FUSION. Elbow Examples

0% Impairment of the Upper Extremity
History: Ten years ago the patient sustained a frac-
ture to her wrist, and 1 year ago wrist arthrodesis
(fusion) was performed due to her ongoing com- EXAMPLE 15-8: LATERAL EPICONDYLITIS
plaints of pain and osteoarthritis.
Current Symptoms: Difficulties with many ADLs
History: A mason with a diagnosis of lateral epi-
due to loss of wrist motion; however, she reports she
condylitis was treated with physical therapy and
is able to perform self-care activities unassisted.
NSAIDs. Symptoms resolved after approximately
Functional Assessment: The QuickDASH score is 6 weeks. The patient was able to resume his usual
45. In-office observation demonstrates difficulties ADLs. Currently, patient reports no pain with regu-
consistent with patient-reported difficulties. lar activity.
Physical Exam: Wrist is fused in neutral position Physical Exam: No tenderness noted on palpation of
both in respects to flexion-extension and radial-ulnar the lateral aspect of the proximal forearm.
deviation. She reports mild tenderness; otherwise
Clinical Studies: Plain X ray of the elbow was
unremarkable.
normal.
Clinical Studies: X rays reveal solid fusion and pre-
Diagnosis: Lateral epicondylitis.
operative X rays revealed evidence of prior fractures
and severe posttraumatic osteoarthritis. Comment: This patient had lateral epicondylitis that
resolved with no residual complaints or findings on
Diagnosis: Status post wrist fusion.
physical examination.
Chapter 15

Impairment Rating: Regional Impairment:
Diagnosis “wrist arthrodesis (fusion)” and per crite-
Diagnosis “lateral epicondylitis” and per criteria
ria of “Wrist arthrodesis in functional position (10°
of “No significant objective abnormal findings,”
extension to 10° flexion, radial 5 ° to ulnar 10 °),”
assigned to class 0 with 0% upper extremity impair-
assigned to class 3 with midrange default value of
ment. With class 0, adjustment is not required; how-
30% UEI. Adjustment Grids: Functional History:
ever, the functional history (patient has no problems)
Grade modifier 2, physical examination: n/a (used
physical examination, and clinical studies also sup-
in DBI placement), Clinical Tests: n/a (Prior radio-
port class 0. 0% UEI.
graphic studies demonstrated severe posttraumatic
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CLASS 1 Comment: For the functional history grade modifier

1% to 13% Impairment of the Upper Extremity the QuickDASH score of 30 fits criteria for grade
modifier 1. Pain with normal activity reflects a grade
modifier 2, and highest value is used, so in this
EXAMPLE 15-9: DISTAL BICEPS TENDON
instance functional history grade modifier is 2.
RUPTURE
Subject: 55-year-old man. Shoulder Examples

History: While lifting a tire onto a truck, the CLASS 1
patient experienced a popping sensation and acute 1% to 13% Impairment of the Upper Extremity
onset of pain in the antecubital region. Initial exam
was consistent with ruptured distal biceps tendon.
EXAMPLE 15-10: NONSPECIFIC SHOULDER PAIN
Surgical treatment was recommended, but the patient
refused. At MMI, the patient had some complaints of Subject: 26-year-old man.
decreased strength of the arm and pain with normal
History: The patient was trimming trees and fell
activity.
from a ladder, landing on his shoulder. He is able to
Functional Assessment: Patient was administered a perform overhead work and requires an NSAID on
QuickDASH questionnaire. The QuickDASH score an occasional basis to manage pain. Diffuse shoulder
was 30. pain with moderate activity.
Physical Exam: Tenderness was noted in the ante- Functional Assessment: A QuickDASH Score of 50.
cubital fossa. Strength in flexion and supination was
Physical Examination: Mild tenderness diffusely
diminished to 4/5. 1 cm atrophy of upper arm com-
with palpation of shoulder girdle muscles, no loss of
pared to opposite. Range of motion of the elbow was
motion.
normal.
Diagnosis: Shoulder contusion.
Clinical Studies: An MRI of the elbow confirmed a
tear of the distal biceps tendon. Clinical Tests: No abnormalities noted on X ray.
Impairment Rating: Regional Impairment: Diagnosis Impairment Rating: Regional Impairment:
of distal biceps tendon rupture and per criteria of Diagnosis: “Shoulder contusion or crush injury with
residual loss of strength and normal range of motion, healed minor soft tissue or skin injury” and per crite-
assigned to class 1 UEI with midrange default value ria for “Residual symptoms and consistent objective
of 5% UEI. Adjustment Grids: Functional History: findings at MMI,” assigned to class 1 with midrange
Grade modifier 2 (pain with normal activity); Physical default of 2% UEI. Adjustment Grids: Functional
Examination: Grade modifier 1 due to muscle atrophy History: Grade modifier 2 for QuickDASH score
of 1 cm. Clinical Studies: n/a since defines the diagno- of 50; Physical Examination: Grade modifier 0
sis criteria (biceps tendon rupture) Numerical adjust- (although there are palpatory findings these are
ment is 1. Moved 1 position to the right of default diffuse, non-anatomic and not consistently docu-
value C to grade D. 6% UEI. Converts to 4% WPI. mented); Clinical Studies: Grade modifier 0. Net
adjustment compared with diagnostic class is 1.
Class 1 Example Calculation: Default for Moved 1 position to the left of default value C to
Diagnosis 5% UEIa grade B. 2% UEI. Converts to 1% WPI.
CDX GMFH GMPE GMCS
1 2 1 n/a
(GMFH CDX) (2 1) 1
(GMPE CDX) (1 1) 0
Chapter 15
(GMCS CDX) n/a
Net adjustment 1
Adjustment of 1 equals 1 position to the right of
default grade C and results in
Class 1, Grade D6% UEI
a
CDX indicates Class of diagnosis; GMFH, grade modifier
for functional history; GMPE, grade modifier for physical
examination; GMCS, grade modifier for clinical studies; and
UEI, upper extremity impairment.
Guides6e_15_383-492.indd 417 2/17/09 2:56:28 PM

Class 1 Example Calculation: Default for Class 1 Example Calculation: Default for
Diagnosis 2% UEIa Diagnosis 5% UEIa
CDX GMFH GMPE GMCS CDX GMFH GMPE GMCS
1 2 0 0 1 2 n/a n/a
(GMFH CDX) (2 1) 1 (GMFH CDX) (2 1) 1

(GMPE CDX) (0 1) 1 (GMPE CDX) n/a
(GMCS CDX) (0 1) 1 (GMCS CDX) n/a
Net adjustment 1 Net adjustment 1
Adjustment of 1 equals 1 position to the left of Adjustment of 1 equals 1 position to the right of
default grade C and results in default grade C, resulting in grade D
Class 1, Grade B 2% UEI Class 1 grade D 6% UEI
a a
UEI indicates upper extremity impairment; CDX, class of UEI indicates upper extremity impairment; CDX, class of
diagnosis; GMFH, grade modifier for functional history; diagnosis; GMFH, grade modifier for functional history;
GMPE, grade modifier for physical examination; and GMCS, GMPE, grade modifier for physical examination; and GMCS,
grade modifier for clinical studies. grade modifier for clinical studies.
functional history
EXAMPLE 15-11: STATUS POST ROTATOR CUFF

REPAIR
CLASS 2
Subject: 44-year-old woman. 14% to 25% Impairment of the Upper Extremity
History: The patient sustained trauma to her left
shoulder after a fall in a parking lot at work. She is EXAMPLE 15-12: TOTAL SHOULDER
6 months post rotator cuff repair. Medical records ARTHROPLASTY
confirm rotator cuff injury with previous full-thick-
ness rotator cuff tear. Residual pain on active range Subject: 43-year-old woman.
of motion interferes with normal activities, such as History: The patient was carrying boxes and slipped
dressing and bathing. on a wet floor. She sustained an injury to her shoul-
Physical Examination: Normal motion. No gross der and required a total shoulder implant arthro-
neurologic deficits or glenohumeral joint instability plasty. She continues to have occasional shoulder
are seen on static or dynamic shoulder examination. pain.
On manual muscle testing there is moderate weak- Functional Assessment: QuickDASH score is 23.
ness of the supraspinatus (abduction) and shoulder
external rotation, but testing produces an increase in Physical Examination: Full range of motion of the
the preexisting pain. 1 cm atrophy of upper arm. affected shoulder.
Clinical Studies: MRI finding of a moderate-sized Clinical Tests: X rays confirm good placement of
(2.5-cm) full-thickness rotator cuff tear. the implant.
Diagnosis: Status post rotator cuff repair. Impairment Rating: Regional Impairment:
Diagnosis of “total shoulder arthroplasty” as per cri-
Impairment Rating: Regional impairment: teria of “Implant with normal motion”, assigned class
Diagnosis of “Rotator cuff injury, full-thickness 2 with midrange default of 24% UEI. Adjustment
tear,” and per criteria of “Residual loss, functional Grids: Functional History: Grade modifier 1 for
with normal motion” assigned to class 1 with minimal interference with ADLs and QuickDash
midrange default of 5% UEI. Adjustment Grids: 23. Physical Examination: n/a because full range of
Chapter 15
Functional History: Grade modifier 2 for pain motion used as a descriptor for assignment to class 2;
with normal activity. Physical Examination: Grade Clinical Studies: n/a. Net adjustment compared with
modifier 1 due to muscle atrophy of 1 cm. Clinical diagnostic class is 1. Moved 1 position to the left
Studies: n/a (tear used as basis for diagnostic criteria of default value C to grade B. 22% UEI. Converts to
and imaging studies pre-operative) Numerical adjust- 13% WPI.
ment is 1. Moved 1 position to the right of default
value C to grade D. 6% UEI. Converts to 4% WPI.
Guides6e_15_383-492.indd 418 2/17/09 2:56:29 PM

Class 2 Example Calculation: Default for

Diagnosis 24% UEIa percentages being combined must be expressed
CDX GMFH GMPE GMCS
using a common denominator or same unit relative
value. Multiple impairments are successively com-
2 1 n/a n/a
bined by first combining the largest number with
(GMFH CDX) (1 2) 1 the next largest remaining number, and then further
(GMPE CDX) n/a combining it with the next largest remaining number,
(GMCS CDX) n/a
and then further repeating the process until all given
impairment numbers are combined.
Net adjustment 1
Tables in this chapter show the impairment percent-
Adjustment of 1 equals 1 position to the left of
default grade C, resulting in grade B
ages at the upper extremity level. The conversion fac-
tor for upper extremity to whole person impairment
Class 2, grade B 22% UEI
is 60%, for hand to upper extremity is 90%, thumb
a
diagnosis; GMFH, grade modifier for functional history;
to hand is 40%, index and middle finger to hand is
GMPE, grade modifier for physical examination; GMCS, 20%, and ring and little finger to hand is 10%. These
grade modifier for clinical studies; and n/a, not applicable. values are shown in Table 15-11 and for digit impair-
ment in Table 15-12. The examiner should report
15.3f Combining and Converting values at the level appropriate for the jurisdiction.
Impairments
If there are multiple diagnoses at MMI, the exam-
iner should determine if each should be considered
or if the impairments are duplicative. If there are
multiple diagnoses within a specific region, then
This section presents a method of evaluating upper
the most impairing diagnosis is rated because it is
extremity nerve impairment. This includes impair-
probable this will incorporate the functional losses
ment of digital nerves, brachial plexus, peripheral
of the less impairing diagnoses. In rare cases, the
nerves, and entrapment syndromes. Peripheral nerve
examiner may combine multiple impairments within
impairment may be combined with DBIs at the upper
a single region if the most impairing diagnosis does
extremity level as long as the DBI does not encompass
not adequately reflect the losses. When uncertain
the nerve impairment. Impairment due to chronic pain
about which method to choose or whether diagnoses
is discussed in Chapter 3, Pain-Related Impairment.
are duplicative, the evaluator should calculate the
Motivation and behavioral concerns are considered in
impairment using different alternatives and choose
Chapter 14, Mental and Behavioral Disorders.
the method or combination of methods that gives the
most clinically accurate impairment rating. The approach to assessing upper extremity neuro-
logic impairment depends on the diagnosis. Accurate
The evaluating physician must explain in writing
diagnosis of peripheral nerve disorders is based on a
the rationale for combining impairments. In assign-
detailed history, a thorough neurologic examination,
ing the grade modifiers in the adjustment grid, the
and appropriate diagnostic tests, including electrodi-
examiner must identify the grade assignment for
agnostic studies when required. Precise knowledge
each component; for example, a patient may have 2
of the anatomy and physiology of the nervous system
ratable conditions, each with different grade deter-
is a prerequisite. Underlying causes of neuromus-
minations. Functional history is used only for the
cular dysfunction that may mimic specific regional
single, highest DBI. Specific jurisdictions may mod-
defects must be detected and may include diabetes
ify this process so that functional history adjustment
mellitus, chronic alcohol abuse, systemic neurologic
is considered for each DBI or not considered at all as
disorders, hypothyroidism, and other systemic dis-
a grade modifier.
eases. Failure to recognize a preexisting alteration of
Chapter 15
If there are multiple upper extremity impairments sensory or motor nerve function can lead to errone-
they are combined except for motion impairments ous conclusions about impairment after nerve injury.
of the digits (other than thumb) and multiple digit
The user should first identify the structure or struc-
impairment, as explained in Section 15.2a. The com-
tures involved; this identification is based on the
bined value determination is based on the following
clinical history, presenting complaints, specific neu-
formula: A% B% (100% A%) the combined
rologic findings, and clinical studies. Neurological
value of A% and B%. The Combined Values Chart
impairment is assessed only for objective involve-
(end-of-book Appendix) is used to determine the
ment of the specific nerve or nerves. The principles
combined value of 2 impairment percentages. All
Guides6e_15_383-492.indd 419 2/17/09 2:56:30 PM

TA B L E 15 -11
Impairment Values Calculated From Upper Extremity Impairment
% Impairment % Impairment
Whole Upper Hand Thumb Index and Ring and Whole Upper Hand Thumb Index and Ring and
Person Extremity Middle Small Person Extremity Middle Small
Finger Finger Finger Finger
0 0 0 0 0 0 Very Severe
Mild 30 50 56
1 1 1 3 6 11 31 51 57
1 2 2 6 11 22 31 52 58
2 3 3 8 17 33 32 53 59
2 4 4 11 22 44 32 54 60
3 5 6 14 28 56 33 55 61
4 6 7 17 33 67 34 56 62
4 7 8 19 39 78 34 57 63
5 8 9 22 44 89 35 58 64
5 9 10 25 50 100 35 59 65
6 10 11 28 56 35 59 66
7 11 12 31 60 36 60 67
7 12 13 33 65 37 61 68
8 13 14 36 70 37 62 69
Moderate 38 63 70
8 14 16 39 80 38 64 71
9 15 17 42 85 39 65 72
10 16 18 44 90 40 66 73
10 17 19 47 95 40 67 74
11 18 20 50 100 41 68 75
11 19 21 53 41 68 76
12 20 22 56 41 69 77
13 21 23 58 42 70 78
13 22 24 61 43 71 79
14 23 26 64 43 72 80
14 24 27 67 44 73 81
15 25 28 69 44 74 82
Severe 45 75 83
16 26 29 72 46 76 84
16 27 30 75 46 77 85
17 28 31 78 46 77 86
17 29 32 81 47 78 87
18 30 33 83 47 79 88
19 31 34 86 48 80 89
19 32 36 89 49 81 90
20 33 37 92 49 82 91
20 34 38 94 50 83 92
21 35 39 97 50 84 93
22 36 40 100 51 85 94
22 37 41 52 86 95
23 38 42 52 86 96
23 39 43 52 87 97
24 40 44 53 88 98
25 41 46 53 89 99
25 42 47 54 90 100
Chapter 15
26 43 48 55 91
26 44 49 55 92
27 45 50 56 93
28 46 51 56 94
28 47 52 57 95
29 48 53 58 96
29 49 54 58 97
59 98
59 99
60 100
Guides6e_15_383-492.indd 420 3/3/09 6:58:32 PM

TA B L E 15 -12
Impairment Values Calculated From Digit Impairment
Note: To convert digit impairment to other units, identify the digit impairment value in the left-hand column, identify the
digit (thumb, index, middle, ring, or little) in the top columns and the converted impairment values are shown based on
unit (hand, upper extremity [UE], or whole person [WP]). Follow directions for combining, as directed in the text.
The conversion factor for upper extremity to whole person is 60%, for hand to upper extremity is 90%, thumb to hand is
40%, index and middle finger to hand is 20%, and ring and little finger to hand is 10%.
Digit Impairment Value Thumb Index or Middle Finger Ring or Little Finger
Digit Conversion Multiplier Hand UE WP Hand UE WP Hand UE WP
(digit to specified unit)
40% 36% 22% 20% 18% 11% 10% 9% 5%
1 0 0 0 0 0 0 0 0 0
2 1 1 0 0 0 0 0 0 0
3 1 1 1 1 1 0 0 0 0
4 2 1 1 1 1 0 0 0 0
5 2 2 1 1 1 1 1 0 0
6 2 2 1 1 1 1 1 1 0
7 3 3 2 1 1 1 1 1 0
8 3 3 2 2 1 1 1 1 0
9 4 3 2 2 2 1 1 1 0
10 4 4 2 2 2 1 1 1 1
11 4 4 2 2 2 1 1 1 1
12 5 4 3 2 2 1 1 1 1
13 5 5 3 3 2 1 1 1 1
14 6 5 3 3 3 2 1 1 1
15 6 5 3 3 3 2 2 1 1
16 6 6 3 3 3 2 2 1 1
17 7 6 4 3 3 2 2 2 1
18 7 6 4 4 3 2 2 2 1
19 8 7 4 4 3 2 2 2 1
20 8 7 4 4 4 2 2 2 1
21 8 8 5 4 4 2 2 2 1
22 9 8 5 4 4 2 2 2 1
23 9 8 5 5 4 2 2 2 1
24 10 9 5 5 4 3 2 2 1
25 10 9 5 5 5 3 3 2 1
26 10 9 6 5 5 3 3 2 1
27 11 10 6 5 5 3 3 2 1
28 11 10 6 6 5 3 3 3 2
29 12 10 6 6 5 3 3 3 2
30 12 11 6 6 5 3 3 3 2
31 12 11 7 6 6 3 3 3 2
Chapter 15
21 8 8 5 4 4 2 2 2 1
33 13 12 7 7 6 4 3 3 2
34 14 12 7 7 6 4 3 3 2
35 14 13 8 7 6 4 4 3 2
36 14 13 8 7 6 4 4 3 2
37 15 13 8 7 7 4 4 3 2
38 15 14 8 8 7 4 4 3 2
39 16 14 8 8 7 4 4 4 2
Guides6e_15_383-492.indd 421 2/17/09 2:56:31 PM

TA B L E 15 -12
Impairment Values Calculated From Digit Impairment (continued)
40% 36% 22% 20% 18% 11% 10% 9% 5%
40 16 14 9 8 7 4 4 4 2
41 16 15 9 8 7 4 4 4 2
42 17 15 9 8 8 5 4 4 2
43 17 15 9 9 8 5 4 4 2
44 18 16 10 9 8 5 4 4 2
45 18 16 10 9 8 5 5 4 2
46 18 17 10 9 8 5 5 4 2
47 19 17 10 9 8 5 5 4 3
48 19 17 10 10 9 5 5 4 3
49 20 18 11 10 9 5 5 4 3
50 20 18 11 10 9 5 5 5 3
51 20 18 11 10 9 6 5 5 3
52 21 19 11 10 9 6 5 5 3
53 21 19 11 11 10 6 5 5 3
54 22 19 12 11 10 6 5 5 3
55 22 20 12 11 10 6 6 5 3
56 22 20 12 11 10 6 6 5 3
57 23 21 12 11 10 6 6 5 3
58 23 21 13 12 10 6 6 5 3
59 24 21 13 12 11 6 6 5 3
60 24 22 13 12 11 6 6 5 3
61 24 22 13 12 11 7 6 5 3
62 25 22 13 12 11 7 6 6 3
63 25 23 14 13 11 7 6 6 3
64 26 23 14 13 12 7 6 6 3
65 26 23 14 13 12 7 7 6 4
66 26 24 14 13 12 7 7 6 4
67 27 24 14 13 12 7 7 6 4
68 27 24 15 14 12 7 7 6 4
69 28 25 15 14 12 7 7 6 4
70 28 25 15 14 13 8 7 6 4
71 28 26 15 14 13 8 7 6 4
72 29 26 16 14 13 8 7 6 4
73 29 26 16 15 13 8 7 7 4
74 30 27 16 15 13 8 7 7 4
Chapter 15
75 30 27 16 15 14 8 8 7 4
76 30 27 16 15 14 8 8 7 4
77 31 28 17 15 14 8 8 7 4
78 31 28 17 16 14 8 8 7 4
79 32 28 17 16 14 9 8 7 4
80 32 29 17 16 14 9 8 7 4
81 32 29 17 16 15 9 8 7 4
82 33 30 18 16 15 9 8 7 4
83 33 30 18 17 15 9 8 7 4
84 34 30 18 17 15 9 8 8 5
Guides6e_15_383-492.indd 422 2/17/09 2:56:32 PM

TA B L E 15 -12
Impairment Values Calculated From Digit Impairment (continued)
40% 36% 22% 20% 18% 11% 10% 9% 5%
85 34 31 18 17 15 9 9 8 5
86 34 31 19 17 15 9 9 8 5
87 35 31 19 17 16 9 9 8 5
88 35 32 19 18 16 10 9 8 5
89 36 32 19 18 16 10 9 8 5
90 36 32 19 18 16 10 9 8 5
91 36 33 20 18 16 10 9 8 5
92 37 33 20 18 17 10 9 8 5
93 37 33 20 19 17 10 9 8 5
94 38 34 20 19 17 10 9 8 5
95 38 34 21 19 17 10 10 9 5
96 38 35 21 19 17 10 10 9 5
97 39 35 21 19 17 10 10 9 5
98 39 35 21 20 18 11 10 9 5
99 40 36 21 20 18 11 10 9 5
100 40 36 22 20 18 11 10 9 5
described in Section 15.4a, Clinical Assessment associated with the nerve lesion. Since sensory and
and Grading Deficits, must be followed. Sensibility manual muscle testing may be influenced by several
impairment in the hand associated with digital nerve factors, including reports and performance of the
lesions is rated using Section 15.4c, Digital Nerve patient, it is imperative to determine the reliability of
Impairment. Purely sensory nerves involving the neurologic findings. Only unequivocal and perma-
hand are assessed using Section 15.4d, Sensory Only nent deficits are given permanent impairment ratings.
Peripheral Nerve Injury Impairment. Traumatic
nerve injuries and CRPS type II are rated using Sensory Deficits
Section 15.4e, Peripheral Nerve and Brachial Plexus Sensation is the awareness of stimulation, while sen-
Impairment. Nerve entrapments (eg, carpal tunnel sibility is the conscious appreciation and interpreta-
syndrome, cubital tunnel syndrome, and other entrap- tion of the stimulus that produced the sensation.
ments) are not isolated traumatic events and are dealt
Sensory deficits are evaluated according to the fol-
with in Section 15.4f, Entrapment Neuropathy.
lowing criteria:
It is important to determine the anatomic distribu-
1. How does the sensory deficit or pain interfere with
tion and severity of loss of function resulting from (1)
the individual’s performance of daily activities?
sensory deficits or pain and (2) motor deficits and loss
of power. Characteristic deformities and manifesta- 2. To what extent does the sensory deficit or pain
tions resulting from peripheral nerve lesions, such as follow the defined anatomic pathways of the
restricted motion, atrophy, and vasomotor, trophic, peripheral nerve?
and reflex changes, have been taken into consideration
3. To what extent is the description of the sensory
Chapter 15
in the estimated impairment values shown in this sec-

deficit or pain consistent with characteristics of
tion. Therefore, when impairment results strictly from
peripheral nerve disorders?
a peripheral nerve lesion, no other rating method is
applied to this section to avoid duplication or unwar- 4. To what extent does the sensory deficit or pain
ranted increase in the impairment estimation. correspond to other disturbances (motor, trophic,
vasomotor, etc) of the involved nerve structure?
15.4a Clinical Assessment and Grading
Evaluation of sensory function in the hand considers
Deficits
all modalities of sensibility, including perception of
Sensory and motor deficits must be accurately
pain, warmth, cold, and touch-pressure, as well as
graded to define the potential range of impairments
vibration.
Guides6e_15_383-492.indd 423 3/3/09 6:58:33 PM

Sensory deficits can be challenging to grade, since blanching or skin indentation. The interval between
the clinical examination is based on subjective applications should be no less than 3 to 5 seconds.
reports by the patient. Grading is based on the results A series of touches with 1 or 2 points is made, and
of sensibility testing and 2-point discrimination, to the individual immediately indicates whether 1 or 2
improve interrater reliability. points are felt. Two of 3 responses must be accurate
for scoring. The distance between the ends is progres-
All clinical tests used to examine the degree of
sively increased until the required accurate responses
functional loss of sensibility are related to cutane-
are elicited, at which time the distance is recorded.
ous touch-pressure sensation. At present, the 2-point
test for fine discrimination sensibility is most widely Semmes-Weinstein monofilament testing or the
used, followed by the monofilament touch-pressure Semmes-Weinstein esthesiometer is an instrument
threshold test. The pinprick test can be useful to widely used in hand surgery and rehabilitation to
determine whether protective sensation is intact and detect and monitor peripheral nerve function of the
to identify discrepancies between dermatomal find- thumb, fingers, and hand. Monofilament is the opti-
ings and reported symptoms. More accurate assess- mum choice for objective touch thresholds examina-
ment is obtained by using the sharp and dull sides of tion because it is simple, inexpensive, easy to use, and
the pin at random. If loss of sharp vs dull perception provides a repeatable instrument stimulus. Normal
is present in a digit, the 2-point discrimination should threshold is considered 2.83 g or less of force, how-
be greater than 15 mm. Vibration testing has yet to be ever recent studies reported that in healthy subjects,
associated with functional levels of sensibility. hand touch thresholds appear to be higher than the
2.83-g monofilament, which is the generally accepted
Semmes-Weinstein monofilament testing measures
cutoff. Monofilament test criteria for the palmar sur-
light-touch and deep-pressure thresholds with suffi-
face of the distal-most portion of a digit are presented
cient accuracy to quantify returning sensibility levels
in Table 15-13, Monofilament Test Criteria.
long before 2-point discrimination is measurable.
The moving 2-point discrimination test may be use- Sensibility assessment is one of the most challenging
ful in evaluating recovering nerve function because tasks in impairment evaluation. The subjective nature
response to this stimulus returns before response to of sensibility testing can relate to a number of variables
a static 2-point stimulus. Functional isolation of the involving the testing environment, the individual being
finger, as noted in the blindfolded picking-up test, tested, the test instruments and methods of administra-
can help determine the presence or absence of any tion, and the examiner. Tests should be administered in
useful sensibility in the digit. a quiet environment, void of extraneous noises that dis-
tract the individual and the tester. Patient-related vari-
The patterns of nerve loss and recovery seen in
ables can include attitude, concentration, anxiety, and
neuropathy or neuritis from disease or nerve com-
the like. Abnormal skin texture, such as calluses, also
pression are different from those following nerve
influences the test results. Instrument-related variables
lacerations. Within the limits of current instruments,
include manufacturing quality control, readjustment of
results of 2-point discrimination tests have been nor-
calibration as needed over time, and the weight of vari-
mal, whereas either the Semmes-Weinstein mono-
ous instruments. Important method-related variables
filament testing or nerve conduction studies may be
include rate and duration of stimulus application, the
abnormal in both clinical and induced neuropathies.
amount of pressure exerted on the skin, and whether the
Two-point discrimination has its widest application
stimulus is moving or constant. Instruments designed to
for individuals who have sustained nerve lacerations,
control the force and velocity of 2-point discrimination
and presence of 2-point discrimination usually indi-
or monofilament application and of other stimuli are
cates significant return of function.
not yet available. The examiner’s experience, attention
The classic Weber static 2-point discrimination test is
most valuable. Moberg in 1958 originally described
Chapter 15
TA B L E 15 -13
the use of a paper clip opened and bent into a caliper.
Testing is started distally and proceeds proximally. Monofilament Test Criteria
The distance between the tips of the instrument is Grams of Force Interpretation
set first at 5 mm. While the individual being tested 1.65 to 2.83 Normal
closes his or her eyes, the tips of the testing device 3.22 to 3.61 Diminished light touch
are applied lightly to the sides of the pulp of the dis-
3.84 to 4.31 Diminished protective
tal segment of the digit in a random sequence, in a sensation
longitudinal orientation. Because it is light-touch dis-
4.56 to 6.65 Loss of protective sensation
crimination that is being tested, the pressure applied
should be very light and must not produce a point of 6.65 No response, no sensation
Guides6e_15_383-492.indd 424 2/17/09 2:56:33 PM

to detail, and adherence to methods of administration than 1 grade between observers or by the same exam-
can minimize the effects of the above variables. iner on separate occasions, the measurement should
be considered invalid. Individuals whose performance
Individuals with severe deficit have decreased protec-
is inhibited by pain or the fear of pain are not good
tive sensibility, which is defined as a conscious appre-
candidates for manual muscle testing.
ciation of pain, temperature, or pressure before tissue
damage results from the stimulus. Individuals with very
15.4b Neurologic Grading and Severity
severe or complete deficit have no protective sensibility.
Determination
The results of the sensory and motor examination
Motor Deficits
are used to define the severity of the deficits. This
Motor deficits are based on muscle strength test-
is reflected in a level of severity as illustrated in
ing. The manual grading of muscle strength is based
Table 15-14.
on the ability of a normal muscle to contract and to
move a bone-joint lever arm through range of motion
15.4c Digital Nerve Impairment
with full resistance. Palpation of the muscle-tendon
Unlike most other sections in this chapter, impairment
unit helps evaluate muscle contractility. Both upper
ratings for sensory loss in the digits will not use the
extremities should be tested and the results compared.
ICF Model. Nerve lesions can occur at any level from
Muscle strength testing is voluntary in that it requires
the finger tip to the MCP joint. The thumb has a dif-
full individual concentration and cooperation. It
ferent value to the hand than the index and middle fin-
remains somewhat subjective until precise methods
gers, which have different values relative to the hand
of measuring muscle contractions become generally
than the ring and little finger. The ulnar-sided digital
available. Muscle atrophy, although not rated sepa-
nerves have higher values than the radial-sided nerves
rately, can be a more objective sign of motor dysfunc-
in the thumb and little finger, while the converse is
tion. Electromyographic studies may confirm motor
true in the remaining digits. Thus, digital nerve injury
function of specific muscles or groups of muscles.
is difficult to fit into 5 classes of severity.
Manual muscle testing, which typically involves
The Third Edition introduced the concept of using
groups of muscles, depends on the patient’s coop-
the level of injury or the length of the nerve that is
eration and is subject to his or her conscious and
affected. Sensory loss in the upper limb has a direct
unconscious control. To be valid, the results should
correlation between anatomy and function, much like
be concordant with other observable pathologic signs
amputations. The more severe the sensory loss, the
and medical evidence. Measurements can be made by
more function has been lost. Therefore, the authors
1 or 2 observers. If the measurements are made by 1
have retained the system perfected over 5 prior edi-
examiner, they should be consistent on different occa-
tions of the Guides, which permits a range of 20 dif-
sions. If made by 2, they should be consistent between
ferent potential ratings for each digital nerve.
examiners. Even in a fully cooperative individual,
strength may vary from one examination to another, The palmar surfaces of the thumb and fingers have a
but not by more than 1 grade. If findings vary by more unique sensibility or capacity for precise interpretation
TA B L E 15 -14
Sensory and Motor Severity
Deficit Severity 0 Severity 1 Severity 2 Severity 3 Severity 4
Normal Mild Moderate Severe Very severe or
complete loss
Sensory Normal sensibility Distorted superficial Distorted superficial Decreased Absent superficial
and sensation tactile sensibility tactile sensibility superficial pain and tactile
with abnormal cutaneous pain and sensibility
Chapter 15
sensation tactile sensibility

Normal monofila- Abnormal monofila- Abnormal monofila- Decreased
ment and normal ment (diminished ment (diminished protective
2-point sensibility) and sensibility) and sensibility
discrimination normal 2-point abnormal 2-point
(6 mm) (6 mm)
Motor Normal (Grade 5) Grade 4/5 (against Grade 3/5 (against Grade 2/5 (move- Grade 0–1/5
gravity with some gravity only without ment with gravity (no evidence of
resistance) resistance) eliminated) contractility or no
joint movement)
No motion
Guides6e_15_383-492.indd 425 2/17/09 2:56:34 PM

of sensation because of their dense population of spe- FIGURE 15 - 4

cialized receptor organs and free nerve endings. The Digit Impairment due to Thumb Amputation at
impairment evaluation of sensibility in the thumb/fin- Various Lengths (top scale) or Total Transverse
gers/hand, therefore, deserves special attention. Sensory Loss (bottom scale)
This section addresses the impairment evaluation of Total transverse sensory loss impairments correspond to
50% of amputation values.
sensibility losses in the thumb/fingers/hand associ-
ated with lesions of digital nerves. Digit impairment %
Amputation
Principles Tip
0 10 20 30 40 50 60 70 80 90 100
Sensory impairment is rated according to the sen-
sory quality and the distribution of the sensory loss.
The sensory quality is based on the results of the IP
2-point discrimination test or the monofilament test
carried out over the distal palmar area of the digit,
or on the most distal part of the stump in the pres-
ence of a partial amputation. Sensibility defects on MCP
0 5 10 15 20 25 30 35 40 45 50
the dorsal surfaces of the thumb and fingers are not Total transverse sensory loss
considered impairing. The sensory quality impair-
ment is classified according to Table 15-15, Sensory Redrawn with permission from Swanson AB. Evaluation of
Quality Impairment Classification. impairment of function in the hand. Surg Clin North Am.
1964;44:925–940.
In this section, the definitions of sensibility are as fol-
lows: normal sensibility is 2-point discrimination of 6 is the level at which the scar is present from the
mm less or monofilament perception at 2.83 g or less; wound that caused the sensory loss.
partial sensory loss is 2-point discrimination of 7 to
15 mm or monofilament perception at 3.22 to 6.65 Partial transverse sensory loss represents 50% sensory
g (poor localization and abnormal response to the loss (2-point discrimination of 7 to 15 mm) involv-
sensory stimuli); total sensory loss is 2-point discrim- ing both digital nerves and receives 25% of the digit
ination of greater than 15 mm or monofilament per- amputation impairment value for the corresponding
ception at greater than 6.65 g (the response to touch, digit length percentage (Tables 15-16 and 15-17).
pinprick, pressure, and vibratory stimuli is absent).
This Sensory Quality Impairment Classification is
FIGURE 15 -5
used only for impairment due to lesions of thumb and
finger nerves. It is not a substitute for selecting the Digit Impairment due to Finger Amputation at
grade of severity of sensory deficits or pain resulting Various Lengths (top scale) or Total Transverse
Sensory Loss (bottom scale)
from a more proximal peripheral nerve disorder.
Total transverse sensory loss impairments correspond to
The distribution, or area, of sensory loss is deter- 50% of amputation values.
mined by the level of involvement (percentage of
digit length affected) of both digital nerves (trans- Digit impairment %
verse sensory loss) or 1 digital nerve on either the Amputation
0 10 20 30 40 50 60 70 80 90 100
radial or ulnar side of the digit (longitudinal sen- Tip
sory loss). The percentage of digit length involved

is derived from the top scale of Figure 15-4 for the DIP
thumb and of Figure 15-5 for the fingers. Most often
the point at which the sensory loss of a digit begins
Chapter 15
PIP
TA B L E 15 -15
Sensory Quality Impairment Classification
Two-point Monofilament, Sensory Sensory
discrimination, grams of force Loss Quality
mm Impairment, MCP
% 0 5 10 15 20 25 30 35 40 45 50
6 2.83 None 0 Total transverse sensory loss
7–15 3.22–6.65 Partial 50 Redrawn with permission from Swanson AB. Evaluation of
15 6.65 Total 100 impairment of function in the hand. Surg Clin North Am.
1964;44:925–940.
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Total transverse sensory loss represents 100% TA B L E 15 -17

sensory loss (2-point discrimination greater than Digit Impairment for Transverse and
15 mm) involving both digital nerves and receives Longitudinal Sensory Losses in Index, Middle,
50% of the digit amputation impairment value for and Ring Fingers Based on Percent of Digital
the corresponding level (Figures 15-4 and 15-5 and Length Involved
Tables 15-16 and 15-17). Percent of Digit Impairment
Transverse Loss Longitudinal Loss
Longitudinal Sensory Loss of Digital Nerves Both Digital Ulnar Digital Radial Digital
Percent
Longitudinal sensory loss impairments are based of Digit
Nerves Nerve Nerve
on the relative importance of the side of the digit for Length Total Partial Total Partial Total Partial
sensory function as follows: thumb and little finger, 100 50 25 20 10 30 15
radial side 40% and ulnar side 60%; index, middle,
90 45 23 18 9 27 14
and ring fingers, radial side 60% and ulnar side 40%.
80 40 20 16 8 24 12
The surfaces used for opposition in various pinch
functions and the ulnar aspect of the little finger are 70 35 18 14 7 24 11
rated more highly. If the little finger has been ampu- 60 30 15 12 6 18 9
tated, the relative value of the ulnar side of the ring 50 25 13 10 5 15 8
finger becomes 60% and that of the radial side, 40%, 40 20 10 8 4 12 6
as the ring finger is now the border digit. The digit
30 15 8 6 3 9 5
impairment values are calculated as described above,
20 10 5 4 2 6 3
based on the sensory quality and distribution of the
sensory loss. 10 5 3 2 1 3 2
From Swanson AB, de Groot Swanson G, Hagert CG, Evaluation
For ease of determination, digit impairment values of impairment of hand function. In: Hunter JM, Mackin E,
for total transverse and longitudinal, and partial trans- Callahan AD, eds. Rehabilitation of the Hand. Surgery and
Therapy. Fourth ed. St Louis, Mo: CV Mosby; 1995
verse and longitudinal sensory losses, were calculated
according to the percentage of digit length involved.
Consult Table 15-16 for the thumb and little finger
sensory loss and Table 15-17 for the index, middle,
and ring finger sensory loss. Once the digital impair-
ment is obtained, the digital impairment can be con-
TA B L E 15 -16 verted to a hand impairment using Table 15-11.
Digit Impairment for Transverse and
Longitudinal Sensory Losses in Thumb and
Little Finger Based on Percent of Digital EXAMPLE 15-13: DIGITAL NERVE INJURY,
Length Involved LONGITUDINAL
Percent of Digit Impairment
Transverse Loss Longitudinal Loss
History: One year ago lacerated his right index
Both Digital Ulnar Digital Radial Digital
Percent finger at the level of the PIP joint; no tendons were
Nerves Nerve Nerve
of Digit
involved, however the laceration was deep on the
Length Total Partial Total Partial Total Partial
radial aspect and required suturing.
100 50 25 30 15 20 10
90 45 23 27 14 18 9 Current Symptoms: Reports the side of his finger,
distal to his laceration, does not feel normal; However,
80 40 20 24 12 16 8
this does not interfere with activities of daily living
70 35 18 21 11 14 7
60 30 15 18 9 12 6 Functional Assessment: QuickDASH score is 7.
Chapter 15
50 25 13 15 8 10 5 Physical Exam: Normal, except for decreased

40 20 10 12 6 8 4 sensation distal to index PIP joint, radial aspect,
30 15 8 9 5 6 3 with two-point discrimination 8 mm.
20 10 5 6 3 4 2 Clinical Studies: None performed.
10 5 3 3 2 2 1
Diagnosis: Radial digital nerve injury, partial.
From Swanson AB, de Groot Swanson G, Hagert CG. Evaluation
of impairment of hand function. In: Hunter JM, Mackin E, Impairment Rating: Per Table 15-15, Sensory
Callahan AD, eds. Rehabilitation of the Hand. Surgery and Quality Impairment Classification, 2 point discrimi-
Therapy. Fourth ed. St Louis, Mo: CV Mosby; 1995
nation of 8 mm defines partial sensory loss and a
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50% sensory quality loss. Figure 15-5 illustrates The following steps are used to determine digital
that involvement at the PIP level is consistent with nerve impairment:
involvement of 80% of the digit length. According
1. Determine the 2-point discrimination (preferred)
to Table 15-17, partial longitudinal sensory loss over
or monofilament test results to identify the
80% of the digit length is a 12% digit impairment.
sensory quality, or type of sensory loss, for the
Per Table 15-12, Impairment Values Calculated
thumb and each finger.
From Digit Impairment, this is equivalent to a 2%
hand impairment, 2% UEI, and 1% WPI. a. Normal (2-point discrimination less than 7 mm
or monofilament perception at 2.83 g or less).
Rating Impairment due to Digital Neuromas
b. Partial (2-point discrimination of 7 to 15 mm
The severity of pain and decreased function
or monofilament perception at 3.22 to 6.65 g).
associated with neuromas of the digital nerves is
rated as complete or partial nerve loss. The term c. Total (2-point discrimination of 16 mm or
complete nerve loss is used to describe a neuroma more or monofilament perception at greater
with distal anesthesia and symptoms severe enough than 6.65 g).
to prevent use of the digit and is given 100% of the
2. Identify the distribution of sensory loss as
value in Figure 15-6. The term incomplete nerve loss
longitudinal (1 nerve) or transverse (both nerves)
describes a neuroma with anesthesia distally that
for the thumb and each finger. This information
causes significantly decreased use of the digit and
will be used in Table 15-16 or Table 15-17.
is given 50% of the value in Figure 15-6. The total
digit impairment cannot exceed 100% using either 3. Determine the level of involvement (digit length)
method. using the top scale of Figure 15-4 for the thumb
or the top scale of Figure 15-5 for the fingers.
4. Consult Table 15-16 for the thumb and little
finger and Table 15-17 for the index, middle, and
FIGURE 15 - 6 ring fingers to determine the digit impairment for
either total or partial, transverse or longitudinal
Hand Impairment Values for Total Transverse
Sensory Loss (numbers at tips of digits) and Total (ulnar- or radial-sided nerve) sensory loss
Longitudinal Sensory Loss on Radial and Ulnar according to the percentage of digit length
Sides (numbers at sides of digits) Involving 100% involved.
of the Digit Length
5. If both digital nerves in the same digit are
involved but at very different levels (digit length)
or at different sensory severities (one has partial
and the other has complete loss), the sensory
impairments relating to the ulnar or radial digital
nerves are determined individually, and the
8%
results are added.
6. Convert the digit impairment to hand, upper
12% extremity, and whole person impairment by
20% using Table 15-12. If a digit has more than one
impairment, obtain the total digit impairment
value by combining its various impairments
before converting the digit value to a hand value.
3%
2%
Chapter 15
6%
4% EXAMPLE 15-14: DIGITAL NERVE CONTUSION
3% 2%
6% 4% Subject: 24-year-old woman.
5%
History: Struck her left ring finger distally with
10% a hammer one year ago. Initially diagnosed as a
5% “bruise.” Ongoing complaints of discomfort and
10%
numbness and a digital neuroma was diagnosed.
Redrawn with permission from Swanson AB. Evaluation of
impairment of function in the hand. Surg Clin North Am. Current Symptoms: Sensation of numbness over
1964;44:925–940.
the ulnar aspect of her right ring finger distal to
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the DIP joint. Reports interference with activities branch of the median nerve and the palmar cutane-
that involve intensive use of her hands, such as ous branch of the ulnar nerve are transected and not
keyboarding. repaired, and there is the expected loss of protective
sensation and pain in the distribution of both nerves,
Functional Assessment: QuickDASH score is 18.
a 4% upper extremity impairment is assigned in
Physical Exam: Normal, except for decreased total.
sensation distal to ring finger DIP joint, ulnar aspect,
with 2-point discrimination 18 mm.
EXAMPLE 15-15: SUPERFICIAL RADIAL
NERVE INJURY
Diagnosis: Digital neuroma, ulnar digital nerve, ring
Subject: 34-year-old man
finger.
History: One year ago had a laceration to the distal
Impairment Rating: Per Table 15-15, Sensory
forearm.
Quality Impairment Classification findings, of 2
point discrimination of 18 mm define total sensory Current Symptoms: Complains of vague pain and
loss and 100% sensory quality impairment. Figure some numbness over the radial side of the dorsum of
15-5 reports that involvement at the DIP level is the hand, which is annoying but does not interfere
consistent with 45% digit length and according to with activity.
Table 15-17, the findings of total longitudinal loss
of the ulnar digital nerve involving 45% digit length
results in 9% digit impairment. According to Table Physical Exam: Normal, except for hypesthesia in
15-12, Impairment Values Calculated From Digit the distribution of the superficial radial nerve.
Impairment this is equivalent to 1% hand, 1% UEI
and 0% WPI.
Diagnosis: Superficial radial nerve injury.
15.4d Sensory Only Peripheral Nerve
Impairment Rating: Per Table 15-18, Impairment
Injury Impairment
for Sensory Only Peripheral Nerve Injury classified
Purely sensory nerves (palmar and dorsal cutaneous
as “mild” since the description is consistent with
branches of the median and the ulnar nerve;
retained protective sensation and some pain. This
superficial radial nerve; medial, lateral, and posterior
results in 2% UEI or 1% WPI.
antebrachial cutaneous nerves, etc) are rated using
Table 15-18, Impairment for Sensory Only Peripheral
15.4e Peripheral Nerve and Brachial
Nerve Injury.
Plexus Impairment
If an individual fulfills some, but not all, of the Impairment from traumatic injury to peripheral
criteria for a specific level of injury, the next lower nerves is defined by the specific nerves involved, and
category is used to describe the injury severity. the associated severity of sensory and motor deficits.
Usually, only one of these nerves will be rated in This section is not used for nerve entrapments since
an extremity. If 2 or more nerves are injured, the nerve entrapments are not isolated traumatic events;
classification of the more severe nerve injury will nerve entrapments are rated in Section 15.4f.
determine the impairment for all purely sensory
nerves. For example, if both the palmar cutaneous
TA B L E 15 -18
Impairment for Sensory Only Peripheral Nerve Injury
Chapter 15
Category Minimal Mild Moderate Severe

Description Retained protective Retained protective No protective Injury to multiple
sensation, but no pain sensation and some sensation (no sharp- purely sensory nerves,
pain dull discrimination with no protective
ability) or significant sensation (no sharp-
pain dull discrimination
ability) and significant
pain
Impairment 1% UEI 2% UEI 3% UEI 4% UEI
Note: UEI indicates upper extremity impairment.
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Peripheral nerve and brachial plexus injuries are he could actively abduct and elevate the upper arm
rated as follows: from 90° to 180° against gravity and slight resis-
tance. There is mild deltoid atrophy compared to
1. Identify the injured nerve. The origins and func-
the opposite extremity. There was some hypesthesia
tions are illustrated in Table 15-19, motor inner-
of the skin over the lower two thirds of the deltoid
vation is depicted in Figure 15-7 and cutaneous
muscle.
innervation is depicted in Figure 15-8.
Clinical Studies: X rays and an MRI of his shoul-
2. Grade the sensory and motor deficit as described
der were normal. No electrodiagnostic studies were
in 15.4a Clinical Assessment and Grading
performed.
Deficits using Table 15-14 Sensory and Motor
Severity and Section 15-4a; the deficit may be: Diagnosis: Axillary nerve injury.
none, mild, moderate, severe, or very severe.
Impairment Rating: Per Table 15-14 the sensory
3. For brachial plexus injuries use Table 15-20, deficits are consistent with severity 1, mild, and
Brachial Plexus Impairment: Upper Extremity the motor deficits are consistent with “grade 4 / 5
Impairments, and for peripheral nerve injuries (against gravity with some resistance)” also resulting
use Table 15-21, Peripheral Nerve Impairment: in classification of severity 1. Table 15-21, Peripheral
Upper Extremity Impairments, to define the Nerve Impairment – Upper Extremity Impairments
impairment. specifies that for the axillary nerve a mild sensory
deficit is a class 1 impairment and a mild motor
a. In the left column identify the nerve involved
deficit is also a class 1 impairment. The mid-range
and then identify the severity of the sensory
default value for the class 1 mild sensory deficit is
and/or motor deficit.
1% UEI and the mid-range default for the motor
b. Adjust the impairment as described in deficit is 5% UEI. Physical examination was used
Section 15.3, Adjustment Grid and Grade to define the class, therefore does not serve as an
Modifiers: Non-Key Factors, excluding Table adjustment. His clinical symptoms and QuickDash of
15-8, Physical Examination Adjustment, 30 are consistent with a grade modifier 1, ie, consis-
since these neurologic examination findings tent with the class 1 deficits. Therefore, the impair-
define the impairment values in Table 15-20. ment remains 1% UEI for sensory involvement and
Adjustments are made only for Functional 5% UEI for motor involvement resulting in combined
History (Table 15-7) and Clinical Studies 6% UEI or 4% WPI.
(Table 15-9) (ie, electrodiagnostic studies).
c. Combine motor and sensory impairments at
EXAMPLE 15-17: BRACHIAL PLEXUS INJURY
the upper extremity impairment value.
Subject: 37-year-old man
History: While painting he fell off a ladder, result-
CLASS 1 ing in a “stretch injury” to his right upper extremity.
1% to 13% Impairment of the Upper Extremity There were no findings of significant bone or joint
injury, however because of persistent complaints he
was seen by a neurologist who diagnosed a brachial
EXAMPLE 15-16: AXILLARY NERVE INJURY
plexus injury involving the upper trunk.
Current Symptoms: Complains of pain and numb-
History: One year ago had a dislocation of the right ness over his anterolateral shoulder, arm, forearm,
shoulder, which was reduced to its anatomic posi- and thumb. There are vague complaints of weakness.
tion as seen on roentgenograms. However, some loss
Chapter 15

of muscle strength persisted despite an appropriate
course of rehabilitation and sufficient time for maxi- Physical Exam: Examination unremarkable except
mal recovery. for sensory examination which revealed normal 2
point discrimination, however diminished light touch
Current Symptoms: Complains of weakness on
(3.61 gms). Motor examination was normal.
raising his arm and numbness over his shoulder.
Clinical Studies: X rays and an MRI of his shoulder
were normal.
Physical Exam: In a standing position with the arm
Diagnosis: Brachial plexus injury
placed alongside the body and the elbow flexed,
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TA B L E 15 -19
Origins and Functions of Peripheral Nerves of Upper Extremity Emanating From Brachial Plexus
Nerves of Plexus Primary Secondary Function
Branches branches
Muscular branches Unnamed Motor to largus colli, scalenes, and subclavius
Dorsal scapular (C5) Motor to rhomboideus major and minor, levator scapulae
Long thoracic (C5, 6, 7) Motor to serratus anterior
Suprascapular (C5, 6) Motor to supraspinatus and infraspinatus
Lateral pectoral (C5, 6, 7) Motor to pectoralis major and minor
Medial pectoral (C8, T1) Motor to pectoralis major and minor
Upper subscapular (C5, 6) Motor to subscapularis
Lower subscapular (C5, 6) Motor to tenes major and subscapularis
Thoracodorsal C6, C7, 6) Motor to latissimus dorsi
Medial brachial cutaneous (T1) Sensory to anteromedial surface of arm (with
intercostobrachial
Intercostobrachial (T2) Sensory to posteromedial surface of arm (with medial brachial
cutaneous)
Medial antebrachial cutaneous Sensory anterocentral surface of arm, anteromedial half
(C8, T1) of forearm, and posteromedial third of elbow, forearm, and
wrist
Musculocutaneous (C5, 6, 7) Unnamed Motor to coracobrachialis, biceps brachii, brachialis
Lateral antebrachial Sensory to anterolateral half and posterolateral third of
cutaneous forearm
Axillary (C5, C6) Teres minor branch Motor to teres minor
Anterior Motor to deltoid (middle and anterior thirds)
Posterior Muscular branches Motor to deltoid (posterior third)
Upper lateral brachial Sensory over lower half of deltoid
cutaneous
Radial (C5, 6, 7, 8 T1) Unnamed Motor to triceps brachii, brachialis (lateral part),
brachioradialis, extensor carpi radialis largus, anconeus
Ulnar colateral Motor to triceps brachii (medial head)
Posterior brachial Sensory to distal posterocentral surface of arm as far as
cutaneous olecranon
Inferior lateral brachial Sensory to distal posterolateral surface of arm and elbow
cutaneous
Posterior antebrachial Sensory to posterocentral surface of forearm
cutaneous
Superficial terminal Dorsal branches Sensory to posterolateral half of wrist and hand
Dorsal digitals Sensory to dorsum of thumb, index, middle, and ring (radial
(5 branches) half) fingers up to middle phalanx
Deep terminal Unnamed Motor to extensor carpi radialis brevis, and supinator
(posterior
interosseous)
Superficial branch Motor to extensor digitorum communis, extensor digiti

minimi, extensor carpi ulnaris
Deep branch Motor to extensor pollicis longus, extensor pollicis brevis,
abductor pollicis longus, extensor indicis proprius
Sensory to wrist joint capsule
Modified from Swanson AB, de Groot Swanson G. Evaluation of permanent impairment in the hand and upper extremity. In: ••• AL, ed. Guides to
the Evaluation of Permanent Impairment. Third ed. Chicago, Ill: American Medical Association; 1989.
Chapter 15
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FIGU R E 15 -7
Motor Innervation of the Upper Extremity
Axillary Musculocutaneous Median Ulnar Radial
C5 C6 C5 C6 C7 C5 C6 C7 C8 C1 C7 C8 C1 C5 C6 C7 C8 C1
Coracoid
Teres Minor
Deltoid Coracobrachialis
Teres Major
Communicating
Biceps Triceps
Triceps (long head)
(lateral head)
Brachialis
Triceps
(medial head)
Brachioradialis
Anconeus
Medial Pron. Teres Ext. Carpi Rad. L.
Epicondyle Pronator Teres Posterior Interosseous
Fl. Carpi Rad. Ext. Carpi Rad. Br.
Anterior Interosseous Ext. Dig. Com.
Palmaris Long. Fl. Carpi Ext. Dig. Min.
Fl. Dig. Superf. Ulnaris
Supinator Ext. Carpi Ulnaris
Fl. Poll. Long.
Fl. Dig. Profund. Abd. Poll. Long.
Ext. Poll. Brev.
Fl. Dig. Superf. Ext. Poll. Long.
Ext. Indicis
Pron. Quadratus
3 Thenar Adductor Pollicis Palmaris Brevis
Pisiform
7 Interossei 3 Hypothenar
Lumbricals to digits 2, 3.
Lumbricals to digits 4, 5.
From Swanson AB, de Groot Swanson G. Evaluation of permanent impairment in the hand and upper extremity. In: Doege TC, ed. Guides to the
Evaluation of Permanent Impairment. Fourth ed. Chicago, III: American Medical Association; 1993.
FIGURE 15 - 8 Impairment Rating: Per Table 15-14 the sensory

Cutaneous Innervation of the Upper Extremity deficits are consistent with “abnormal monofilament
and Related Peripheral Nerves and Roots (diminished sensibility) and normal 2 point (6
mm)” resulting in classification of severity 1, mild.
(Supraclavicular
nerve C3, C4) There are no motor deficits. Table 15-20, Brachial
Plexus Impairment – Upper Extremity Impairments
(Axillary nerve C5, C6)
Superior lateral (Radial nerve specifies for involvement of the upper trunk a mild
brachial cutaneous C5–C8)
sensory deficit as class 1 impairment with a mid-
Intercostobrachial
Posterior
brachial
range default value of 3% UEI. Physical examination
(T1-T2) and
medial brachial
cutaneous was used to define the class, therefore does not serve
cutaneous (T1)
Inferior lateral as an adjustment. Symptoms and QuickDash of 23
brachial
cutaneous are consistent with a grade modifier 1, ie, consistent
Medial antebrachial
cutaneous (C8, T1) Posterior with the class 1 deficits. Therefore, the impairment
antebrachial
remains 3% UEI or 2% WPI.
Chapter 15
(Musculocutaneous cutaneous
nerve, C5-C7)
Lateral antebrachial
cutaneous 15.4f Entrapment Neuropathy
(Radial nerve, C5-C8)
superficial branch (Ulnar nerve, C8, T1)
Superficial
This section is used to rate peripheral nerve “entrap-
Palmar Dorsal
(Median nerve, cutaneous cutaneous and dorsal
digitals
ment” or focal compromise (local compression),
C6-C8, T1) Dorsal involving the median, ulnar or radial nerves. Local
Palmar cutaneous Palmar digitals
Palmar
digitals compression of the median nerve at the wrist lead-
digitals Palmar
digitals (Median nerve,
C6-C8, T1)
ing to the diagnosis of carpal tunnel syndrome is the
Palmar digitals most frequently encountered condition, followed by
Adapted with permission from an original painting by F.H. Netter In:
focal compromise of the ulnar nerve at the elbow.
The Atlas of Human Anatomy. Summit, NJ: CIBA-GEIGY Corp; 1989. Since the specific pathophysiology of peripheral
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nerve dysfunction is still being developed, the terms Mild, intermittent symptoms describes symptoms
nerve compression, entrapment, compromise, and that are not constant. The individual can perform all
focal functional loss are all considered appropriate the ADLs, despite symptoms.
descriptive terms and will be used interchangeably
Significant, intermittent symptoms means that pain
in this chapter.
or numbness is not constant, but the individual
The method used to calculate impairment in entrap- is unable to perform at least one of the ADLs.
ment neuropathies deviates slightly from the DBI Someone else consistently does the activity for the
method. The diagnosis of entrapment neuropathy individual, and the individual’s failure to function
has already been established; therefore, only grade in this role makes sense to the examiner (the entrap-
modifiers need be determined for the purposes of ment is severe enough to make the failure to function
calculating the impairment rating. Grade modifiers in the specific ADL “believable”). This criterion
for history, physical findings, and functional scale may be met by inability to perform any single ADL;
(QuickDASH) are described in Appendix 15-A at however, the examiner should verify the stated
the end of this chapter. A more detailed discussion of inability by direct observation of the activity or a
physical findings and test findings or electrodiagnos- similar activity. The activity the individual is unable
tic findings specific for several common entrapment to do must be stated in the report, along with the
neuropathies follows the section titled Rating Process. examiner’s validation of this history.
Entrapment neuropathy is determined using the Constant symptoms means that pain or numbness is
methods described in this section alone. If test constantly present and at least conduction block if
results exclude the condition from rating using this not axon loss must be present on electrodiagnostic
method, rating may be performed using the appro- testing to substantiate the symptom severity.
priate regional DBI class for nonspecific hand, wrist,
Physical Examination. The physical examination
or elbow pain. Additional impairment values are not
evaluates sensibility alterations, muscle strength,
permitted for decreased grip strength, loss of motion,
range of motion, and muscle reflexes. “Provocative
or pain.
testing” using the Tinel sign, Phalen test, Adson test,
and so on may give clues as to the diagnosis, but the
Diagnosis, History, Physical Findings, and
sensitivity and specificity of these tests are too low
Functional Scale
to be useful for confirmation of a diagnosis for the
The diagnosis of focal nerve compromise is based on
purpose of impairment rating. Reliable objective
(1) the history and symptoms, (2) objective clinical
exam findings are muscle atrophy and neurologic
signs and findings on neurologic examination, and
weakness (not weakness due to pain produced by
(3) documentation by electrodiagnostic studies.
strength testing, which may be seen with use of the
Standard roentgenograms and more involved imaging
dynamometer grip strength testing). Somewhat reli-
studies may also be useful to exclude other diagnoses.
able subjective findings include decreased sensibility
History. The history should include a listing of as measured by 2-point discrimination, absent sharp
occupations; avocations; ADLs; factors that alleviate vs dull stimulus perception, or abnormal monofila-
or aggravate the symptoms; comorbid medical inju- ment testing. Sensory change in which the individual
ries, diagnoses, and conditions; and past surgical comments that a stimulus feels subjectively different
procedures or trauma. The compromise of a major in one nerve distribution compared with others and
peripheral nerve or one of its branches is manifested changes in vibratory perception are not sensitive
by a disturbance of a specific motor, sensory, or or specific enough for use in the diagnosis of local
autonomic function. The symptoms may vary from nerve compromise for impairment rating purposes.
slight, intermittent paresthesias (numbness and/or
The vast majority of focal neuropathy syndromes
tingling), to constant paresthesias. Pain with activ-
come to medical attention long before they develop
Chapter 15
ity may or may not be present. Motor weakness and

the severe neuropathy that manifests as objective
muscle atrophy are uncommon. The severity of the
findings of sensory loss (decreased 2-point dis-
nerve damage and symptoms depends on the dura-
crimination or sharp vs dull perception) or motor
tion, magnitude, and type of compromise, as well as
weakness on examination. Thus, the vast majority of
on the microanatomy of the nerve involved.
nerve entrapment syndromes are diagnosed based on
Grade modifiers for History are based on interfer- believable symptoms and an abnormal nerve conduc-
ence in ADLs, as indicated in Table 15-22, Activities tion study, but a normal neurologic exam (strength
of Daily Living (ADLs). Work is not considered an and sensibility).
ADL.
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TA B L E 15 -20 Brachial Plexus Impairment: Upper Extremity Impairments
Brachial Plexus Impairment-UEI

Note: Grade severity of sensory and motor deficits per objective parameters specified in Table 15-14.
IMPAIRMENT
IMPAIRMENT
RANGES (UE %) 0 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
Brachial Plexus 0 1 7 13 13 13 14 17 20 23 25 26 35 43 49 49 61 65 71 75 80
(C5 through C8,
Mild sensory Mild sensory defi- Moderate sen- Severe sensory
T1)
deficit or cit or mild CRPS sory deficit or deficit or severe
mild CRPS II II approaching moderate CRPS CRPS II (objec-
(objectively moderate II (objectively tively verified)
verified) (objectively verified)
81 86 90 95 99
verified)
1 7 13 13 13 26 32 38 44 49
Very severe sen-
Mild motor Moderate motor sory deficit or
deficit deficit very severe CRPS
II (objectively
verified)
51 57 63 69 75
Severe motor
deficit
71 79 88 93 99
Very severe
motor deficit
Upper Trunk 0 0a 2 3 5 6 15 16 18 19 20 38 42 47 48 49 53 59 66 70 74
(C5, C6,
Mild sensory defi- Severe sensory Severe motor Very severe
Erb-Duchenne)
cit or mild CRPS deficit or severe deficit motor deficit
II (objectively CRPS II (objec-
verified) tively verified)
7 9 11 13 13 20 21 23 24 25
Moderate sen- Very severe sen-
sory deficit or sory deficit or
moderate CRPS very severe CRPS
II (objectively II (objectively
verified) verified)
1 5 9 13 13 18 22 25 25 25
Mild motor deficit Moderate motor
deficit
Chapter 15
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TA B L E 15 -20 (C O N TI N U E D) Brachial Plexus Impairment: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
a a
Middle Trunk (C7) 0 0 0 1 1 1 18 20 22 24 25 26 28 31 33 35
Mild sensory defi- Severe motor Very severe
cit or mild CRPS deficit motor deficit
II (objectively
verified)
1 2 2 3 3
Moderate sen-
sory deficit or
moderate CRPS
II (objectively
verified)
3 3 4 4 4
Severe sensory
deficit or severe
CRPS II (objec-
tively verified)
4 4 5 5 5
Very severe sen-
sory deficit or
very severe CRPS
II (objectively
verified)
0a 2 5 7 9
Mild motor
deficit
9 11 13 13 13
Moderate motor
deficit
Lower Trunk 0 0a 1 3 4 5 13 13 14 15 16 36 40 44 48 49 50 55 61 65 69
(C8 T1, Dejerine-
Mild sensory defi- Severe sensory Severe motor Very severe
Klumpke)
cit or mild CRPS deficit or severe deficit motor deficit
II (objectively CRPS II (objec-
verified) tively verified)
5 7 9 10 12 16 17 18 19 20
Moderate sen- Very severe sen-
sory deficit or sory deficit or
moderate CRPS very severe CRPS
II (objectively II (objectively
verified) verified)
1 5 9 13 13 18 22 25 25 25
Mild motor Moderate motor
Chapter 15
deficit deficit
Note: UE indicates upper extremity; CRPS, complex regional pain syndrome.
a
No ratable impairment
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TA B L E 15 -21 Peripheral Nerve Impairment: Upper Extremity Impairments
Perpheral Nerve Impairment (UEI)

Grade severity of sensory and motor deficits per objective parameters specified in Table 15-14.
IMPAIRMENT
IMPAIRMENT
RANGES (UE) 0 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
a a
Pectoralis (medial 0 0 0 1 1 1
and lateral)
Mild motor deficit
1 2 2 2 3
Moderate motor deficit
3 3 3 3 4
Severe motor deficit
4 4 4 5 5
Very severe motor deficit
Axillary 0 0a 0a 1 1 1 18 20 22 24 25 26 28 31 33 35
Mild sensory deficit or Severe motor Very severe
mild CRPS II (objectively deficit motor deficit
verified)
1 2 2 3 3
Moderate sensory defi-
cit or moderate CRPS II
(objectively verified)
3 3 4 4 4
Severe sensory deficit
or severe CRPS II (objec-
tively verified)
4 4 5 5 5
Very severe sensory def-
icit or very severe CRPS
II (objectively verified)
0a 2 5 7 9
Mild motor deficit
9 11 13 13 13
Dorsal Scapular 0 0a 0a 1 1 1
Mild motor deficit
1 2 2 2 3
Chapter 15

3 3 3 3 4
4 4 4 5 5
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TA B L E 15 -21 (C O N TI N U E D) Peripheral Nerve Impairment: Upper Extremity Impairments

IMPAIRMENT
IMPAIRMENT
a
Long Thoracic 0 0 1 2 3 4
Mild motor deficit
4 5 6 7 8
8 8 9 10 11
11 12 13 13 13
Medial Brachial 0 0a 0a 1 1 1
Cutaneous
Mild sensory deficit or
mild CRPS II (objectively
verified)
1 2 2 3 3
3 3 4 4 4
tively verified)
4 4 5 5 5
Median
Above 0 0a 3 5 8 10 14 14 17 20 23 26 26 27 29 31
midforearm
Mild sensory deficit or Moderate sen- Severe sensory
mild CRPS II (objectively sory deficit or deficit or severe
verified) moderate CRPS CRPS II (objec-
0a 3 6 9 12 II (objectively tively verified)
verified)
Mild motor deficit 32 33 35 37 39
14 15 17 20 23
Very severe sen-
Moderate motor sory deficit or
deficit very severe CRPS
II (objectively
verified)
26 26 29 32 35
Severe motor
deficit
Chapter 15
33 36 40 43 44
Very severe
motor deficit
a
(continued)
Guides6e_15_383-492.indd 437 2/17/09 2:56:41 PM


IMPAIRMENT
IMPAIRMENT
Median
Anterior 0 0a 1 2 3 4
interosseous
Mild motor deficit
branch
4 5 6 7 8
8 8 9 10 11
11 12 13 13 13
Below 0 0a 3 5 8 10 14 14 17 20 23 26 26 27 29 31
midforearm—
Mild sensory deficit or Moderate sen- Severe sensory
entire nerve
mild CRPS II (objectively sory deficit or deficit or severe
(See Table 15-23
verified) moderate CRPS CRPS II (objec-
for carpal tunnel
0a 1 1 2 3 II (objectively tively verified)
syndrome)
verified)
Mild motor deficit 32 33 35 37 39
3 3 4 4 5 Very severe sen-

sory deficit or
Moderate motor deficit very severe CRPS
5 6 6 7 8 II (objectively
verified)
7 8 9 9 10
Below 0 0a 0a 1 1 2
midforearm—
radial palmar
digital of thumb
verified)
2 2 3 4 4
4 5 5 5 6
tively verified)
6 6 6 7 7
Chapter 15
a
(continued)
Guides6e_15_383-492.indd 438 2/17/09 2:56:42 PM


IMPAIRMENT
IMPAIRMENT
Median
Below 0 0a 1 1 2 3
midforearm—
ulnar palmar
digital of thumb
verified)
3 4 5 6 7
7 7 8 8 9
tively verified)
9 9 10 10 11
Below 0 0a 0a 1 1 1
midforearm—
radial palmar
digital of index
verified)
finger
1 2 2 3 3
3 3 4 4 4
tively verified)
4 4 5 5 5
Below 0 0a 0a 1 1 1
midforearm—
ulnar palmar
digital of index
verified)
finger
1 1 2 2 2
Chapter 15
2 3 3 3 3
tively verified)
3 3 4 4 4
(continued)
Guides6e_15_383-492.indd 439 2/17/09 2:56:42 PM


IMPAIRMENT
IMPAIRMENT
a a
Below 0 0 0 1 1 1
midforearm—
radial palmar
digital of middle
verified)
finger
1 2 2 3 3
3 3 4 4 4
tively verified)
4 4 5 5 5
Below 0 0a 0a 1 1 1
midforearm—
ulnar palmar
digital of middle
verified)
finger
1 1 2 2 2
2 3 3 3 3
tively verified)
3 3 4 4 4
Below 0 0a 0a 0 1 1
midforearm—
radial palmar
digital of ring
verified)
finger
1 1 1 2 2
Chapter 15
2 2 2 2 2
tively verified)
2 3 3 3 3
Very sensory deficit
a
(continued)
Guides6e_15_383-492.indd 440 2/17/09 2:56:42 PM


IMPAIRMENT
IMPAIRMENT
a a
Musculocutaneous 0 0 0 1 1 1 14 14 16 17 19
Mild sensory deficit or Severe motor
mild CRPS II (objectively deficit
verified)
18 20 22 23 25
1 2 2 3 3
Very severe
Moderate sensory defi- motor deficit
3 3 4 4 4
tively verified)
4 4 4 4 4
0a 2 3 5 6
Mild motor deficit
7 8 10 11 13
Radial
Upper arm with 0 0a 0a 1 1 1 14 15 17 20 23 34 36 38 40 42
loss of triceps
Mild sensory deficit or Moderate motor Very severe
verified)
23 25 25 25 25
1 2 2 3 3
Severe motor
Moderate sensory defi- deficit
3 3 4 4 4
tively verified)
4 4 4 4 4
0a 3 6 9 12
Mild motor deficit
Chapter 15
(continued)
Guides6e_15_383-492.indd 441 2/17/09 2:56:43 PM


IMPAIRMENT
IMPAIRMENT
a a
Elbow with 0 0 0 1 1 1 18 20 22 24 24 25 28 31 33 35
sparing of triceps
verified)
1 2 2 3 3
3 3 4 4 4
tively verified)
4 4 5 5 5
0a 2 5 7 9
Mild motor deficit
9 11 13 13 13
Subscapulars 0 0a 0a 1 1 1
(upper and lower) Mild motor deficit
1 2 2 2 3
3 3 3 3 4
4 4 4 5 5
Suprascapular 0 0a 0a 1 1 1 14 14 14 15 16
Mild sensory deficit or Very severe
mild CRPS II (objectively motor deficit
verified)
1 2 2 3 3
3 3 4 4 4
tively verified)
Chapter 15
4 4 5 5 5
0a 1 2 3 4
Mild motor deficit
4 5 6 7 8
8 9 10 11 12
(continued)
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IMPAIRMENT
IMPAIRMENT
a
Thoracodorsal 0 0 1 1 2 3
Mild motor deficit
3 3 4 4 5
5 6 6 7 8
7 8 9 9 10
Ulnar
Above 0 0a 0a 1 1 2 14 15 17 20 23 26 26 29 32 35
midforearm
Mild sensory deficit or Moderate motor Severe motor
mild CRPS II (objectively deficit deficit
verified)
33 36 40 43 46
2 2 3 4 4
Very severe
Moderate sensory defi- motor deficit
4 5 5 5 6
tively verified)
6 6 6 7 7
0a 3 6 9 12
Mild motor deficit
Below 0 0a 0a 1 1 2 18 20 22 24 24 26 28 31 33 35
midforearm—
entire nerve
(See Table 15-23
verified)
for cubital tunnel
syndrome) 2 2 3 4 4
4 5 5 5 6
Chapter 15
tively verified)
6 6 6 7 7
0a 2 5 7 9
Mild motor deficit
9 11 13 13 13
a
(continued)
Guides6e_15_383-492.indd 443 2/17/09 2:56:44 PM


IMPAIRMENT
IMPAIRMENT
Ulnar
Below 0 0a 0a 0a 0a 1
midforearm—
ulnar palmar
digital of ring
verified)
finger
1 1 1 1 1
1 1 1 2 2
tively verified)
2 2 2 2 2
Below 0 0a 0a 0a 0a 1
midforearm—
radial palmar
digital of little
verified)
finger
1 1 1 1 1
1 1 1 2 2
tively verified)
2 2 2 2 2
Below 0 0a 0a 0a 1 1
midforearm—
ulnar palmar
digital of little
verified)
finger
1 1 1 2 2
Chapter 15
2 2 2 2 2
tively verified)
2 3 3 3 3
a
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TA B L E 15 -22
Functional Score. The QuickDASH functional Activities of Daily Living (ADLs)
assessment tool (Appendix 15-A) is used to fur- Bathing, showering
ther modify the grade of impairment related to
Bowel and bladder management
entrapment neuropathy in this rating process.
Dressing
Findings range from normal (0 to 20) to severe and
very severe (greater than 60). A functional score Eating
greater than 60 is not consistent with mild impair- Feeding
ment and suggests that either the presenting diagno- Functional mobility
sis is incorrect, or that a second diagnosis, including Personal device care
symptom magnification, has been overlooked. Personal hygiene and grooming
Sexual activity
Electrodiagnostic Evaluation
Sleep/rest
The electrodiagnostic examination includes nerve
conduction studies (NCS), with or without EMG Toilet hygiene
(needle) studies or examination. The EMG (needle)
examination evaluates muscle cell membrane activ-
ity, confirming that a neurologic cause of muscle Prolongation of distal motor latency and/or distal
dysfunction is present. Nerve conduction studies peak sensory latency are signs of conduction delay or
assess only the largest, most heavily myelinated slowing, which is the mildest degree of neuropathy.
axons. The lightly myelinated and unmyelinated The degree of slowing (how prolonged the measured
smaller diameter axons that transmit pain are not latency, or how slow the calculated conduction veloc-
directly evaluated. A fundamental point is that, ity) has little or no correlation with symptom sever-
regardless of the cause of nerve damage, the elec- ity and no correlation with the severity of clinical
trodiagnostic studies essentially can detect only signs, such as motor weakness or static large-fiber
(1) demyelination (neurapraxic lesion), which can sensory loss. Distal latencies that are more than 1
cause either conduction slowing or conduction block, millisecond beyond normal are more likely to reflect
depending on the severity of the process; (2) axon significant slowing, and less likely to represent false-
loss (axonotmetic lesion), which is manifested as positive tests. If either motor weakness or sensory
conduction failure, muscle membrane instability; and loss is present on examination, substantial amounts
(3) re-innervation (on needle EMG). For impairment of at least conduction block (moderate neuropathy),
rating purposes, upper limb nerve conduction studies and usually actual axon loss (severe neuropathy), or
must be done with a limb temperature maintained at a combination of both must be present on nerve con-
or above 32°C. The limb temperature must be stated duction testing.
in the report.
In a case in which an examiner finds either sensory
Focal demyelination is characteristic of isolated loss or neurologic strength loss on physical exam and
compression neuropathy. Longitudinal demyelination yet the nerve conduction studies are either normal
is typical of a generalized peripheral neuropathy. In or show only conduction delay, logically, either the
moderate (conduction block) or severe (axon loss) physical examination or the nerve conduction testing
focal nerve compromise, the amplitude (voltage) is incorrect. It may be appropriate to repeat the phys-
of the motor (compound motor action potential or ical examination by the same or a different examiner
CMAP) and sensory (sensory nerve action potential and/or to repeat the nerve conduction testing by an
or SNAP) responses will be significantly decreased appropriately trained physician, which could include
with stimulation proximal to the site of compres- consideration of a physician with certification by
sion and recording distal to the site of compromise. the American Association of Neuromuscular and
In severe focal nerve compromise (axon loss), the Electrodiagnostic Medicine (www.aanem.org).
Chapter 15
nerve conduction studies will show loss of ampli-

tude with stimulation both proximal to and distal Impairment Rating
to the site of compression. Stimulation distal to the The diagnosis of a focal neuropathy syndrome must
compromise gives the best indication of live axons. be documented by sensory and motor nerve con-
In severe focal neuropathy with axon loss the needle duction studies and/or needle EMG in order to be
EMG exam will show denervation changes of fibril- ratable as impairment, using this section. If nerve
lation potentials and positive waves subacutely, and conduction testing has not been performed or does
re-innervation changes of large amplitude polyphasic not meet this section’s diagnostic criteria, there is no
and decreased recruitment chronically. ratable impairment from this section. These cases
Guides6e_15_383-492.indd 445 2/17/09 2:56:45 PM

may still be rated in Section 15.2, Diagnosis-Based transfer to restore function. This is almost never seen
Impairment, and with the appropriate regional grid, in peripheral nerve entrapment.
using the diagnosis of nonspecific hand, wrist, or
Test Findings. Normal electrodiagnostic tests fail to
elbow pain, depending on the affected region.
meet the definitions necessary to permit a diagnosis
Threshold values for latency and conduction velocity of focal nerve compromise for the purpose of impair-
for specific nerves are provided in Appendix 15-B. The ment rating (Appendix 15-B). Electromyographers use
values necessary to qualify for a diagnosis of a specific different, nonstandardized definitions of normal. A
focal nerve compromise are conservative. The criteria physician may for treatment purposes, choose to accept
in Appendix 15-B must be met to make the diagnosis an electromyographer’s report interpreting a study
of focal neuropathy for impairment rating purposes. as abnormal and consistent with focal neuropathy.
In nerve conduction testing there are no universally However, unless the study meets the criteria listed in
accepted definitions of “normal” for latencies. The Appendix 15-B, it is considered a normal study for the
definitions of abnormal nerve conduction studies stated purpose of impairment rating. The interpretation of
in this section are for impairment rating purposes and findings for specific entrapment syndromes is provided
have been chosen to minimize the number of false- in Appendix 15-B, Electrodiagnostic Evaluation of
positive nerve conduction tests. Physicians may choose Entrapment Syndromes.
to use different values when diagnosing focal nerve
Conduction delay is defined as a significantly
compromise for treatment purposes.
prolonged distal peak sensory and/or motor latency.
If test findings are normal or nondiagnostic, the It is measured by distal latencies (milliseconds) and
diagnosis is class 0 and the final rating will be class conduction velocity calculations (meters per second).
0 for nerve entrapment (0% upper extremity impair- Latencies and conduction velocities that are slower
ment), regardless of the grade chosen for history and than those in Appendix 15-B qualify as conduction
physical findings, and/or functional scale score. Test delay for the purpose of impairment rating. Upper
findings are the “key factor” for determining impair- limb temperature must be stated in the report and
ment in this section. The individual may, alterna- must be at least 32°C.
tively, be rated for impairment by Section 15.2 using
Conduction block is measured by the amplitude
the appropriate class for nonspecific hand pain.
(voltage) of the motor, sensory, or mixed nerve
The Functional Scale is based on the QuickDash, response. Stimulation proximal to the nerve compro-
as described in Appendix 15-A. Descriptions of the mise site results in a decreased amplitude recorded
grade modifiers for physical findings and test find- distal to the compromise (motor testing or anti-
ings follows: dromic sensory testing). With orthodromic sensory
testing, stimulation distal to the compromised site
Physical Findings. Selection of the grade modifier
results in a decrease in amplitude recorded proximal
for physical findings is based on documentation of
to the site of compromise. For purely sensory nerves,
significant objective sensory and motor findings.
the SNAP amplitude must be used. For mixed motor
Decreased sensation means decreased 2-point dis-
and sensory nerves, the CMAP is used preferentially
crimination (greater than 6 mm) for compression
for impairment rating purposes; the lower voltage
involving the median or ulnar nerve, or loss of sharp
sensory amplitudes are harder to record and are
vs dull recognition for the rare compromise of the
more influenced by technical factors during testing.
radial nerve. Atrophy is defined as clearly recognized
neurologic atrophy (not disuse atrophy) of muscle Axon loss is documented by the needle EMG and/or
innervated distal to the focal compromise. Thus, dis- nerve conduction studies. Recent and/or ongoing axon
use atrophy from thumb carpal metacarpal joint osteo- death (axonotmesis) is reflected in positive waves and
arthritis is not a “physical finding” for the purposes of fibrillation potentials in muscles innervated by the
calculating impairment related to focal compression. involved nerve. Chronic axon loss is documented by
Chapter 15
Atrophy should be recognizable by other examiners. high-amplitude motor units and decreased motor unit
Pain caused by or worsened during strength testing recruitment. Axon loss may also be demonstrated by
invalidates that part of the examination. nerve conduction testing. A significantly low ampli-
tude recorded distal to the site of compromise, with
To qualify for class 3 by physical findings, there
both stimulation proximal to the site and stimulation
should be constant numbness (history), and no pro-
distal to the site is consistent with axon loss.
tective sensation (no sharp vs dull recognition), and
for the median or ulnar nerve 2-point discrimination In an individual who has not had surgical treatment,
of 16 mm or greater. There must also be grade 3 or a finding of high-amplitude polyphasic motor unit
less motor function, or a history of a surgical tendon potentials on the needle EMG and normal distal
Guides6e_15_383-492.indd 446 2/17/09 2:56:45 PM

latencies for the nerve supplying that muscle sug- In the presence of CRPS II (causalgia) associated
gests misinterpretation of the potentials seen on with either focal neuropathy or surgical treatment
EMG. It is, therefore, not sufficient for the diagnosis of focal neuropathy, the impairment is evaluated
of a focal neuropathy syndrome for the purpose of according to the principles of CRPS II. The diag-
impairment rating. nostic criteria specified in Section 15.5 must be met,
and the impairment is obtained using Section 15.4e
Very mild nerve entrapments do exist and may fail
Peripheral Nerve and Brachial Plexus Impairment.
to meet the Guides’ criteria for impairment related to
nerve entrapment diagnosis. Similarly, although real
Maximum Medical Improvement
symptoms exist in tension pattern headache, dysmen-
Postoperatively, a sufficient amount of time for opti-
orrhea, irritable bowel syndrome, and fibromyalgia
mal physiologic recovery and rehabilitation should
syndrome, these conditions do not typically rise to
have elapsed before an individual is considered to
the level of ratable impairment.
be at MMI and to qualify for a permanent impair-
The diagnosis of severe neuropathy is made based ment rating. Factors affecting nerve recovery in focal
on appropriate symptoms, a nerve conduction study neuropathy lesions include the severity of nerve fiber
compatible with at least major conduction block if pathology, the level of injury, the presence and dura-
not actual axon loss, and, more importantly, the pres- tion of compression (if present), and the status of the
ence of positive clinical findings on neurologic exam end organs. Sensory function usually returns before
(neurologic weakness or atrophy, and decreased motor function.
2-point discrimination or loss of sharp vs dull dis-
Lesions at the wrist may take 6 to 9 months for
crimination). The electrodiagnostic tests must meet
maximal recovery of nerve function, and more
the definition of at least conduction block and almost
proximal focal axon loss lesions may take 1 to 2
always will meet the definition of axon loss if the
years for maximal recovery. An advancing Tinel sign
sensory exam is abnormal or if there is neurologic
can be monitored and is a good prognostic sign. Grip
motor weakness present on examination.
strength may continue to gradually improve for up to
Severe motor neuropathy (axon loss) must also be 2 years following carpal tunnel release; however, the
documented by needle EMG. rating need not be delayed for this finding.
It is critical to understand that there is no correlation Although maximal recovery of nerve function may
between the severity of conduction delay on nerve take up to 2 years, the individual can be considered
conduction velocity testing (latencies) and the sever- at MMI when no additional improvement is likely to
ity of either symptoms or, more importantly, the occur and when no specific medical intervention is
impairment rating. In other words, how “mild” the necessary. The evaluator may consider the individual
mild neuropathy is does not directly correlate with at MMI and calculate the impairment rating before
either symptoms or ADL performance. Moderate the 9-month to 2-year time frame if, after surgery,
(conduction block) or severe (axon loss) neuropathy the condition is stable for 2 consecutive office visits
should also be documented by loss of amplitude spaced at least 1 month apart.
(voltage) on nerve conduction testing.
If the physician finds that the clinical status of the
If multiple nerve conduction tests have been per- individual is more severe than suggested by electro-
formed, the most recent preoperative test should gen- diagnostic studies that are more than 1 year old, a
erally be used. If the results of the most recent study current electrodiagnostic study may be appropriate.
cannot be directly compared with this section’s diag- The examiner may defer rating the impairment until
nostic criteria, and results of a prior study are easily a current nerve conduction test is performed.
compared with this section’s diagnostic criteria, the
Permanent impairment for focal neuropathy may be
physician should use the results that can most easily
calculated even when the patient has declined sur-
Chapter 15
be compared with these criteria.

gery. However, the functional score should reflect
If a preoperative electrodiagnostic study fails to meet symptoms insufficiently severe to warrant surgery.
this section’s definition of abnormal, but surgical If an individual has a QuickDASH functional score
complications result in a postoperative electrodiag- greater than 60, and chooses not to have surgery, the
nostic study that meets these criteria, the individual examiner should suspect symptom magnification on
should be rated by Section 5.4e, Peripheral Nerve the QuickDASH questionnaire. Since entrapments
and Brachial Plexus Impairment. This section should typically produce numbness as the dominant symp-
not be used for these rare cases. tom, and not pain, the QuickDASH must be used for
functional assessment (the visual analog pain scale,
Guides6e_15_383-492.indd 447 2/17/09 2:56:46 PM

or VAPS, may not be used, since it measures pain). rated at 50% (one-half) of the impairment listed in
If symptom magnification is not present, a psychia- Table 15-23, Entrapment/Compression Neuropathy
trist or psychologist may be consulted to document a Impairment. The impairments are then combined.
phobia relating to surgical treatment. If an individual In the event that the rating ends in .5%, it should be
who chooses not to have surgical treatment is rated rounded to the next integer. This method considers
“at MMI,” the physician should comment in the the fact that both ratings incorporate symptoms and
report that the neuropathy may change with time, the functional scale. Nerve conduction testing of
and that in the future the impairment rating may be the upper limbs can clarify the role of generalized
different. peripheral nerve disease and is especially helpful
in jurisdictions that require apportionment between
Postoperative Electrodiagnostics systemic disease and work activity.
Postoperative nerve conduction studies are not
If 3 focal neuropathies are diagnosed and supported
required to rate impairment for focal nerve com-
by the requirements of inclusion, the third (or small-
promise syndromes. Significant improvement in
est impairment) is not rated. If more than 3 diagnos-
nerve conduction studies usually occurs. Some of
able focal neuropathies are identified and supported
the improvement is almost immediate, and some
by the requirements of inclusion, this section should
occurs over months. Many individuals recover and
not be used. The peripheral neuropathy section of the
are asymptomatic, but nerve conduction testing
neurology chapter should be used, as in these cases
still detects minor slowing (prolonged latencies).
almost always the principal problem is a general-
Whether or not the nerve conduction tests recover to
ized peripheral neuropathy (medical disease) and not
normal after surgical or nonsurgical treatment does
related to occupational or avocational activities. In
not influence the impairment rating. The preopera-
jurisdictions that require apportionment, the majority
tive electrodiagnostic test should be used in the
of causation for the individual with 3 or more simul-
impairment rating unless postoperative studies were
taneous focal nerve neuropathies should be appor-
done for a clinical indication of failure to improve
tioned to the medical disease and not to occupation.
with surgery and the postoperative study is clearly
worse than the preoperative electrodiagnostic study.
Rating Process
In this rare case the postoperative study is used in
To rate the impairment for focal nerve compro-
this section.
mise, use Table 15-23, Entrapment/Compression
Persistence of symptoms and failure of preoperative Neuropathy Impairment. Grade modifiers are
nerve conduction studies to improve after surgery described for test findings, history, and physical
suggests that either the diagnosis was incorrect findings. If test findings are grade modifier 0 (ie,
(peripheral neuropathy is present and not focal electrodiagnostic testing is normal or does not meet
neuropathy) or that surgical decompression did not standards), do not use this section. The QuickDASH
result in improved nerve function. Nerve decompres- is used to further modify the grade and to choose the
sion may have been incomplete, or the nerve may appropriate numerical impairment rating.
have been so severely compromised that it could not
1. Determine the appropriate grade modifier for
recover. Further evaluation by both an electromyog-
test findings, history (symptoms), and physical
rapher certified by the American Association of
findings. Determine the average value for these
Neuromuscular and Electrodiagnostic Medicine and
3 modifiers using the associated number for
a hand surgeon is indicated in these rare cases.
each grade; for example, grade 0 has a value of
0 and grade 1 has a value of 1. Round that aver-
Multiple Simultaneous Neuropathies
age value to the nearest integer to determine the
Multiple, concurrent focal nerve compromise syn-
average grade. For example, if grade modifiers
dromes in the same upper limb are being diagnosed
are grade 1 for history, grade 2 for physical find-
Chapter 15
more frequently. Individual risk factors such as pre-

ings, and grade 1 for tests findings, add the cor-
existing diabetic peripheral neuropathy and heredi-
responding numerical values: 1 2 1 4.
tary generalized peripheral neuropathy likely play a
Then 4 divided by 3 is 1.33, which rounds to 1, so
role in persons who present with simultaneous carpal
grade 1 is the final rating category.
tunnel syndrome and ulnar neuropathy at the elbow.
Both impairments may be rated using this section, 2. Identify the row “Upper Extremity Impairments”
and in this section only, the functional scale would at the bottom of the table. This contains the range
apply to each diagnosis. The nerve qualifying for of impairment values for the grade. The middle
the larger impairment is given the full impairment.
The nerve qualifying for the smaller impairment is
Guides6e_15_383-492.indd 448 2/17/09 2:56:46 PM

TA B L E 15 -23
Entrapment/Compression Neuropathy Impairment
Clinical Grade Modifier 0 Grade Modifier 1 Grade Modifier 2 Grade Modifier 3 Grade Modifier 4
TEST FINDINGS Normal Conduction delay Motor conduction Axon loss Almost dead
(sensory and/or block nerve
motor)
HISTORY Asymptomatic Mild intermittent Significant inter- Constant NA

symptoms mittent symptoms symptoms
PHYSICAL Normal Normal Decreased Atrophy or NA

FINDINGS sensation weakness
FUNCTIONAL Normal (0–20) 0 Normal (0–20) 0 Mild (21–40) 1 Mild (21–40) 1 NA

SCALE Mild (21–40) 1 Mild (21–40) 1 Moderate (41–60) 2 Moderate (41–60) 2
Moderate (41–60) 2 Moderate (41–60) 2 Severe (61–80) 3 Severe (61–80) 3
UE IMPAIRMENT 0 1 2 3 4 5 6 7 8 9 NA
Note: NA indicates not applicable; UE, upper extremity.
number is the default impairment value for the (Section 15.4) and as if a partial nerve laceration had
grade. occurred.
3. This value is modified up or down from the For individuals whose only nerve conduction abnor-
default value based on the functional scale grade. mality is relatively prolonged median, ulnar, or
If the grade modifier assigned to the functional radial nerve latencies, compared with the other upper
scale score is equal to the grade assigned for the extremity nerve latencies for similar distances, the
condition (eg, QuickDASH score of 21 to 40 is diagnosis of carpal tunnel syndrome or ulnar nerve
grade 1 and the condition is grade 1), the default compression for impairment rating has not been
or middle value of Upper Extremity Impairment established. Such individuals are placed in class 0 for
in that grade is the appropriate rating. If the func- test findings according to Table 15-23, Entrapment/
tional scale score is 1 grade lower or higher than Compression Neuropathy Impairment, and are not
the grade assigned to the condition, the lower ratable by this section.
or higher value, respectively, is the appropriate
Individuals whose test results describe normal laten-
impairment rating.
cies, but in whom “inching” results in detection of
If more than 1 entrapment syndrome is being a conduction delay and/or a change in amplitude
rated in a limb, refer to the subsection, Multiple in 1 or a few 1-cm segments of a nerve, are consid-
Simultaneous Neuropathies. ered to have a normal nerve conduction study result
for impairment rating purposes. The interpreta-
General Considerations for Test Results: A study
tion of findings for specific entrapment syndromes
result may be considered abnormal for treatment
is provided in Appendix 15-B, Electrodiagnostic
purposes, but, for impairment rating purposes, elec-
Evaluation of Entrapment Syndromes.
trodiagnostic studies that do not meet the specified
criteria are considered normal, and the individual
is either placed in grade 0 by test findings, and has
EXAMPLE 15-18:CARPAL TUNNEL SYNDROME
no impairment, or is rated as applicable according
to DBI. Subject: 55-year-old woman.
Chapter 15
In cases in which surgical decompression has been History: Insidious onset of right-side symptoms
performed, if the preoperative study fails to meet consistent with carpal tunnel syndrome. Diagnosis
the specified criteria, this section cannot be used confirmed electrodiagnostically and underwent car-
to rate the impairment. The DBI should be used for pal tunnel release two years ago. Symptoms stable
those cases. If preoperative electrodiagnostic studies for over a year. Determined administratively to be
were normal by these criteria, and yet surgical com- work-related.
plications result in a postoperative electrodiagnostic
Current Symptoms: Complaints of significant
study that meets these criteria, the patient should
intermittent problems with numbness and discom-
be rated using the peripheral nerve injury section
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fort; however, able to perform all activities of daily Clinical Studies: Electrodiagnostic studies pre-
living, despite symptoms. operatively revealed mild sensory and motor conduc-
tion delays of the right median nerve and condution
block of the right ulnar nerve at the elbow.
Physical Exam: Normal, including sensory examina-
Diagnosis: Carpal tunnel syndrome (median nerve
tion (2 point and monofilament testing), focal muscle
entrapment) and cubital tunnel syndrome (ulnar neu-
testing and range of motion. Well-healed scar.
ropathy), s/p release.
Clinical Studies: Electrodiagnostic studies
Impairment Rating: The diagnosis of median nerve
pre-operatively revealed mild sensory and motor
and ulnar nerve entrapment was confirmed electro-
conduction delays of the right median nerve.
diagnostically and the patient is at maximal medi-
Diagnosis: Carpal tunnel syndrome, s/p carpal cal improvement. Rating is based on Table 15-23,
tunnel release Entrapment/Compression Neuropathy.
Impairment Rating: The diagnosis of carpal tun- For median nerve entrapment, testing findings are
nel syndrome was confirmed electrodiagnostically grade modifier 1 (conduction delay), history is grade
and the patient is at maximal medical improve- modifier 1 (mild intermittent symptoms), and physi-
ment. Rating is based on Table 15-23, Entrapment/ cal findings are grade modifier 1 (normal). The
Compression Neuropathy. Testing findings are grade modifiers total 3 (1 1 1) and average 1.
grade modifier 1 (conduction delay), history is grade Therefore, grade modifier 1 is selected with a default
modifier 2 (significant intermittent symptoms), and of 2% UEI. The QuickDASH is 32 (mild) and this
physical findings are grade modifier 1 (normal). results in assignment of the mid-range default value
The grade modifiers total 4 (121) and average of 2% UEI for the median nerve.
1.33. Therefore, grade modifier 1 is selected with a
For ulnar nerve entrapment, test findings are grade
default of 2% UEI; however, the QuickDASH is 14
modifier 2 (conduction block), history is constant
in the normal range, therefore, the lowest UEI for
symptoms, but only conduction block is present on
that grade modifier is selected, i.e. 1% UEI which is
nerve conduction testing, so grade 2 is the highest
equivalent to 1% hand impairment or 1% WPI.
permitted grade. Physical findings are grade modi-
fier 2 (decreased sensation). The grade modifiers
total 6 (2 + 2 + 2) and average 2. Therefore, grade
EXAMPLE 15-19: MULTIPLE ENTRAPMENTS
modifier 2 is selected with a default of 5% UEI. The
Subject: 40-year-old man. QuickDASH is 32 (mild), therefore, for grade modi-
fier the lowest value for that grade is selected and the
History: Insidious onset of right-side symptoms
impairment is 4% UEI for the ulnar nerve.
diagnosed as right carpal tunnel syndrome and right
ulnar syndrome. Diagnoses confirmed electrodiag- With multiple entrapments the nerve qualifying for the
nostically and underwent carpal tunnel and ulnar larger impairment is given the full impairment, ie, the
release eighteen months ago. Symptoms stable for ulnar nerve with 4% UEI. This is combined with 50%
four months. Determined administratively to be of the rating of the second nerve, the median nerve that
work-related. was rated at 2% UEI. The combined value of 4% UEI
and 1% UEI (50% of 2% UEI) results in 5% UEI.
Current Symptoms: Reports minimal problems in
the distribution of the median nerve, basically mild
intermittent paresthesias, however no true numb-
ness. In the distribution of the ulnar nerve continues 15.5Complex Regional Pain
to have significant complaints of numbness that are
essentially constant. He is able to perform all activi- Syndrome Impairment
Chapter 15
ties of daily living, despite symptoms. Feels right

hand is weaker than it was in the past. Complex regional pain syndrome is a challenging
and controversial concept. It is difficult to diagnose
Functional Assessment: QuickDASH score is 32. accurately, and epidemiological studies indicate that
Physical Exam: Diminished sensibility in the distri- most such diagnoses are made within a workers’
bution of the ulnar nerve (monofilament testing 3.61 compensation context. Therefore, this is a particu-
grams); however two point discrimination normal (5 larly challenging diagnosis to rate. The hallmark of
mm). Normal sensory assessment of median nerve. this condition is a characteristic burning pain that is
Motor examination normal. Range of motion normal. present without stimulation or movement, that occurs
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beyond the territory of a single peripheral nerve, and an evaluator must determine if there is relationship
that is disproportionate to any suspected inciting between CRPS and the injury in question.
event. The pain is associated with specific clinical
Complex regional pain syndrome may be rated only
findings, including signs of vasomotor and sudomo-
when: (1) the diagnosis is confirmed by objective
tor dysfunction and, later, trophic changes of all tis-
parameters (specified later in this section), (2) the
sues from skin to bone.
diagnosis has been present for at least 1 year (to
The International Association for the Study of Pain ensure accuracy of the diagnosis and to permit
(IASP) created the diagnoses of CRPS type I to adequate time to achieve MMI), (3) the diagnosis
replace the diagnosis of RSD, and CRPS type II to has been verified by more than 1 physician, and (4) a
replace causalgia. Historically, sympathetic nervous comprehensive differential diagnostic process (which
system dysfunction was thought to be a cause of may include psychological evaluation and psychologi-
symptoms, and the term RSD reflects that. Causalgia cal testing) has clearly ruled out all other differential
was considered similar to RSD except it followed an diagnoses. Emphasis is placed on the differential
unambiguous lesion of a peripheral nerve, either a diagnostic process because accurate diagnosis of
major mixed nerve in the proximal extremity (major CRPS is difficult and because even objective findings
causalgia) or of a purely sensory branch more dis- have been demonstrated to lack diagnostic validity.
tally (minor causalgia). Currently, CRPS I is consid-
The taxonomy and criteria, which were adopted by the
ered when clinically appropriate signs and symptoms
IASP Committee for Classification of Chronic Pain
are present in the limb without nerve injury, and
of the International Association for the Study of Pain
CRPS II is considered when appropriate signs and
(IASP), have contributed to progress in understand-
symptoms are present in the clinical setting of an
ing the syndrome. These substantial efforts finally
unambiguous injury to a specific peripheral nerve.
provided standardized diagnostic criteria, improved
Since a subjective complaint of pain is the hallmark clinical communication and homogeneity of research,
of this diagnosis, and since all of the associated and provided the promise of results that could be com-
physical signs and radiologic findings can be the pared across studies. These criteria have been exam-
result of disuse, an extensive differential diagnostic ined both in terms of external and internal validation.
process is necessary. Differential diagnoses that The IASP criteria, while sensitive, lack specificity,
must be ruled out include disuse atrophy, unrec- that is, they would identify patients as having CRPS
ognized general medical problems, somatoform when they do not. As a result of validation studies,
disorders, factitious disorder, and malingering. A proposed modified research diagnostic criteria were
diagnosis of CRPS may be excluded in the presence developed. A formal international consensus resulted
of any of these conditions, or any other conditions in the criteria shown in Table 15-24.
which could account for the presentation. This exclu-
Signs are objective evidence of disease perceptible
sion is necessary due to the general lack of scientific
to the examiner, as opposed to symptoms, which are
validity for the concept of CRPS, and due to the
subjective sensations of the individual. The examiner
reported extreme rarity of CRPS (any of the differ-
should provide objective evidence of the reported
entials would be far more probable).
findings (eg, photographic documentation, tempera-
Because accurate diagnosis of CRPS is difficult, the ture measurements) whenever possible. The presence
diagnostic approach should be conservative, and sup- or absence of the objective factors shown in Table
ported by objective findings. The diagnosis of CRPS 15-25 should be noted.
has not been scientifically validated as representing a
In CRPS I, neither the initiating causative factor nor
specific and discrete health condition. The diagnostic
the symptoms involve a specific peripheral nerve
process is itself unreliable, as competing diagnostic
structure; therefore, impairment is based on Table
protocols and definitions are continuously being
15-26, Complex Regional Pain Syndrome (Type I).
Chapter 15
introduced and utilized. There is no gold standard

In CRPS II a specific sensory or mixed nerve struc-
diagnostic feature which reliably distinguishes the
ture is involved; therefore, the rating is based on
diagnosis of CRPS from presentations that clearly
Table 15-21 Peripheral Nerve Impairment – Upper
are not CRPS. Scientific findings have actually
Extremity Impairments. With CRPS II the sever-
indicated that whenever this diagnosis is made, it is
ity of CRPS is first determined using Table 15-26
probably incorrect. A diagnosis of CRPS may create
Complex Regional Pain Syndrome (Type 1).
a dilemma for the evaluator with regard to a specific
injury. Specifically, a lack of proportionality between The steps in assessing CRPS type 1 impairment are
a clinical presentation and any suspected inciting as follows:
event is inherent to the concept of CRPS. Therefore,
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1. Determine if CRPS is a ratable diagnosis—that CLASS 3

the diagnosis has been confirmed (Table 15-24 26% to 49% Impairment of the Upper Extremity
Diagnostic Criteria for Complex Regional Pain
Syndrome), the diagnosis has been present for at
EXAMPLE 15-20: COMPLEX REGIONAL PAIN
least 1 year, the diagnosis has been verified by
SYNDROME, TYPE 1
more than 1 physician, and a comprehensive dif-
ferential diagnostic process has clearly ruled out Subject: 32-year-old man.
all other differential diagnoses.
History: Two years ago sustained blunt trauma to
2. Determine the number of objective diagnostic his right arm, and subsequently developed problems
criteria points (Table 15-25 Objective Diagnostic consistent with complex regional pain syndrome.
Criteria Points for Complex Regional Pain He underwent extensive diagnostic evaluation, both
Syndrome). physical and psychological, and no other diagnoses
were identified. Despite appropriate therapy he con-
3. Assess adjustment factors, as described in
tinues to have significant difficulties.
Section 15.3.
Current Symptoms: Reports significant problems
4. The classification of severity is based on the
with pain, particularly with touch, and that the arm
number of objective diagnostic criteria points and
will swell, change colors, and feel cool. He has noted
assessment of adjustment factors, as described in
that motion and strength are decreased. Able to per-
Section 15.3. A minimum of 4 points is required
form self-care activities, however with significant
for a class 1 rating, 6 points for a class 2 rating,
difficulty and requires assistance for some activities.
and 8 points for a class 3 or 4 rating. If there are
3 points or less, the rating for pain complaints Functional Assessment: QuickDASH score is 73.
may be based on Chapter 3, Pain, as applicable.
Physical Exam: Makes minimal use of right upper
5. Using Table 15-7 Functional History Adjustment limb, maintaining it at his side. Complains of sig-
Modification, Table 15-8 Physical Examination nificant tenderness on palpation particularly over
Adjustment Modification, and Table 15-9 the forearm. The limb is edematous, mottled and
Clinical Studies Adjustment Modification, iden- feels cool; the opposite side is normal. Skin texture
tify the grade modifier number for each adjust- is smooth and nonelastic. Hair on right forearm
ment factor that is determined to be reliable. is fine compared to the opposite side. There is a
The process differs from that used for DBIs. mild decrease in elbow, wrist, and hand motion.
Average the grade modifier numbers and use this Weakness due to pain is present. The findings were
information to define the class number in Table consistent through out the visit.
15-26 Complex Regional Pain Syndrome (Type
Clinical Studies: Radiographs reveal moderately
1) – Upper Extremity Impairments. If that class
severe trophic bone changes and bone scan is consis-
number is not supported by the objective diag-
tent with CRPS.
nostic criteria points, the highest class specified
by those points is selected. For example, if an Differential Diagnosis: A comprehensive medical
individual has grade modifiers that ultimately investigation, including a review of the examinee’s
resulted in assignment to class 2 but the objective records from his entire life, failed to reveal any
diagnostic criteria points were only 4, the indi- general medical differentials. A comprehensive
vidual would be assigned to class 1. Using clini- psychological evaluation, including a review of the
cal judgment, select the appropriate grade within examinee’s records from his entire life, diagnostic
the class. Since the adjustment factors are used to evaluation in accordance with the American
define the class, they cannot be used to determine Psychiatric Association’s diagnostic manual (Axes
the grade within the class. The physician may I and II), collateral input, and scientifically credible
Chapter 15
use clinical judgment to decrease or increase the psychological testing, failed to reveal any psychologi-
grade within the assigned class and must explain cal diagnoses.
in detail the rationale for any adjustments.
Work-relatedness Considerations: Administratively
The rating for CRPS is a “stand alone” approach. it was determined that his complex regional pain syn-
If impairment is assigned for CRPS, no additional drome was attributable to the injury two years prior.
impairment is assigned for pain from Chapter 3, nor
Diagnosis: Complex regional pain syndrome
is the CRPS impairment combined with any other
(CRPS), Type 1.
approach for the same extremity from this chapter.
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TA B L E 15 -2 4
Diagnostic Criteria for Complex Regional Pain Syndrome
1) Continuing pain, which is disproportionate to any inciting event.
2) Must report at least 1 symptom in 3 of the 4 following categories:

_____ Sensory: Reports of hyperesthesia and/or allodynia
_____ Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
_____ Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
_____ Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin)
3) Must display at least 1 signa at time of evaluation in 2 or more of the following categories:
_____ Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure
and/or joint movement)
_____ Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry
_____ Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
_____ Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin)
4) There is no other diagnosis that better explains the signs and symptoms.
a
A sign is counted only if it is observed and documented at time of the impairment evaluation.
Comment: He meets the standards defined in Table description is consistent with grade modifier 3, ie,
15-24 Diagnostic Criteria for Complex Regional Pain “Pain/ symptoms with less than normal activity
Syndrome, ie, (1) continuing pain which is dispro- (minimal); / medications to control symptoms.
portionate to any inciting event; (2) reports at least Requires assistance to perform self-care activities”
1 symptom in 3 of the 4 following categories: sen- and a QuickDASH Score of 73. Referencing Table
sory (allodynia), vasomotor (temperature and color 15-8 Physical Examination Adjustment – Upper
asymmetry), sudomotor (edema), and motor / trophic Extremities physical examination findings are
(decreased motion and weakness); (3) displays at least best characterized as “very severe” and thus grade
1 sign at time of evaluation in 2 or more of the follow- modifier 4. Referencing Table 15-9 Clinical Studies
ing categories:- sensory (allodynia), vasomotor (tem- Adjustment – Upper Extremities, clinical studies
perature asymmetry), sudomotor / edema (edematous), confirm the diagnosis, and interpreted as “clinical
and motor / trophic (decreased motion, weakness, and studies confirm diagnosis, severe pathology” and
trophic changes); (4) There is no other diagnosis that
better explains the signs and symptoms. Referencing
Table 15-25, Objective Diagnostic Criteria Points for TA B L E 15 -25
Complex Regional Pain Syndrome he has 8 Objective Objective Diagnostic Criteria Points for Complex
Diagnostic Criteria Points: (1) skin color mottled, Regional Pain Syndrome
(2) skin temperature cool, (3) edema, (4) skin texture Local clinical signs Points
smooth and non-elastic, (5) hair fine, (6) joint stiff- Vasomotor changes:
ness and decreased passive motion, (7) trophic bone • Skin color: mottled or cyanotic 1
changes and (8) bone scan consistent with CRPS. • Skin temperature: cool 1
• Edema 1
Impairment Rating: The condition is ratable since Sudomotor changes
the diagnosis has been confirmed, it has been pres- • Skin dry or overly moist 1
Chapter 15
ent for at least 1 year, and it has been verified by Trophic changes:
more than 1 physician. A comprehensive differential • Skin texture: smooth, nonelastic 1
• Soft tissue atrophy: especially digit tips 1
diagnostic process has clearly ruled out all other dif- • Joint stiffness and decreased passive motion 1
ferential diagnoses. There are 8 Objective Diagnostic • Nail changes: blemished, curved, talonlike 1
Criteria Points. • Hair growth changes: fall out, longer, finer 1
Radiographic signs
Functional history was determined to be reliable, • Radiographs: trophic bone changes, 1
consistent both with other documentation and osteoporosis
observations. Referencing Table 15-7 Functional • Bone scan: findings consistent with CRPS 1
History Adjustment – Upper Extremities, the Note: CRPS indicates complex regional pain syndrome.
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TA B L E 15 -26 Complex Regional Pain Syndrome (Type I): Upper Extremity Impairments
Complex Regional Pain Syndrome (UEI)

Note: Prior to using table, examiner must review Sections 15.1 and 15.5. The diagnosis of CRPS must be defined by Table
15-24, Diagnostic Criteria for Complex Regional Pain Syndrome, and specified points threshold must be met as defined
by Table 15-25, Objective Diagnostic Criteria for Complex Regional Pain Syndrome. The default value for impairment is
grade C and modified by reliable findings and use of adjustment grids.
DIAGNOSTIC
CRITERIA
(KEY FACTOR) CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4
IMPAIRMENT
RANGES (UE %) 0% UE 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
OBJECTIVE 4 points 6 points 8 points 8 points
FINDINGS (POINTS
THRESHOLD)
SEVERITY Mild Moderate Severe Very severe
GRADE 0; CRPS diagnosis A B C D E A B C D E A B C D E A B C D E

not supportable
1 3 7 11 13 14 17 20 23 25 26 32 38 44 49 50 60 70 80 90
therefore grade modifier 3. The average of grade next larger unit, and eventually, the whole person.
modifiers is 3.33 (rounded to 3). On the basis of the By understanding the appropriate percent impair-
average of 3, using Table 15-26, Complex Regional ment of each anatomic unit, impairments can be
Pain Syndrome (Type 1) – Upper Extremity converted sequentially to hand, upper limb, and
Impairments assigned Class 3. Based on the sever- whole person by using Table 15-11 and Table 15-12.
ity of functional difficulties that were determined to These impairments are shown in Tables 15-27 and
be reliable, the physician applying clinical judgment 15-28, and in Figures 15-9 through 15-12.
assigned the maximum for class 3 of 49% UEI which
If a limb has both an amputation and a nerve injury,
is equivalent to 29% WPI.
do not rate the nerve injury for loss of sensation in
the amputated part.
15.6 Amputation Impairment 15.6a Amputation of Thumb/Finger

Principles
Impairment for amputation is based on the level of The digits represent 5 coordinated units, which
the amputation, with adjustment for proximal prob- contribute unequally to hand function. To avoid con-
lems, and adjustment for functional history, physi- fusion, digits are named rather than numbered as fol-
cal examination, and clinical studies. Impairment lows: thumb, index, middle, ring, and little. Each digit
ratings for upper limb amputation increase with is given a relative value to the entire hand as follows:
progressively shorter stumps, and reach 70% of the
whole person for a scapulothoracic (forequarter) • Thumb: 40%.
amputation. Impairments that may be rated and • Index and middle fingers: 20% each.
• Ring and little fingers: 10% each.
Chapter 15
combined to the amputation impairment include

impairments for loss of motion in retained joints, These values are listed in Figure 15-10 and Table 15-27.
impairments for neurologic loss in the retained por-
tion of the limb, and DBIs of the residual stump. Amputation through each joint level of a digit is given
a relative value of loss to the entire digit as follows:
The upper limb is considered as a unit of the whole
person and is divided into thumb, fingers, hand, Thumb (Figure 15-10 and Table 15-28):
wrist, elbow, and shoulder. From distal to proximal, • Interphalangeal (IP) joint: 50% of thumb.
each anatomic unit is given a relative value to the
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• Metacarpophalangeal (MCP) joint: 100% of Amputations of the thumb at levels proximal to the
thumb. MCP joint (through the metacarpal bone) are con-
sidered to result in a greater severity of impairment
Finger (Figure 15-10 and Table 15-28):
than amputation at the MCP joint level. These ampu-
• Distal interphalangeal (DIP) joint: 45% of finger. tations remove part of the palm, and thus decrease
• Proximal interphalangeal (PIP) joint: 80% of function. For amputations through the thumb meta-
finger. carpal, the impairments are as follows:
• Metacarpophalangeal joint: 100% of finger.
• Amputation through the thumb MCP joint is a
For amputations of 1 or more digits, Figures 15-11 40% impairment of the hand or a 36% impair-
and 15-12 easily permit an impairment rating based ment of the upper limb.
on the retained length of the digit. • Amputation at the middle of the thumb metacar-
pal is a 41% impairment of the hand or a 37%
Amputation of the thumb and all fingers at the MCP
impairment of the upper limb.
joints removes the most essential parts of the hand
• Amputation at the CMC joint represents a 42%
and is considered 100% impairment of the hand or
impairment of the hand or a 38% impairment of
90% impairment of the upper limb, as in Figure 15-9
the upper limb.
and Table 15-28. This 90% upper limb impairment
is equivalent to a 54% whole person impairment, as For amputations through 1 to 4 metacarpals, the
seen in Figure 15-9 and Table 15-28. impairments are as follows:
Impairment is determined individually for each • Amputation at the middle half of the index or
amputation of thumb/fingers/hand and impairments middle finger metacarpal is a 21% impairment of
of the digits are converted to hand impairments the hand or 19% impairment of the upper limb.
using Table 15-12. The hand impairments are added; • Amputation at middle half of the ring or little fin-
however, the total hand impairment cannot exceed ger metacarpal is a 12% impairment of the hand
100%. Hand impairment can then be converted to an or an 11% impairment of the upper limb.
upper limb impairment, and to whole person impair- • Amputation at the CMC joint of the index or
ment by using Table 15-11. middle finger ray is a 22% impairment of the
hand or a 20% impairment of the upper limb.
• Amputation at the CMC joint of the ring or little
EXAMPLE 15-21: AMPUTATION OF FINGERS finger ray is a 13% impairment of the hand or a
12% impairment of the upper limb.
When all 5 rays have transmetacarpal amputations,
History: The patient was working in an assembly line
the impairments are:
and sustained an amputation of the index finger and
middle finger through the PIP joint of each of these • Amputation of all 5 rays at the middle of the
fingers. During the evaluation, the fingers are well metacarpals is a 91% upper limb impairment.
healed and there is retained motion at the MCP joints. • Amputation of all 5 rays at the CMC joint is a
92% upper limb impairment.
Functional Assessment: Not obtained.
• Amputation at the wrist (either through the
Physical Exam: Well-healed stumps at the index radius-proximal carpal row joint or through the
and middle finger with no tenderness of the healed proximal carpal row-distal carpal row joints) is a
scars or digital neuromas. 93% upper limb impairment.
Clinical Studies: Confirm amputation levels. If the total hand impairment exceeds 100% because
of amputations involving all 5 digits or rays, the
Diagnosis: Amputation at the PIP joint of index and
upper limb percentages just listed are used.
Chapter 15
middle finger.
Impairment Rating: Per Table 15-28, amputation 15.6c Amputation Forearm to Shoulder
at the PIP joint of the index finger is rated at 16% of This section applies to amputations from the radio-
the hand and amputation of the middle finger is rated carpal joint to the glenohumeral joint. The amputa-
at 16% of the hand. Hand impairments are added and tion impairment ratings increase with progressively
total 32% of the hand. This equates to 29% UEI or shorter stumps, as illustrated in Figure 15-9 and
17% WPI. Table 15-28.
• Amputations occurring through the radius and
15.6b Amputation of Hand Metacarpals
ulna between the bicipital tuberosity of the radius
(Proximal to Metacarpophalangeal Joint)
or Through the Wrist
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TA B L E 15 -27 F I G U R E 15 -1 0
Level of Amputation Impairments of the Digits (values outside
digits) and the Hand (values inside digits) for
Upper Whole Amputation at Various Levels
Amputation Level (%) Hand Extremity Person
Metacarpal ray loss – CMC 42 38 23 Transmetacarpophalangeal amputation of all digits
thumb represents 100% hand impairment
Distal half of index or 21 19 11
middle metacarpal
CMC of index or middle 22 20 12
ray
Distal half of ring or little 12 11 7
metacarpal
CMC of ring or little ray 13 12 7
Note: CMC indicates carpometacarpal. 42 14
24 24 14
Digit 41
12
Impairment 23 23 12
MCP 100% 40
and the wrist are a 94% impairment of the upper Hand
Impairment
limb (56% impairment of the whole person). If 10
IP 50% 20 10 100%
these individuals use a prosthesis, they generally 20 20
use a below-elbow prosthesis. MCP 100%
8
• Amputations occurring between a level just
distal to the deltoid tubercle and the bicipital 5
8
16 16
tuberosity (insertion of the biceps brachii on the PIP 80%
5
radius) constitute a 95% impairment of the upper 9
DIP 45% 9
FIGURE 15 -9
Impairment Estimates for Upper Extremity MCP = metacarpophalangeal
Amputation at Various Levels PIP = proximal interphalangeal
DIP = distal interphalangeal
impairment of function in the hand. Surg Clin North Am.
1964;44:925–940.
Whole person Upper extremity

impairment impairment
limb or a 57% impairment of the whole person.
60% 100% These individuals either do not use a functional
prosthesis or are fitted with an above-elbow
prosthesis.
• Amputations through the humerus at or proximal
to the deltoid tubercle level (approximately the
axillary fold) correspond to a 100% loss of the
limb or a 60% impairment of the whole person.
57% 95% These individuals rarely use a prosthesis.
• The impairment for forequarter amputation (70%
whole person) exceeds the 60% value of the
entire upper limb because excision of the scapula
Chapter 15
and part of the clavicle has removed part of the

trunk.
54% 90%
15.6d Conditions Associated With
Amputation
Evaluation of the residual stump must include assess-
ment of the status of soft-tissue coverage and of
the peripheral nerve and vascular systems, and of
Redrawn with permission from Swanson AB. Evaluation of the bone itself. In general, the impairment rating
1964;44:925–940.
Guides6e_15_383-492.indd 456 2/17/09 2:56:51 PM

TA B L E 15 -28
Impairment for Upper Limb Amputation at Various Levels
Impairment %
Upper Whole
Amputation Level Digit Hand Extremity Person
Thumb at:
IP joint 50 20 18 11
MCP joint 100 40 36 22
Half metacarpal 41 37 22
Metacarpal at CMC 42 38 23
Index or Middle Finger at:

DIP joint 45 9 8 5
PIP joint 80 16 14 9
MCP joint 100 20 18 11
Ring or Little Finger at:

DIP joint 45 5 5 3
PIP joint 80 8 7 4
MP joint 100 10 9 5
— 60 54 32
Hand: all fingers at MP joints except thumb
Hand: all digits at MP joints — 100 90 54
Forearm/hand: from distal to bicipital insertion to — — 94–90 56–54
transmetacarpophalangeal loss of all digits
Arm/forearm: from distal to deltoid insertion to bicipital insertion — — 95 57
Arm: deltoid insertion and proximally — — 100 60
Shoulder disarticulation — — 100 60
Scapulothoracic (forequarter) — — 70
Note: IP indicates interphalangeal; MCP, metacarpophalangeal; CMC, carpometacarpal, DIP, distal interphalangeal; and PIP,
proximal interphalangeal.
provided for a given anatomic level of amputation digit in functional tasks, an additional impairment
includes the usual pain and discomfort, abnormal is present. In such cases, if a ratable amputation has
soft-tissue contours of the stump, and vascular occurred, the physician may combine an additional
changes such as cold intolerance. Thus, additional 10% digit impairment to the digit amputation
impairment is not given for pain with amputations impairment.
through or proximal to the metacarpals.
Chapter 15
Digital Neuromas and Digital Nerve Injury

Injuries to the tip or distal phalanx of a digit can
Amputations through digits may have residual
result in loss of pulp (soft-tissue padding over the
sensory loss from associated digital nerve injury
bone of the distal phalanx) or the presence of tender
and may have a neuroma in the retained portion of
scars that limit function. If the pulp loss is suffi-
the digit. Sensory loss should be documented by
cient to qualify as an amputation by Figure 15-11 or
decreased 2-point discrimination. Loss of sensa-
Figure 15-12, the impairment rating for the amputa-
tion is rated by use of Figure 15-4 and Figure 15-5
tion is usually adequate. If the loss of pulp or a ten-
to determine how much of the remaining length of
der scar causes the individual to exclude (not use) the
the digit has sensory loss, and Table 15-16 and 15-17
Guides6e_15_383-492.indd 457 2/17/09 2:56:51 PM

F I G U R E 15 -11 F I G U R E 15 -12
Digit Impairment Percent for Thumb Digit Impairment Percent for Finger Amputation
Amputation at Various Levels at Various Levels
Digit impairment % Digit impairment %

Thumb amputation levels Finger amputation levels
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 %
Tip Tip
DIP
IP
PIP
MCP

1964;44:925–940. MCP

which rate the impairment by considering the length impairment of function in the hand. Surg Clin North Am.
1964;44:925–940
of the digit over which sensation is decreased and the
degree of sensory loss. The digit impairment rating
for loss of sensation is combined to the digit impair-
ment rating for amputation. The impairment of the
digit cannot exceed 100%. retained portion of an upper limb with an amputa-
tion through or proximal to the metacarpals are not
With a digital nerve neuroma, there should be no generally given additional impairment ratings. If,
sensibility distal to the neuroma (no sharp vs dull however, these additional problems are present and
recognition and greater than 20 mm of 2-point significantly prevent any use of the retained limb, an
discrimination). The amputation impairment is amputation that by itself would be rated at 90% to
determined using Figure 15-11 or Figure 15-12. If 94% may instead be rated as 95% of the upper limb.
the examiner determines that a digital neuroma or An amputation that by itself would be rated at 95%,
phantom pain is present, an additional 10% can be in the presence of additional injuries or impairments
combined with the digit impairment. A digit with that prevent all use of the limb, may be rated at
an amputation cannot receive both a rating for a 100% upper extremity impairment.
neuroma and a rating for a tender scar, because both
ratings consider the same decrease in function. The
10% digit impairment for a symptomatic neuroma EXAMPLE 15-22: AMPUTATION ABOVE MCP
may be combined to the impairments for amputation JOINT WITH ADDITIONAL IMPAIRMENTS
and for sensory loss. This method of impairment
calculation can be repeated for each digit (thumb or Subject: 63-year-old man.
fingers). Even if both digital nerves have neuromas, History: The patient sustained a crush injury to the
the maximum allowable additional impairment for left little finger, which was treated with open reduc-
neuromas and scars for each digit is 10% digit. The tion, internal fixation (ORIF). A flexion contracture
final impairment cannot exceed 100% of the digit. developed, and ultimately the patient was treated
Chapter 15
with an amputation through the fifth metacarpal.

Amputations Above Metacarpophalangeal At the time of current evaluation, the patient has a
Joint With Additional Impairments neuroma in the distribution of the ulnar digital nerve
For amputations through or proximal to the meta- of the little finger; grip strength is decreased.
carpals, poorly padded and symptomatic stumps
and painful stump scars that limit use of a prosthe- Functional Assessment: QuickDASH score 35.
sis are not generally given additional impairment Physical Exam: Well-healed incision; increased
ratings, because the impairments already exceed sensitivity to touch consistent with a neuroma of the
90% of the upper limb. Similarly, phantom pain or
vascular, neurologic, and range of motion loss in the
Guides6e_15_383-492.indd 458 2/17/09 2:56:52 PM

ulnar digital nerve of the fifth finger; full range of in assignment to grade D or grade E). These adjust-
motion of other fingers. ments are performed as outlined in Section 15.3.
The amputation impairment may be combined with
Clinical Studies: X ray confirms amputation at the
either proximal DBIs or range of motion impair-
middle of the fifth metacarpal.
ments; they cannot be combined with both since this
Diagnosis: Amputation of the little finger at the is duplicative. If combined with range of motion the
middle of the fifth metacarpal with a digital neu- Table 15-29 midrange default is used unless there
roma (ulnar digital nerve of the little finger). are significant other adjustment factors that should
be considered. If an amputation is only to a digit and
Impairment Rating: Per Figure 15-10, an amputa-
the resulting impairment is to be expressed at the
tion through the metacarpal shaft of the little finger
digit level, the processes described above will allow
rates a 12% impairment of the hand. A 10% impair-
a more precise calculation of the digit impairment.
ment of the digit can be combined for the symptom-
atic digital neuroma; this is first converted to hand
using Table 15-12 resulting in 1% hand impairment.
EXAMPLE 15-23: AMPUTATION WITH RANGE
The 12% hand impairment due to amputation and
OF MOTION LOSS
the 1% hand impairment associated with the neu-
roma results in a combined 13% hand impairment Subject: 44-year-old man.
which converts to 12% UEI or 7% WPI.
History: The patient sustained an open fracture
Comment: An alternative is to not rate the neuroma, of the distal forearm with soft-tissue loss. Chronic
but rather to rate the amputation from Table 15-29 with draining osteomyelitis developed, which was treated
adjustments. with an amputation. A flexion contracture of the
elbow developed during treatment of the initial con-
Amputations With Range of Motion Loss dition, and this persisted after the amputation.
Any impairment resulting from lost of or restricted
Current Symptoms: The stump is not painful and
motion of proximal joints is evaluated according to
the patient is able to use a below-elbow prosthesis
Section 15.7, Range of Motion Impairment. For each
with little difficulty; no complaints of phantom limb
functional unit, the impairment rating cannot exceed
pain or other sensations.
100% of the unit.
Physical Exam: Well-healed stump without tender-
For example, if a digit has an amputation through the
ness; range of motion of the elbow is full in flexion,
middle phalanx, loss of motion at the PIP and/or MCP
with an extension lag of 50°.
joint or joints, and sensory loss in the retained portion
of the digit, the impairments for each of the 3 prob- Clinical Studies: Consistent.
lems are calculated and combined. The final impair-
Diagnosis: Amputation of the forearm distal to the
ment for the digit cannot exceed 100% of the digit.
bicipital tuberosity of the radius with flexion con-
Similarly, hand impairments determined by adding
tracture of the elbow above the amputation.
impairments for amputation, loss of motion, and neu-
rologic loss cannot exceed 100% of the hand. Upper Impairment Rating: Amputation through the radius
extremity impairments determined by combining and ulna between the bicipital tuberosity of the radius
impairments for amputation, loss of motion, and neu- and the wrist per Figure 15-9 is between 90% UEI and
rologic loss cannot exceed 100% of the upper extremity. 95% UEI and per Table 15-28 90% to 94% UEI. Per
Table 15-29, Amputation Impairment this is a Class
15.6e Final Amputation Rating 4 impairment with a midrange default of 92% UEI.
Use the process described above to determine the In that the amputation is combined with the impair-
impairment due to the level of amputation and ment of the upper limb, the midrange default is used.
Chapter 15
also use of Table 15-29. In most circumstances the Per Table 15-33 Elbow/Forearm Range of Motion a
impairment is based on the level of the amputa- 50°extensor lag at the elbow is 5% UEI. Combining
tion with adjustment for proximal problems, and on these 2 values is still 92% UEI or 55% WPI.
functional history, physical examination, and clini-
cal studies. The default middle grade value (C) and
values to the left are consistent with the impairment
values presented in this section. It is not possible 15.7 Range of Motion Impairment
to decrease impairment below the value associated
with the amputation level; however, proximal prob- Range of motion determination is an essential com-
lems may increase the impairment (ie, may result ponent of upper extremity impairment ratings with a
Guides6e_15_383-492.indd 459 2/17/09 2:56:53 PM

TA B L E 15 -29 Amputation Impairment
Amputation Impairment
DIAGNOSTIC
CRITERIA
IMPAIRMENT
RANGES (UE %) 0% UE 1%–13% UE 14%–25% UE 26%–49% UE 50%–100% UE
Thumb, at: 18 18 18 20 22 36 36 36 38 40
IP joint MCP joint
37 37 37 39 41
Half Metacarpal
38 38 38 40 42
Metacarpal at CMC
Index or Middle 8 8 8 9 10 14 14 14 16 18
Finger, at: DIP joint PIP joint
18 18 18 20 22
MCP joint
19 19 19 21 23
Half Metacarpal
20 20 20 22 24
Metacarpal at CMC
Ring or Little 5 5 5 6 7
Finger, at: DIP joint
7 7 7 8 9
PIP joint
9 9 9 10 11
MCP joint
11 11 11 12 13
Half Metacarpal
12 12 12 13 13
Metacarpal at
CMC
Hand, at: 54 54 54 58 58
All fingers at MP
joints except thumb
90 90 90 92 94
All digits at MP joints
92 92 92 94 96
Distal to biceps inser-
tion to transmetacar-
pophalangeal loss of
all digits
Arm, at: 92 92 92 94 96
Chapter 15
Distal to deltoid
insertion to bicipital
insertion
100 100 100 100 100
Deltoid insertion and
proximally
Shoulder, at: 100 100 100 100 100

Shoulder
disarticulation
Note: IP indicates interphalangeal; MCP, metacarpophalangeal; CMC, carpometacarpal, DIP, distal interphalangeal;
PIP, proximal interphalangeal; and UE, upper extremity.
Guides6e_15_383-492.indd 460 2/17/09 2:56:54 PM

strong historical precedent. Although the procedure tendon laceration injuries, severe crush injuries,
may be time-consuming, valuable objective informa- residual compartment syndrome, or other condi-
tion concerning joint function can be ascertained. tions having significant functional loss.
Surface goniometry can be carried out reliably and
effectively on the joints of the extremities, so that 15.7a Clinical Measurements of Motion
range of motion can be objectively determined. The As in prior editions of the Guides, active range
conventional range of motion goniometric proce- of motion is measured for impairment rating and
dures advocated in earlier Editions of the Guides takes precedence over passive range of motion.
should be followed. However, certain procedural However, the 2 should be examined concurrently
modifications, described below, have been imple- for the following reasons: many different factors
mented to enhance simplicity and reproducibility can limit the normal range of motion of the joints
of results, and the tables have been reformatted and of the upper extremities; limitation of active motion
simplified considerably to conform more effectively can be due to failure of the nerve, muscle, tendon,
to the requisite ICF approach. or effort to execute the motion. If pain is present
during range of motion testing, muscle guarding
Section 15.2 Diagnosis-Based Impairments, is
may also limit motion. This guarding should be
the method of choice for calculating impairment.
palpable. Limitation of passive motion can be from
Range of motion is used principally as a factor in
involvement of the joint itself, a fixed contracture,
the Adjustment Grid: Physical Examination, as
or the antagonistic muscle or tendon that holds back
explained in Section 15.3b. Some of the DBI grids
the motion because it is adherent or too short.
refer to the range of motion section when that is the
most appropriate mechanism for grading the impair- Active range of motion is a more sensitive indicator
ment. This section is to be used as a stand-alone of joint loss of motion but is also more sensitive to
rating when other grids refer you to this section symptom magnification and self-inhibition by the
or when no other diagnosis-based sections of this patient. If active motion differs significantly from
chapter are applicable for impairment rating of a passive range of motion, the examiner should note
condition. The final impairment may be adjusted for the difference and provide a pathological explana-
functional history in certain circumstances. Figure tion (eg, abduction weakness after a rotator cuff tear
15-13, Upper Extremity Range of Motion Record, prevents full motion against gravity). As in prior
is used to record motion findings and to document editions of the Guides, the examiner is permitted to
impairments. Examples of the latter include burns disallow the rating for loss of active range of motion
or other severe scarring causing permanent passive if there is not a patho-anatomic or physiological cor-
and active range of motion losses, complex flexor relate, and there is suboptimal effort or symptom
or extension tendon or multiple tendon laceration magnification. Sound clinical knowledge and mea-
injuries, severe crush injuries, residual compartment surement techniques are necessary for appropriate
syndrome, or other conditions not addressed in the impairment evaluation and rating using range of
regional grids but having significant functional loss. motion deficits.
Range of motion may also be used for rating in the
If the opposite extremity is neither involved nor
following 2 situations:
previously injured, it must be used to define normal
1. For amputation ratings, deficits of motion for the for that individual; any losses should be made in
remaining portion of the limb may be combined comparison to the opposite normal extremity.
with the amputation impairment.
Joint range of motion measurements are rounded to
2. In very rare cases, severe injuries may result in the nearest whole number ending in 0. Thus, joint
passive range of motion losses qualifying for motion is not recorded as 32° or as 48°, but rather
class 3 or 4 impairment. If the active range of as 30° and 50°, respectively. Joint motion cannot be
Chapter 15
motion impairment percentage is greater than the reliably measured to the level of single degrees.
percentage impairment derived from the diag-
nosis-based class, then the impairment is rated Neutral Zero Reference System
by range of motion as a stand-alone rating. This The Neutral Zero (system of goniometric reference)
range of motion for the impairment may only be is used for all joint measurements, and is based on
used if the active range of motion is within 10° of the premise of the neutral position of a joint being
the passive range of motion measured. The active the zero position, as illustrated in Figure 15-14.
range of motion measurement is what determines
As illustrated in Figure 15-14, the “extended ana-
the final impairment rating. Examples include
tomic position” is accepted as 0° rather than 180°
complex flexor or extension tendon or multiple
and the degrees of joint motion increase in the
Guides6e_15_383-492.indd 461 2/17/09 2:56:54 PM

F I G U R E 15 -13
Upper Extremity Range of Motion Record
Name Date __________________________________________

Dominant Side ___ Right ___ Left ___ Ambidextrous
File No. Injured Side ___ Right ___ Left ___ Bilateral
Right ___ Injured Left ___ Injured Impaired ___ Right

___ Uninjured ___ Uninjured ___ Left
Motion Normal Motion Impairment Motion Impairment Impairment

Thumb
IP Flexion 80º % Digit % Digit % Digit
Extension 10º % Digit % Digit % Digit
Add Flexion & Extension % Digit % Digit % Digit

MCP Flexion 60º % Digit % Digit % Digit

CMC Adduction 2 cm % Digit % Digit % Digit
Radial Abduction 50º % Digit % Digit % Digit
Opposition 7 cm % Digit % Digit % Digit
Add All CMC % Digit % Digit % Digit

Total Add IP, MP, CMC % Digit % Digit % Digit
Convert to Hand % Hand % Hand % Hand
Index Motion Normal Motion Impairment Motion Impairment Impairment
DPI Flexion 70º % Digit % Digit % Digit

PIP Flexion 100º % Digit % Digit % Digit

Extension 20 % Digit % Digit % Digit

Total Combined DIP, PIP and MP % Digit % Digit % Digit
Middle Motion Normal Motion Impairment Motion Impairment Impairment



Chapter 15

Ring Motion Normal Motion Impairment Motion Impairment Impairment

Guides6e_15_383-492.indd 462 2/17/09 2:56:55 PM


Little Motion Normal Motion Impairment Motion Impairment Impairment



Total Hand Add All Hand % for All Digits % Hand % Hand % Hand
Convert to Upper Extremity % UE % UE % UE
Wrist Motion Normal Motion Impairment Motion Impairment Impairment

Flexion 60º % UE % UE % UE
Extension 60º % UE % UE % UE
Add Flexion & Extension % UE % UE % UE

Radial Deviation 20º % UE % UE % UE
Ulnar Deviation 30º % UE % UE % UE
Add Radial & Ulnar % UE % UE % UE

Total Add All Wrist % UE % UE % UE
Elbow Motion Normal Motion Impairment Motion Impairment Impairment

Pronation 80º % UE % UE % UE
Supination 80º % UE % UE % UE
Add Pronation and % UE % UE % UE

Supination
Total Add All Elbow % UE % UE % UE
Shoulder Motion Normal Motion Impairment Motion Impairment Impairment

Chapter 15
Abduction 170º % UE % UE % UE
Adduction 40º % UE % UE % UE
Add Abduction & Adduction % UE % UE % UE

Internal Rotation 80º % UE % UE % UE
External Rotation 60º % UE % UE % UE
Add Rotations % UE % UE % UE
Total Add All Shoulder % UE % UE % UE
Combined Combine Hand, Wrist, % UE % UE % UE
Elbow and Shoulder
Convert to Whole Person % WP % WP % WP
Guides6e_15_383-492.indd 463 2/17/09 2:56:56 PM

direction the joint moves from the zero starting point. these are very familiar to physicians treating muscu-
The term extension describes motion opposite to loskeletal disorders.
flexion. Incomplete extension from a flexed position
Active or voluntary motion is movement that is
to the neutral starting point is defined as extension
performed by the active contraction of the govern-
lag. Extension exceeding the zero starting position, as
ing muscles and is evaluated first. When a person
can be seen in normal MCP, elbow, and knee joints,
has full active joint motion ( joint excursion or arc
is referred to as hyperextension. Ankylosis refers to
of motion), passive motion does not need to be
complete absence of motion of a joint.
assessed because a joint that has full active excur-
For ease of notation, a plus sign () is used to indi- sion will also have full passive range. However, if
cate joint hyperextension and a minus sign () to the full active joint excursion is incomplete, assisted
indicate extension lag. These signs have no math- active and/or passive motion measurements are nec-
ematical significance. Using this notation system, a essary to evaluate the joint motion. Measurements
finger joint flexion contracture (limitation of passive of active motion take precedence in the Guides. The
extension) with an identical extension lag (limitation actual measured goniometer readings are rounded to
of active extension) of 10°, with active flexion to 40° end in 0 and are then recorded.
would be recorded as 10° to 40°. A joint motion
Passive motion is movement produced by an
with 10° hyperextension and 40° flexion would be
external force to evaluate the freedom and range
recorded as 10° to 40°.
of motion of a joint when all muscles are relaxed.
The arc of motion represents the total number of Assisted active motion is the result of active muscle
degrees traced between the 2 extreme positions of contraction and an external force applied to the
movement in a specific plane of motion, for example, joint; it allows for stabilization of a segment to
from maximum flexion to maximum extension of improve the mechanical advantage of the muscles
the PIP joint. When a joint has more than 1 plane that move the joint being measured. In both cases,
of motion, each type of motion is referred to as a approximately 0.5 kg of force is applied while a seg-
unit of motion. For example, the wrist has 2 units of ment of the joint is stabilized. Joint motion may be
motion: flexion/extension (AP or sagittal plane) and uncomfortable but, when examined in this manner,
ulnar/radial deviation (lateral or coronal plane). The neither active assisted nor passive range of motion
term functional position of a joint denotes the opti- measurements will cause injury to an individual.
mal or least impairing angle or angles recommended These techniques are part of traditional musculosk-
for surgical joint fusion. When a joint has more eletal physical examination.
than 1 unit of motion, each separate unit is assigned
Range of motion should be measured after a “warm
a functional position. For example, the functional
up,” in which the individual moves the joint through
position of the elbow is considered to be 80° flexion
its maximum range of motion at least 3 times. The
and 20° pronation.
range of motion examination is then performed by
recording the active measurements from 3 separate
Assessing Motion
range of motion efforts.* Measurements should be
In assessing motion, the examiner should first
rounded up or down to the nearest number end-
observe what a patient can and cannot do by ask-
ing in 0 (eg, 20°instead of 24° and 30° instead of
ing him or her to move each joint of the extremity,
25°). All measurements should fall within 10° of
from thumb and fingers up to the shoulder, through
the mean of these 3 measurements. The maximum
its full range of motion. Both extremities should
observed measurement is used to determine the
be examined whenever possible, since right vs left
range of motion impairment. The examiner should
comparisons between the affected and unaffected
compare the observed findings with other findings
side are useful to help determine the “normal”
documented since the individual has been at MMI,
baseline. Individual joints are then evaluated sepa-
Chapter 15
to further determine the reliability of the measure-

rately. Similarly, movements of the digits are first
ments. It is recognized that patients may under-
evaluated as a unit by having the individual make
demonstrate their capabilities.
a complete fist and then extend the digits fully
over several repetitions. In determining the range
15.7b International Classification of
of motion of individual joints, the examiner must
Functioning Range of Motion Model
evaluate both active and passive motion. The posi-
To facilitate reproducibility and to adjust to the
tions and techniques used to measure active range
ICF Model of impairment, the Sixth Edition of the
of motion are retained from the Fifth Edition, since
Guides6e_15_383-492.indd 464 2/17/09 2:56:57 PM

Guides reflects motion loss as grade modifiers, as 1. Measure the maximum active flexion and exten-
shown in the following table. sion according to Figure 15-15 and record to the
nearest 10°.
Grade Severity Range of Motion 2. Using the row for IP flexion in Table 15-30, com-
Modifier
pare the measured greatest angle of flexion to the
0 Normal IP flexion ranges in each column to establish the
1 Mild 60%–90% of normal motion appropriate grade modifier (and impairment per-
(average: 75% of normal motion)
centage if indicated). Repeat this process for IP
2 Moderate 30%–60% of normal motion extension.
(average: 45% of normal motion)
3 Severe 30% of normal motion (aver- 3. Add the flexion impairment to the extension
age: 15% of normal motion) impairment to determine the total thumb impair-
4 Very severe Joint ankylosis ment for decreased active motion of the IP joint.
4. If the IP joint is ankylosed, grade modifier 4 is
Grade modifiers are determined by the criteria pro- used. The impairment is based on the angle of
vided or relative to the opposite extremity if it is nor- the ankylosis.
mal. Specific range of motion tables are provided for
the thumb, fingers, wrist, elbow, and shoulder in the Thumb Metacarpophalangeal Joint:
following sections. Each table provides a range of Flexion and Extension
motion loss in degrees that places the individual into The thumb MCP joint motion can range from 40°
an impairment grade modifier that provides a spe- hyperextension to 60° flexion, although many
cific impairment rating. Grade modifier 4 impair- normal people have no hyperextension or a slight
ments for ankylosis provide specific impairments flexion contracture. The functional position is 20°
based on the position of the ankylosis. flexion. The relative value of the functional unit is
10% of the thumb.
15.7c Thumb Motion
The thumb has 3 articular units: IP joint, MCP 1. Measure the maximum active flexion and
joint, and CMC joint. The actual range-of-motion extension according to Figure 15-16.
measurements for each unit are recorded and the 2. Using the row for MCP flexion in Table 15-30,
appropriate thumb impairments are identified. Because compare the measured greatest angle of flexion to
they are expressed with the same relative value of the the MCP flexion ranges in each column to estab-
denominator, the impairment percentages contributed lish the appropriate grade modifier and impair-
by each unit are added directly. The 5 thumb functional ment. Repeat this process for MCP extension.
units of motion have been assigned a relative value to
the entire thumb on a 100% scale as follows: 3. Add the flexion impairment to the exten-
sion impairment to determine the total thumb
Interphalangeal joint flexion and extension: 15%. impairment for decreased active motion of the
Metacarpophalangeal joint flexion and MCP joint.
extension: 10%.
Carpometacarpal joint: 75% (radial abduction: 4. If the MCP joint is ankylosed, grade modifier 4
10%, adduction: 20%, and opposition: 45%). is used. The impairment is based on the angle of
the ankylosis.
Thumb Interphalangeal Joint:
Flexion and Extension Thumb Carpometacarpal Radial Abduction
The thumb IP joint motion ranges from 30° hyper- Radial abduction is measured in degrees as the larg-
extension to 80° flexion. The functional position is est angle of separation actively or passively formed
Chapter 15
20° flexion. The relative value of this functional unit between the first and second metacarpals in the coro-
is 15% of the thumb. nal plane, as in Figure 15-18. The stationary arm of
* If the individual cannot demonstrate 3 consistent motion attempts by the above criteria, impairment for that direction of motion cannot
be assigned on that day. For example, if shoulder flexion is measured at 120°, then 130°, and finally at 140° (motion frequently improves
with repetitive effort reflecting the stretching principle), the mean value is 130°, and all measurements are within 10° of the mean. This
can be considered a valid effort, and flexion impairment is rated using the maximum observed motion, 140°. Motion that decreases on
each consecutive effort is usually a sign of pain behavior and not pathology. If instead, active shoulder flexion is measured at 130°, then
110°, and then 90°, the mean is 110° and the measurements do not all fall within 10° of the mean (between 100° and 120°). A second set
of 3 measurements may be recorded. If the same inconsistency is present, impairment for loss of active shoulder flexion cannot be rated
at that time, and the evaluator should note this in the report.
Guides6e_15_383-492.indd 465 2/17/09 2:56:58 PM

F I G U R E 15 -14 centimeters. For this motion, the reliability of

Measurement of MCP Joint Position in Flexion, measurement criterion is that all 3 measurements
Extension Lag, Full Extension, and Hyperextension should fall within 1 cm of the mean. If the mea-
sured distances are 2 cm, 3 cm, and 4 cm, the
Full extension or the neutral position is considered to be 0°. mean is 3 cm, and all 3 measurements fall within
90° the range of 2 to 4 cm. The smallest distance, or
2 cm, is used to determine the impairment.
2. Using the row for thumb adduction in Table 15-30,
compare the smallest measured distance of thumb
+15° Hyperextension adduction to the thumb adduction ranges to estab-
lish the appropriate grade modifier and impairment.
0° Full Extension
–15° Extension Lag 3. If the CMC joint is ankylosed, grade modifier 4
is used. The impairment is based on the angle of
the ankylosis.
45° Flexion
90°
Thumb Opposition
Thumb opposition is measured in centimeters as the
Redrawn with permission from Swanson AB. Evaluation of largest achievable distance between the flexor crease
1964;44:925–940.
of the thumb IP joint and the distal palmar crease
directly over the third (middle finger) MCP joint,
according to Figure 15-20.
the goniometer is aligned over the second metacarpal The relative value of this functional unit is 45% of the
and the movable arm over the first metacarpal. The thumb. The normal range of opposition is from 0 to 8
normal angle of radial abduction is 50°. Note that in cm. However, in smaller hands, the normal distance of
full radial adduction, the smallest angle of separation opposition can be slightly smaller. Both sides are mea-
is 15° due to anatomic configurations. The relative sured and compared. If the contralateral “normal” hand
value of radial abduction is 10% of the thumb. opposition distance is smaller by 2 cm (total distance
1. Measure and record the goniometer reading for 6 cm or less), the impairment value corresponding to
maximum active radial abduction according to the uninvolved side (assuming no prior injury of that
Figure 15-18. side) serves as a baseline, and 5% thumb impairment is
subtracted from the impairments listed in Figure 15-20.
2. Using the row for radial abduction in Table 15-30, This adjustment should be stated in the report.
compare the measured greatest angle of radial
abduction with the radial abduction ranges to estab- 1. Measure and record the actual linear distance of
lish the appropriate grade modifier and impairment. maximum opposition in whole centimeters accord-
ing to Figure 15-20. For this motion the reliability
3. If the CMC joint is ankylosed, grade modifier 4 of measurement criterion is that all 3 measure-
is used. The impairment is based on the angle of ments should fall within 1 cm of the mean.
the ankylosis.
2. Using the row for thumb opposition in Table 15-
Thumb Carpometacarpal Adduction 30, compare the greatest measured distance of
Thumb CMC adduction is a combination of thumb opposition to the thumb opposition ranges
adduction at the CMC joint and flexion at the to establish the appropriate grade modifier and
MCP joint. However, it is the traditional way of impairment.
measuring the ability of the thumb to function by 3. If the CMC joint is ankylosed, grade modifier 4
Chapter 15
reaching the ulnar side of the hand, as previously is used. The impairment is based on the angle of
introduced by the Third Edition of the Guides. the ankylosis.
While use of this method may slightly “double
dip” (rate MCP flexion twice), it rates a critical Final Thumb Impairment
hand function and has been generally accepted. If range of motion is used as a stand-alone approach,
The normal range of motion is from 1 to 8 cm of the additive impairment must be calculated. Add
adduction. The relative value of this functional the impairments for loss of thumb IP motion, MCP
unit is 20% of the thumb. motion, and CMC motion that include adduction,
1. Measure and record the actual smallest radial abduction, and opposition. Using Table 15-12,
adduction distance in centimeters according convert the thumb impairment to hand, UE, and WPI
to Figure 15-19. This should be in whole as appropriate.
Guides6e_15_383-492.indd 466 3/3/09 6:58:37 PM

Neutral Position (top) and

F I G U R E 15 -15 F I G U R E 15 -18 Thumb Radial Abduction
Flexion (bottom) of Thumb IP Joint
0°
0°
50°
0° F I G U R E 15 -19 Adduction of Thumb
80°
F I G U R E 15 -16 Flexion of Thumb MCP Joint
0°
F I G U R E 1 5 - 2 0 Linear Measurements of
Thumb Opposition (cm) at Various Positions
Motion unit impairment curve for lack of opposition.

60°
100 %
90
80
Motion unit impairment percent
F I G U R E 15 -17 Neutral Position of Thumb 70

MCP Joint 60
50 4 cm
20%
40 8 cm
30 0%
20
Chapter 15
10
0°
0
0 1 2 3 4 5 6 7 8 cm
Thumb opposition
Guides6e_15_383-492.indd 467 2/17/09 2:56:59 PM

TA B L E 15 -3 0
Thumb Range of Motion
Grade
Modifier 0 1 2 3 4
None
Severity (Normal) Mild Moderate Severe Ankylosis
Motion 90% 61% to 90% 31% to 60% 30%
(percentage
compared to
normal)
Joint
IP 15% Thumb
Flexion 80º 0% 60º to 70º 50º to 30º 20º 6% DI 20º 7% DI
Motionº 1% DI 3% DI 10º to 10º or 30º to
% Thumb 40º 9% DI
Impairment 10º or 50º
(% DI) 13% DI
(compared to
Extension normal) 10º 0% 0º 1% DI 10º to 30º 30º lag
lag 3% DI 6% DI
MCP 10% Thumb
Flexion 60º 0% 40º to 50º 30º to 20º 10º 5% DI 20º 5% DI
Motionº 2% DI 4% DI 10º to 10 or 30º to 40º
% Thumb 7% DI
Impairment 10º or 50º 9% DI
Extension (% DI) 0º 0% 10º to 20º 30º to 40º 50º lag
lag 1% DI lag 4% DI 5% D
CMC 75% Thumb
Adduction 2 cm 0% 3 to 5 cm 5 to 7 cm 8 cm 20% 4 cm 10% DI
4% DI 8% DI DI 3 cm or 5 cm 15% DI
Motionº
Radial 50º 0% 40º 2% DI 30º 5% DI 20º 10% 30º to 40º 6 % DBI
% Thumb
Abduction DI 20º or 50º 10% DI
Impairment
Opposition (% DI) 7 cm 0% 5 to 6 cm 3 to 4 cm 2 cm 20% DI 5 cm 22% DI
4% DI 9% DI 1 cm 40% 4 cm or 6 cm 27% DI
DI 3 cm 40% DI
Note: IP indicates interphalangeal; DI, digit impairment; MCP, metacarpophalangeal; and CMC, carpometacarpal.
15.7d Finger Motion Unlike the thumb, these units are not expressed
The finger has 3 articular units: distal interphalan- using the same relative value for the denominator
geal (DIP) joint, proximal interphalangeal (PIP) joint, and, consequently, the impairment percents contrib-
and MCP joint. The actual range-of-motion measure- uted by each respective unit are combined.
ments at each unit are recorded and applied for vari-
ous finger impairments. These 3 units of motion have Finger Distal Interphalangeal Joint:
the same relative functional value as that found in Flexion and Extension
amputation impairment (Table 15-31) as follows: Normal finger DIP joint motion ranges from 0°
hyperextension to 70° flexion.
Distal interphalangeal joint flexion and
Chapter 15
extension: 45%. 1. Measure the maximum flexion and extension

Proximal interphalangeal joint flexion and according to Figure 15-21 and record to the
extension: 80%. nearest 10°.
Metacarpophalangeal joint flexion and
extension: 100%.
Guides6e_15_383-492.indd 468 2/17/09 2:57:00 PM

2. Using the row for DIP flexion in Table 15-31, com- joint, then the impairments for the affected joints
pare the measured greatest angle of flexion with are combined. Using Table 15-12, convert the digit
the DIP flexion ranges in each column to establish impairment to hand impairment. Add the hand
the appropriate grade modifier and impairment. impairment values contributed by each digit to
Repeat this process for DIP extension. obtain the total hand impairment.
3. Add the flexion impairment to the exten-
15.7e Wrist Motion Impairment
sion impairment to determine the total finger
The wrist articular unit represents 60% of upper
impairment for decreased active motion at the
extremity function. The wrist has 2 functional units
DIP joint.
of motion as follows:
4. If the DIP joint is ankylosed, grade modifier 4
Flexion and extension: 70% wrist function
(42% of upper extremity function).
the ankylosis.
Radial and ulnar deviation: 30% wrist function
Finger Proximal Interphalangeal Joint:
Flexion and Extension
Wrist Flexion and Extension
Normal finger PIP joint motion ranges from 0°
Normal range of wrist motion is from 60° of exten-
sion to 60° of flexion. The position of function is from
1. Measure the maximum flexion and extension 10° extension to 10° flexion. The relative value of this
according to Figure 15-22. motion unit is 42% of upper extremity function.
2. Using the rows for PIP flexion and extension 1. Measure the maximum flexion and extension
in Table 15-31, establish the appropriate grade according to Figure 15-24.
modifier and impairment.
2. Using the row for wrist flexion in Table 15-32,
3. Add flexion and extension impairment at the compare the measured greatest angle of flexion
PIP joint. with the wrist flexion ranges in each column to
establish the appropriate grade and impairment.
4. If the PIP joint is ankylosed, grade modifier 4 is
Repeat this process for wrist extension.
used. The impairment is based on the angle of
the ankylosis. 3. Add the upper extremity impairment for wrist
flexion and extension.
Finger Metacarpophalangeal Joint:
4. If the wrist joint is ankylosed, grade modifier 4
Flexion and Extension
Normal finger MCP joint motion ranges from 20°
the ankylosis.
1. Measure the maximum flexion and extension Wrist Radial and Ulnar Deviation
according to Figure 15-23. Normal range of wrist motion is from 20° of radial
deviation to 30°of ulnar deviation.
2. Using the rows for MCP flexion and extension
in Table 15-31, establish the appropriate grade 1. Measure the maximum radial and ulnar deviation
modifier and impairment. according to Figure 15-25.
3. Add flexion and extension impairment at the 2. Using the row for wrist radial deviation in Table
MCP joint. 15-32, compare the measured greatest angle
of radial deviation with the wrist radial devia-
4. If the MCP joint is ankylosed, grade modifier 4
tion ranges in each column to establish the
Chapter 15
appropriate grade and impairment rating. Repeat

the ankylosis.
this process for wrist ulnar deviation.
Combining Abnormal Motion at More Than
One Finger Joint
If range of motion is used as a stand-alone approach
to measure abnormal motion in more than 1 finger
Guides6e_15_383-492.indd 469 2/17/09 2:57:01 PM

TA B L E 15 -31
Finger Range of Motion
Grade
Modifier 0 1 2 3 4
None
Motion 90% 61% to 90% 31% to 60% 30%
(percentage
compared to
normal)
Joint
DIP 45% Finger
Flexion 70º 0% 40º to 60º 10º to 30º 10º 20º 30% DI
10% DI 25% DI 40% DI
Motionº 10º to 10º or 30º to
% Digit 50º 35% DI
(% DI)
Extension 0º 0% 10º to 20º 30º to 40º 50 º lag
lag 2% DI lag 12% DI 32% DI
PIP 80% Finger
Flexion 100º 0% 90º 6% DI 20º to 40º 10º 40º 50% DI
50º to 80º 42% DI 54% DI
Motionº 10º to 10 or 50º to
21% DI
% Digit 70º 60% DBI
(% DI)
Extension 0º 0% 10º lag 20º to 50º 60º lag
3% DI lag 14% DI 58% DI
MCP 100% Finger
Flexion 90º 0% 80º 6% DI 20º to 30º 10º 30º 45% DI
40º to 70º 35% DI 48% DI
Motionº 30º or 40º to 60º
19% DI
% Digit 60% DI
Impairment 70º 90% DI
(% DI)
Extension 20º 0% 10º to 20º 30º to 60º 70º lag
lag 7% DI lag 34% DI 91% DI
Note: DIP indicates distal interphalangeal; DI, digit impairment; PIP, proximal interphalangeal; and MCP,
metacarpophalangeal.
FIGURE 15 -21 Neutral Position (top) and FIGURE 15 -22 Neutral Position (top) and
Flexion (bottom) of Finger DIP Joint Flexion (bottom) of Finger PIP Joint (isolated
joint measurement shown)
Chapter 15
0°
70°
100°
0°
Guides6e_15_383-492.indd 470 2/17/09 2:57:01 PM

FIGURE 15 -23 1. Measure the maximum elbow flexion and exten-

Neutral Position (top) and Flexion (bottom) of sion according to Figure 15-26.
Finger MCP Joint (total active range of motion
measurement shown) 2. Using the row for elbow flexion in Table 15-33,
compare the measured greatest angle of flexion
0° with the elbow flexion ranges in each column to
establish the appropriate grade modifier and impair-
ment. Repeat this process for elbow extension.
3. Add the upper extremity impairment for elbow
4. If the elbow joint is ankylosed, grade modifier 4
0° is used. The impairment is based on the angle of
the ankylosis.
Forearm Pronation and Supination

Normal range of forearm motion is from 70° of supi-
nation to 80° of pronation. The position of function
90°
is 20° of pronation. The relative value of this motion
unit is 28% of upper extremity function.
Impairments of pronation and supination are
3. Add the upper extremity impairment for wrist ascribed to the elbow because the major muscles
radial and ulnar deviation. controlling this function are inserted about the
elbow. This applies even if the loss of forearm rota-
4. If the wrist joint is ankylosed, grade modifier 4 tion results primarily from wrist involvement in the
is used. The impairment is based on the angle of presence of an intact elbow.
the ankylosis.
1. Measure the maximum forearm pronation and
Total Wrist Impairment
supination according to Figure 15-27.
If range of motion is used as a stand-alone approach, 2. Using the row for forearm pronation in Table 15-33,
the total impairment for all planes of motion must compare the measured greatest angle of pronation
be calculated. All values for the joint are added and with the forearm pronation ranges in each column
the impairment is converted to whole person using to establish the appropriate grade and impairment.
Table 15-11. Repeat this process for forearm supination.
15.7f Forearm/Elbow Motion 3. Add the upper extremity impairment for forearm
The forearm/elbow articular unit represents 70% of pronation and supination.
upper extremity function. The elbow has 2 functional 4. If the elbow joint is ankylosed, grade modifier 4
units of motion as follows: is used. The impairment is based on the angle of
Flexion and extension: 60% elbow function the ankylosis.
Pronation and supination: 40% of elbow function Total Forearm/Elbow Impairment
(28% of upper extremity function). If range of motion is used as a stand-alone approach,
the total impairment for all units of function must be
Elbow Flexion and Extension
calculated. All values for the joint are added and the
impairment is converted to whole person using Table
Chapter 15
Normal range of elbow motion is from 0° of exten-

sion to 140° of flexion. The position of function is 15-11 Impairment Values Calculated From Upper
80° flexion. The relative value of this motion unit is Extremity Impairment.
42% of upper extremity function.
Guides6e_15_383-492.indd 471 2/17/09 2:57:02 PM

FIGURE 15 -24 Shoulder Flexion and Extension

Wrist Flexion (above) and Extension (below) Normal range of shoulder motion is from 180° of
flexion to 50° of extension. The positions of func-
tion range from 40° flexion to 20° of extension. The
relative value of this motion unit is 30% of upper
extremity function.
1. Measure the maximum shoulder flexion and
60°
extension according to Figure 15-28.
2. Using the row for shoulder flexion in Table 15-34,
compare the measured greatest angle of flexion
with the shoulder flexion ranges in each column
to establish the appropriate grade and impair-
ment. Repeat this process for shoulder extension.
3. Add the upper extremity impairment for shoulder
4. If the shoulder joint is ankylosed, grade modifier
4 is used. The impairment is based on the angle
of the ankylosis.
60°
Shoulder Abduction and Adduction
Normal range of shoulder motion is from 170° of
abduction to 40° of adduction. The positions of func-
tion range from 50° of abduction to 20° of adduction.
The relative value of this motion unit is 18% of upper
extremity function.
Redrawn with permission from Swanson AB, Hagert CG,
de Groot Swanson G. Evaluation of impairment of hand 1. Measure the maximum shoulder abduction and
function. In: Hunter JM, Schneider LH, Mackin E, Calahan A, adduction according to Figure 15-29.
eds. Rehabilitation in the Hand. St Louis, Mo: CV Mosby Co;
1978:31–69.
2. Using the row for shoulder abduction in
Table 15-34, compare the measured greatest
15.7g Shoulder Motion angle of abduction with the shoulder abduction
The shoulder articular unit represents 60% of upper ranges in each column to establish the appropri-
extremity function. The shoulder has 3 functional ate grade and impairment. Repeat this process
units of motion as follows: for shoulder adduction.
Flexion: 40% shoulder function (24% of upper 3. Add the upper extremity impairment for shoulder
extremity function). abduction and adduction.
Extension: 10% shoulder function (6% of upper 4. If the shoulder joint is ankylosed, grade modifier
extremity function) (flexion and extension 4 is used. The impairment is based on the angle
unit: 50% of shoulder function, 30% of upper of the ankylosis.
extremity function).
Abduction: 20% shoulder function (12% of upper Shoulder Internal and External Rotation
extremity function). Normal range of shoulder motion is from 80°
Adduction: 10% shoulder function (6% of upper of internal rotation to 60° of external rotation.
Chapter 15
extremity function) (abduction and adduction The positions of function range from 30° of
unit: 30% shoulder function, 18% of upper internal rotation to 50° of external rotation. The
extremity function). relative value of this motion unit is 12% of upper
Internal rotation: 10% shoulder function (6% of extremity function.
upper extremity function).
External rotation: 10% shoulder function (6% of 1. Measure the maximum shoulder internal and
upper extremity function). external rotation according to Figure 15-30.
Guides6e_15_383-492.indd 472 2/17/09 2:57:02 PM

TA B L E 15 -32
Wrist Range of Motion
Grade
Modifier 0 1 2 3 4
None
Motion 90% 61% to 90% 31% to 60% 30%
(percentage
compared
to normal)
Joint
Wrist 70% Wrist
Flexion 60º 0% 30º to 50º 20º 7% UEI 10º 9% UEI 10º to 10º 21% UEI
Motionº 3% UEI
20º to 40º or 20º to
% Upper 40º 25% UEI
Extremity
Impairment 50º or 50º 40% UEI
Extension (% UEI) 60º 0% 30º to 50º 20º 7% UEI 10º 9% UEI
3% UEI
Wrist 30% Wrist
Radial 20º 0% 10º 2% UEI 0º 4% UEI 10° ulnar 0º to 10º ulnar deviation
Deviation deviation 9% UEI
12% UEI
10º radial deviation or 20º
Motionº ulnar deviation 14% UEI
% Upper
Extremity 20º radial deviation or
Impairment 30º ulnar deviation
(% UEI) 18% UEI
Ulnar 30º 0% 20º 2% UEI 10º to 0 º 10° radial
Deviation 4% UEI deviation
12% UEI
FIGURE 15 -25
Radial Deviation (left) and Ulnar Deviation 2. Using the row for shoulder internal rotation in
(right) of the Right Wrist
Table 15-34, compare the measured greatest
0° 0° angle of internal rotation with the shoulder inter-
20°
30° nal rotation ranges in each column to establish
the appropriate grade and impairment. Repeat
this process for shoulder external rotation.
3. Add the upper extremity impairment for shoulder
internal and external rotation.
4. If the shoulder joint is ankylosed, grade modifier
4 is used. The impairment is based on the angle
of the ankylosis.
Total Shoulder Impairment

Chapter 15
If range of motion is used as a stand-alone approach,

the total impairment for all units of function must be
calculated. All values for the joint are added and the
impairment is converted to whole person using Table
15-11 Impairment Values Calculated From Upper
Extremity Impairment.
Adjustments for Functional History

Redrawn with permission from Swanson AB, Hagert CG, de Groot Adjustments for functional history may be made if:
Swanson G. Evaluation of impairment of hand function. In: Hunter (1) range of motion impairment is the only approach
JM, Schneider LH, Mackin E, Calahan A, eds. Rehabilitation in the
Hand. St Louis, Mo: CV Mosby Co; 1978:31–69. used to rate the extremity, (2) there are reliable
Guides6e_15_383-492.indd 473 2/17/09 2:57:03 PM

FIGURE 15 -26 difference between the range of motion grade modifier

Flexion and Extension of Elbow and the functional history grade modifier.
Based on the motion deficits, the physician will
Flexion determine the physical examination adjustment
140° grade modifier, using Table 15-35 Range of Motion
Grade Modifiers solely for the motion deficits. These
are based on the total findings for that digit (thumb
or fingers) or joint (wrist, elbow, or shoulder).
The physician will identify the grade modifier from
0° Table 15-7, Functional History Adjustment. The func-
Extension
tional history net modifier (see Table 15-36, Functional
History Grade Adjustment: Range of Motion) is based
on the relative difference between the grade modifier
number and the range of motion impairment class; this
number is determined by subtracting the impairment
class number from the functional history grade number.
For example, if the functional history grade modifier
was 3 and the physical examination grade modifier was
findings of motion impairment, (3) the evaluator 1, the functional history net modifier is 3 1, or 2. The
determines that the resulting impairment does not impairment is increased by multiplying the functional
adequately reflect functional loss, and (4) functional history net modifier times 10% times the total motion
reports are determined to be reliable. The adjust- impairment. With the above example, if the range of
ment is a percentage add-on to total range of motion motion impairment was 10% upper extremity impair-
impairment; this add-on is based on the relative ment (class 1), the functional history grade (class 3)
TA B L E 15 -33
Elbow/Forearm Range of Motion
Grade
Modifier 0 1 2 3 4
None
Motion 90% 61% to 90% 31% to 60% 30%
(percentage
compared to
normal)
Joint
Elbow 60% Elbow
Flexion 140º 0% 110º to 130º 60º to 20º 10º 80º 21% UEI
3% UEI 70º 27% UEI 40% UEI
50º to 70º or 90º to 100º
Motionº to 100º
25% UEI
% Upper 8% UEI
Extremity 40º or 110º 38% UEI
Extension Impairment 0º 0% 10º to 40º lag 70º to 90º lag 90º lag
(% UEI) 2% UEI 50º 11% UEI 30% UEI
to 60 lag
5% UEI
Chapter 15
Forearm 40% Elbow

Pronation 80º 0% 70º to 50º 40º to 20º 10º 20º pronation 8% UEI
1% UEI 3% UEI 10% UEI
30º to 60º pronation or
Motionº 10º pronation to 20º supi-
% Upper nation 15% UEI
Extremity
Impairment 70º pronation or 30º
(% UEI) supination 25% UEI
Supination 70º 0% 60º to 50º 40º to 20º 10º
1% UEI 2% UEI 10% UEI
Guides6e_15_383-492.indd 474 3/3/09 6:58:38 PM

FIGURE 15 -27 FIGURE 15 -28

Pronation and Supination of Forearm Shoulder Flexion and Extension
180°
0°
90°
Supination Pronation
50°
50°
80° 80°
35°
0° 0°
TA B L E 15 -3 4
Shoulder Range of Motion
Grade
Modifier 0 1 2 3 4
None
Motion 90% 61% to 90% 31% to 60% 30%
(percentage
compared to
normal)
Joint
Shoulder 50% Shoulder
Flexion 180º 0% 90º to 170º 20º to 80º 10º 20º to 40º flexion
3% UEI 9% UEI 16% UEI 15% UEI
Motionº
% Upper 10º flexion to extension or
Extremity 50º flexion 25% UEI
Impairment
Extension 50º 0% 30º to 40º 10º extension 10º
(% UEI)
1% UEI to 10º flexion flexion
2% UEI 10% UEI
Abduction 170º 0% 90º to 160º 20º to 80º 10º 20º to 50º of abduction
3% UEI 6% UEI 10% UEI 9% UEI
Chapter 15
Motionº
% Upper 10º or 60º abduction
Extremity 16% UEI
Impairment
Adduction 40º 0% 10º to 30º 0º to 30º 40º abduc-
(% UEI)
1% UEI abduction tion
2% UEI 10% UEI
Internal 80º IR 0% 50º IR to 70º 10º ER to 40º 20º ER 20º to 50º IR 6% UEI
Motionº
rotation (IR) IR 2% UEI IR 4% UEI 8% UEI
% Upper 60º IR or 10º IR to ER
Extremity 0% UEI
Impairment
External 60º ER 0% 50º ER to 30º 50º IR to 40º 60º IR
(% UEI)
Rotation (ER) IR 2% UEI IR 4% UEI 9% % UEI
Guides6e_15_383-492.indd 475 2/17/09 2:57:05 PM

FIGURE 15 -29 and the net modifier 2, the increase is 10% (net modi-
Shoulder Abduction and Adduction fier) times 10% (impairment), or a 1% increase, which
should be added to the 10% impairment rating for a
final 11% upper extremity impairment. Note that 10%
180 ° is not an add-on of 10%, rather it is a multiplier used
in conjunction with the functional history net modifier
and the total impairment.
Abduction Range of Motion Examples
EXAMPLE 15-24: THUMB AND FINGER

MOTION DEFICITS
90 °
Subject: 32-year-old woman
History: One year ago sustained a full thickness
Adduction burn to the right thumb and index finger. After mul-
tiple grafts and therapy she is left with severe range
of motion loss in both digits.
50 ° 50 °
Current Symptoms: Complains of motion deficits
that result in significant interference with activities
0° of daily living, particularly use of her hand for tasks
involving grasping and digital dexterity. She requires
the assistance of others to open jars.
FIGURE 15 -30
Shoulder External Rotation and Internal Rotation
90°
Internal
Rotation
0° 0°
External
Rotation
Chapter 15
90°
Guides6e_15_383-492.indd 476 2/17/09 2:57:06 PM

TA B L E 15 -35
Range of Motion Grade Modifiers
Digit Normal 20% total digit 20% to 39% digit 40% to 70% digit 70% digit
impairment impairment impairment impairment.
Hand, wrist, 12% upper 12% to 23% upper 24% to 42% upper 42% upper
elbow, or extremity impair- extremity impair- extremity impair- extremity impair-
shoulder ment for total ment for total ment for total ment for total
motion impairment motion impairment motion impairment motion impairment
TA B L E 15 -36
Functional History Grade Adjustment: Range of Motion
Net Modifier 0 1 2 3
Functional History grade adjustment Equal 1 Higher 2 Higher 3 Higher
compared to range of motion ICF Class
Increase to total range of motion No change Total Range Total Range Total Range
impairment of Motion of Motion of Motion
Impairment 5% Impairment 10% Impairment 15%
ICF indicates International Classification of Functioning, Disability, and Health.
Functional Assessment: QuickDASH score is 73. impairment) and the index finger impairment of 79%
DI equals 16% HE. These impairments are added
Physical Exam: Examination is only remarkable for
resulting in 30% HI. Per Table 15-11 Impairment
her motion deficits secondary to the scarred digits;
Values Calculated From Upper Extremity
thumb and index. She retains protective sensation
Impairment this converts to 27% UEI.
in these digits. Thumb - IP joint ankylosed at 20°;
MCP - flexion to 40° and extension to -30°; CMC Referencing Table 15-35, Range of Motion Grade
joint opposition at 4cm, radial abduction to 20° and Modifiers, her 27% UEI is consistent with grade
adduction to 5cm. Index finger DIP ankylosed at 20° modifier 3. Referencing Table 15-7 Functional
of flexion; PIP ankylosed at 60° of flexion; MCP History Adjustment- Upper Extremity, both her
flexion limited to 70° and extension limited to 0°. symptoms and her QuickDASH are consistent with
Motion deficits were reproducible and consistent grade modifier 3. Since her range of motion grade
with other documentation. modifier and functional history adjustment are both
the same grade modifier 3, no modification of her
Clinical Studies: Unremarkable
impairment is required per Table 15-36 Functional
Diagnosis: Thumb and finger deficits secondary to History Grade Adjustment: Range of Motion. Her
burns and grafts. final impairment is 27% UEI or 16% WPI.
Impairment Rating:. Thumb - IP joint ankylosed Comment: There is no diagnosis on the finger or
at 20° 7% DI; MCP - flexion to 40° 2% DI and thumb grids which reflects the severity of her injury.
extension to 30° 4% DI, added 6% DI; CMC Range of motion is most appropriate method to
adduction to 5cm 4% DI, radial abduction to 20° assess her impairment.
10% DI, and opposition at 4 cm 9% DI for the
thumb. Impairments are added resulting in 36% DI.
EXAMPLE 15-25: SHOULDER MOTION DEFICIT
Index finger DIP ankylosed at 20° of flexion 30%
Chapter 15
DI; PIP ankylosed at 60° of flexion 60% DI; MCP Subject: 55-year-old woman
flexion to 70° 19% DI and extension to 0° 7% DI
History: Developed an impingement syndrome
which are added resulting in 26% DI. The 30% DI,
related to her constant overhead work. She was
60% DI, and 26% DI are combined resulting in 79% DI
treated with subacromial decompression. Following
for the index finger.
the procedure she developed a postoperative infec-
Referencing Table 15-12 Impairment Values tion. After 6 months of appropriate antibiotic treat-
Calculated From Digit Impairment the thumb ment and physical therapy she has reached maximum
impairment of 36% DI equals 14% HI (hand medical improvement.
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Current Symptoms: Complains of motion deficits 15.8 Summary

that result in significant interference with activities
of daily living, particularly involving work activities EXAMPLE 15-26 MULTIPLE UPPER
above shoulder level. EXTREMITY IMPAIRMENTS
Functional Assessment: QuickDASH score is 60. Subject: 57-year-old man.
Physical Exam: Examination is only remarkable History: A factory worker has a 20-year history of
for her motion deficits with shoulder flexion 90°, performing repetitive, forceful tasks, primarily involv-
extension 30°, abduction 83°, adduction 0°, exter- ing his right upper extremity. He has been an exem-
nal rotation 0° and internal rotation 12°. Motion plary employee and has continued to work despite a
deficits were reproducible and consistent with other several year history of problems with discomfort in
documentation. his elbow and wrist. He was diagnosed years ago as
Clinical Studies: MRI revealed findings consistent having lateral epicondylitis, and has received appro-
with rotator cuff disease, without evidence of tear. priate conservative therapy which improved his symp-
toms. Four years ago an MRI revealed a triangular
Diagnosis: Shoulder motion deficit, presumed sec- fibrocartilage complex (TFCC) tear and he underwent
ondary to prolonged immobilization and infection. surgical intervention with marked improvement in the
Impairment Rating: Measurements are rounded up pain he had been experiencing. Two years ago he was
or down to the nearest number ending in 0 (per Table diagnosed as having a right carpal tunnel syndrome,
15-34 Shoulder Range of Motion, flexion 90° 3% electrodiagnostically confirmed, and he underwent a
UEI; extension 30° 1% UEI; abduction 83° (rounded carpal tunnel release with resolution of his symptoms.
to 80°) 6% UEI; adduction 0° 2% UEI; internal One year ago he caught his right little finger in a press
rotation 12° (rounded to 10°) 4% UEI; external rota- and the distal portion was amputated. There were no
tion0° 2% UEI. Total motion deficit is obtained by previous impairment ratings.
adding values resulting in 18% UEI. Current Symptoms: His only complaint of sig-
Referencing Table 15-35, Range of Motion Grade nificance is his “tennis elbow” pain, and to a lesser
Modifiers, her 18% UEI is consistent with grade degree occasional discomfort in his wrist. He denies
modifier 2. Referencing Table 15-7 Functional any sensory difficulties or weakness. He denies any
History Adjustment: Upper Extremity, both her difficulties with his activities of daily living that he
symptoms and her QuickDASH are consistent with would attribute to his amputation.
grade modifier 2. Since her Range of Motion and Functional Assessment: The QuickDASH score is 21.
functional history adjustment are both the same
grade modifier 2, no modification of her impair- Physical Exam: Right little finger is amputated at
ment is required, per Table 15-36 Functional History the level of the distal interphalangeal joint; other-
Grade Adjustment: Range of Motion. Her final wise no observed abnormalities except very faint
impairment is 18% UEI or 11% WPI. scars from his surgeries. Tender approximately 2
cm. distal to the lateral epicondyle in the area of the
Comment: There is no diagnostic category which extensor carpi radialis brevis muscle. Wrist exten-
fits her injury and there are significant motion sion and supination against resistance with the elbow
deficits, therefore the most appropriate rating is extended increases his symptoms. Minimal tender
the range of motion. Her functional reports were over the TFCC and proximal palm. Range of motion
consistent with other documentation and her is full and no neurological deficits.
examination. If her functional history, as defined
in Table 15-7, was more severe, at level of grade Clinical Studies: Wrist and elbow X rays are unre-
modifier 3, there would have been a 1 grade differ- markable. MRI revealed a small triangular fibro-
cartilage complex (TFCC) tear. Electrodiagnostic
Chapter 15
ence with the grade assigned to her motion deficit.

In such a case, per Table 15-36 Functional History studies pre-operatively revealed mild sensory and
Grade Adjustment: Range of Motion her impair- motor conduction delays of the right median nerve.
ment would be increased by Total Range of Motion Diagnosis: (1) Lateral epicondylitis, (2) Triangular
Impairment
5%, ie, increased by 18% UEI
5%, fibrocartilage complex (TFCC) tear, surgically
or 0.9% UEI (rounded up to 1% UEI) and would repaired, (3) Carpal Tunnel Syndrome, resolved, s/p
result in 19% UEI or 11% WPI. Carpal tunnel release, (4) Amputation little finger at
DIP joint.
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Impairment Rating: There are 4 ratable condi- observed abnormalities), and Clinical tests: n/a. The
tions. The first 2 diagnoses are rated as a Diagnosis- only potential adjustment is the physical examination;
Based Impairment (Section 15.2). The carpal tunnel however, this has a grade consistent with the diagnos-
syndrome is rated by Section 15.4f, Entrapment tic class and therefore the impairment remains at the
Neuropathy and the amputation is rated by Section default 1% UEI.
15.6. Functional adjustments are applied only to the
Carpal tunnel syndrome was confirmed electrodi-
single, highest diagnosis-based impairment (DBI),
agnostically and the patient is at maximal medi-
which after rating was determined to be his triangu-
cal improvement. Rating is based on Table 15-23,
lar fibrocartilage complex (TFCC) tear.
Entrapment / Compression Neuropathy. Testing find-
Triangular fibrocartilage complex (TFCC) tear ings are grade modifier 1 (conduction delay), history
is rated using Table 15-3, Wrist Regional Grid: is grade modifier 0 (no symptoms), and physical
Upper Extremity Impairments. Under the section findings are grade modifier 1(normal). The grade
“Ligament/Bone/Joint” and diagnosis “Triangular modifiers total 2 (1 0 1) and average 0.67 (1).
fibrocartilage complex (TFCC) tear” and per criteria Therefore, grade modifier 1 is selected with a default
of “Documented TFCC injury / surgery with of 2% UEI. The QuickDASH is 21, however using
residual findings” he is assigned to class 1 with mid- clinical judgment the physician determined that his
range default value of 8% UEI. Adjustment Grids: current difficulties relating to the QuickDASH were
Functional History: Grade modifier 1 (QuickDASH unrelated to the carpal tunnel syndrome, and rather
in range of 21 to 40), Physical Examination: Grade due to other conditions, primarily his lateral epicon-
modifier 1 (Minimal palpatory findings, consistently dylitis. From a functional perspective the physician
documented, without observed abnormalities), and determined that the carpal tunnel syndrome was
Clinical Tests: Grade modifier 1 (interpreted as resolved and that from a functional perspective this
“Clinical studies confirm diagnosis, mild pathol- would most appropriately be considered as normal.
ogy”). Net adjustment compared with diagnostic class Therefore the lowest UEI for that grade modifier is
is 0, resulting in grade C and remains at 8% UEI. selected, ie, 1% UEI.
Amputation impairment is based on Figure 15-10,
Class 1 Example Calculation: Default for Impairments of the Digits and the Hand for
Diagnosis 8% UEIa Amputations at Various Levels. Amputation of the
little finger at the DIP joint results in 5% UEI.
CDX GMFH GMPE GMCS
1 1 1 1
His final impairment is based on the combined impair-
ment of 1% UEI (lateral epicondylitis), 8% UEI (TFCC
Net adjustment tear), 1% UEI (carpal tunnel syndrome), and 5% UEI
(GMFH CDX) (1 1) 0
(GMPE CDX) (1 1) 0 (amputation). The largest impairments are combined
(GMCS CDX) (1 1) 0 first and the combined rating is 15% UEI. Converts
Net adjustment 0 by Table 15-11, Impairment Values Calculated From
Upper Extremity Impairment to 9% WPI.
default grade C 8% UEI Comment: The completed Figure 15-2, Upper
a
UEI indicates upper extremity impairment; CDX, class of Extremity Impairment Evaluation is provided as
diagnosis; GMFH, grade modifier for functional history; GMPE,
grade modifier for physical examination; and GMCS, grade
Figure 15-31.
modifier for clinical studies.
When evaluating an individual with upper extremity
Lateral Epicondylitis is rated using Table 15-4, impairment, first obtain the patient’s detailed history
Elbow Regional Grid: Upper Extremity Impairments. and perform a thorough and careful physical exami-
Under the section “Muscle/Tendon” and diagnosis nation; then follow these suggested steps.
Chapter 15
“Epicondylitis” and per criteria of “History of pain- 1. Record process and results using the Upper
ful injury, residual symptoms without consistent Extremity Impairment Evaluation Record
objective findings” he is assigned to class 1 with (Figure 15-2).
midrange default value of 1% UEI. Adjustment Grids:
Functional History: Grade modifier 1 (QuickDASH 2. Obtain detailed history and perform an appro-
in range of 21 to 40, however cannot be applied since priate physical examination, as explained in
this is not the highest diagnosis-based impairment), Section 15.1a.
Physical Examination: Grade modifier 1 (Minimal 3. Review clinical studies, as explained in
palpatory findings, consistently documented, without Section 15.1b.
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FIGURE 15 -31
Upper Extremity Impairment Evaluation Example
Name: John Sample Exam Date: 1/1/2008

ID Number: 1234 Sex: F M Side: R L Birth Date: 12/27/50
Diagnosis: Injury Date: 1/1/2004 (CT)
Grid Diagnosis / Criteria Assigned Class Grade Modifier Adjustments Assigned Dx Grade Final UEI
Digit (D) Triangular fibrocartilage 0 1 2 3 4 Net

Wrist (W) complex (TFCC) tear GMFH 0 1 2 3 4 0 2 1 0 1 ≥2 8%
Elbow (E) GMPE 0 1 2 3 4 0 A B C D E
Shoulder(S) GMCS 0 1 2 3 4 0
(Optional: QuickDASH Score: 21)
D Lateral epicondylitis 0 1 2 3 4 Net

W GMFH 0 1 2 3 4 n/a 2 1 0 1 ≥2 1%
E GMPE 0 1 2 3 4 0 A B C D E
S GMCS 0 1 2 3 4 n/a
(Optional: QuickDASH Score:)
D 0 1 2 3 4 Net
W GMFH 0 1 2 3 4 2 1 0 1 ≥2
E GMPE 0 1 2 3 4 A B C D E
S GMCS 0 1 2 3 4
(Optional: QuickDASH Score:)
Combined UEI 9% UEI
Peripheral
Nerve/CPRS II
Impairments
Nerve Sensory and Motor Grading Assigned Class Grade Modifer Adjustments Assigned Dx Grade Combined UEI
Sensory Deficit Sensory Deficit GMFH 0 1 2 3 4 n/a Sensory:
0 1 2 3 4 n/a 0 1 2 3 4 GMCS 0 1 2 3 4 n/a A B C D E
Motor Deficit Motor Deficit GMFH 0 1 2 3 4 n/a Motor:

0 1 2 3 4 n/a 0 1 2 3 4 GMCS 0 1 2 3 4 n/a A B C D E
Entrapment
Median Nerve Electrodiagnostics: Test 0 1 2 3 4 n/a Average: 1 1%
Conduction delay History 0 1 2 3 4 n/a Functional Grade: n/a
Physical 0 1 2 3 4 n/a Mild Moderate Severe
CRPS I
Impairment
Points Assigned Class Adjustments Assigned Grade Final UEI Adjustment
Abbreviations
0 1 2 3 4 FH 0 1 2 3 4 n/a A B C D E
S - Shoulder
PE 0 1 2 3 4 n/a E = Elbow
CS 0 1 2 3 4 n/a W = Wrist
H = Hand
Amputation D - Digit
GMFH = Grade Modifer Functional History
Level Assigned Class Adjustments Assigned Grade Final UEI GMPE = Grade Modifer Physical
Little at DIP 0 1 2 3 4 FH 0 1 2 3 4 n/a A B C D E 5% UEI Examination
GMCS = Grade Modifer Clinical Studies
PE 0 1 2 3 4 n/a
CS 0 1 2 3 4 n/a
Chapter 15
Motion Summary Final UEI

Joint Total UEI Assigned Class Diagnosis-Based Impairment 9%
0 1 2 3 4 Peripheral Nerve
0 1 2 3 4 Entrapment 1%
CRPS (Stand-alone)
0 1 2 3 4
Amputation 5%
Combined UEI
Range of Motion (Stand-alone)
Final Combined Impairment 15%
Signed: Date:
Whole Person Impairment 9% WPI
Printed name:
(Regional Impairment)
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4. Determine the diagnoses and those that are to be 10. Identify and calculate impairment related to
rated. CRPS, as explained in Section 15.5.
5. Determine the DBI for each ratable diagno- 11. Identify and calculate impairment related to
sis, using the regional grids, as explained in amputation, as explained in Section 15.6.
Sections 15.2 and 15.3.
12. Only if no other approach is available to rating,
6. Use the adjustment grids for functional his- calculate impairment based on range of motion,
tory, physical examination, and clinical studies, as explained in Section 15.7.
as described in Sections 15.3a through 15.3c,
13. Typically, only a single approach is used and in
to define the grade modifier for each factor.
nearly all cases this will be the DBI assessment;
Functional history adjustment is performed only
however, if multiple approaches are applicable,
for the single most significant diagnosis, unless
combine the impairments at the upper extremity
otherwise specifically stated by a jurisdiction.
level.
7. Adjust the DBI, as explained in Section 15.2.
14. As appropriate, convert the final impairment to
8. If there is more than 1 ratable diagnosis, com- regional or whole person impairment.
bine the final impairment value at the upper
15. If both upper extremities are involved, each
extremity level.
extremity is rated separately and converted to
9. Identify and calculate impairment related to the whole person impairment; then both whole per-
peripheral nerve impairment, as explained in son ratings (right and left upper extremity) are
Section 15.4. combined using the Combined Values Chart.
Chapter 15
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15.9 Appendix 15-A: Functional complete the questions (eg, the patient has died and
Assessment Inventories a theoretical rating is being calculated from medical
records), the QuickDASH cannot be used.
QuickDASH If the QuickDASH is to be used to modify the

The QuickDASH is a shortened version of the DASH default impairment rating, the examiner must cor-
(Disabilities of the Arm, Shoulder, and Hand). The relate the information provided by the QuickDASH
DASH Outcome Measure and the QuickDASH and a list of Activities of Daily Living (ADLs).
are the shared property of the Institute for Work The examiner can verify that problems exist with
& Health (IWH) and the American Academy of ADLs, by having the individual complete Table 15-
Orthopaedic Surgeons (AAOS). The tools were 37 Activities of Daily Living Questionnaire and the
developed by the Institute and the AAOS. The proj- QuickDASH Questionnaire. The physician should
ect was supported by the American Association for record, when taking the patient’s history, which of
Hand Surgery, the American Orthopaedic Society these activities can be done without difficulty, which
for Sports Medicine, the American Shoulder and can still be done, but with difficulty, and which
Elbow Surgeons, the American Society for Surgery the individual says he or she is unable to perform.
of the Hand, the Arthroscopy Association of North The physician can then look for consistency in the
America, and the American Society of Plastic answers to the 2 questionnaires and in the patient’s
Surgeons. The QuickDash is available at history. Actual problems with ADLs should be easy
http://www.dash.iwh.on.ca/outcome_quick.htm. for an individual to recall, and the answers should
be consistent. Inconsistent answers suggest either
The QuickDASH can be presented in 2 formats. The symptom exaggeration or problems comprehending
traditional model is with discrete integers that range the questionnaires due to low proficiency in English
from 1 to 5 (1 is not difficult, not limited, or none; 2 or comorbid brain pathology (eg, head injury or
is mild difficulty, slightly limited, or mild; 3 is mod- dementia). In addition, individual answers should be
erate difficulty, moderately limited, or moderate; 4 logical. Activities such as walking should not usually
is severe difficulty, very limited, or severe; and 5 is be impaired by upper limb impairments.
unable, extremely, or extreme). The second format is
using a visual analog scale. In this method a line that Many of the activities listed in the Table 15-37,
is 10 cm long is marked from 0, none, to 10, worst Activities of Daily Living Questionnaire should not
possible. The patient then makes a mark on the line logically be affected by isolated problems with 1 or
to indicate his or her degree of difficulty in complet- both upper limbs, as depicted in Table 15-38, ADLs
ing the task. This mark is measured and rounded Questionnaire Evaluation. Answers that these activi-
to the nearest centimeter, with the resulting integer ties are difficult or impossible to perform, assuming
being the patient’s answer. Each format has unique the questions are understood, implies either symp-
advantages and disadvantages. Whatever method tom magnification or associated comorbidity in
is used, the patient’s answers to the PDQ should be another body part or organ system.
dated and attached to the impairment evaluation Many of the activities in the Activities of Daily Living
report. For Chapter 15, either method may be used. Questionnaire can be directly observed by the phy-
The QuickDASH contains 11 questions, and the sician to document that difficulty with the activity
Work Module contains 4 additional questions. Since does exist, and to quantify the degree of difficulty.
impairment addresses loss of function but not work Individuals can be asked to dress and to simulate eat-
activities specifically, only the first 11 questions will ing, brushing teeth, combing hair, writing, typing,
be used in reference to the AMA Guides. The evalu- feeling, grasping, and lifting. Such ADLs as seeing,
ator may use the Work Module’s 4 questions for addi- hearing, and speaking can be judged while taking the
tional insight. If there is more than 1 QuickDASH medical history. Individuals can also be asked to stand,
Chapter 15
question that is not answered or is missing, the sit, walk, climb stairs, and so forth. These activities
QuickDASH cannot be calculated. Therefore, if 10 should be unaffected by upper limb problems.
or 11 QuickDASH questions have been answered, the The completed ADLs Questionnaire is evaluated by
QuickDASH can be used to establish the “Functional comparing the individual’s answers on the question-
Scale score” used in the evaluation of upper extrem- naire to the answers to inquiries about ADL dif-
ity impairment. If fewer than 10 QuickDASH ques- ficulties when the physician takes a history from the
tions have been answered, the evaluator should ask individual. Consistency is further evaluated by the
the patient to complete the unanswered questions. physician directly observing the individual perform
If for some reason the patient refuses or is unable to specific activities listed in Table 15-37.
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TA B L E 15 -37
Activities of Daily Living Questionnaire
Name: Date:
Some Cannot
Activity No difficulty difficulty perform
Self-care, Personal Hygiene
Urinating
Defecating
Brushing teeth
Combing hair
Bathing
Dressing
Eating
Communication
Writing
Typing
Seeing
Hearing
Speaking
Physical Activity
Standing
Sitting
Reclining
Walking
Climbing stairs
Sensory Function
Hearing
Seeing
Tactile feeling
Tasting
Smelling
Nonspecialized Hand Activities

Grasping
Lifting
Tactile discrimination
Sexual Function
Orgasm
Ejaculation
Chapter 15
Lubrication
Erection
Sleep, Restful Pattern
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TA B L E 15 -3 8
ADLs Questionnaire Evaluation
Activity Difficulty logical with Difficulty NOT logical Difficulty logical only
impairment of a single if only a single upper if both upper limbs
upper limb limb is impaired have impairments
Self-care, Personal Hygiene
Urinating X X
Defecating X X
Brushing teeth X X
Combing hair X X
Bathing X X
Dressing Buttons and zippers X
Eating Some foods X
Communication
Writing Yes a if dominant limb X
involved
Typing Yes a X
Seeing X
Hearing X
Speaking X
Physical Activity
Standing X
Sitting X
Reclining X
Walking X
Climbing stairs X
Sensory Function
Hearing X
Seeing X
Tactile feeling X* Xa
Tasting X
Smelling X
Nonspecialized Hand Activities

Grasping Some objects X
Lifting Some objects X
Tactile discrimination X Xa
Sexual Function
Orgasm
Ejaculation
Lubrication
Chapter 15
Erection
Sleep, Restful Pattern Yes, due to pain Yes, if pain is not an Yes, due to pain
issue
a
Difficulty should not occur with proximal limb problems, such as shoulder pathology, because this function uses the distal upper limb.
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Another measure of the consistency of ADL dif- established measures were compared. The most
ficulty is to compare the answers on the Activities important criteria are:
of Daily Living Questionnaire to the answers on
• Reliability: This is the degree to which data
the QuickDASH using Table 15-39, Comparison
derived are dependable. Because the functional
Between QuickDASH and ADL Questionnaires.
assessment measure will be administered in
Logically, these statements follow about the con-
many different settings, to a wide variety of indi-
sistency relationship between answers to the
viduals, and may need to be administered to the
QuickDASH Questionnaire and answers to the
same person at various times, procedures must be
Activities of Daily Living Questionnaire.
standardized and described in an administrator’s
The physician who is rating impairment should make manual. Instructions must be understandable in
allowances for comorbidity that potentially explains the primary language of the individual. Items
illogical answers. Thus, if an individual with a rota- must be understandable in the primary language
tor cuff tear indicates difficulty walking due to the of the individual. The items must be easily
rotator cuff tear, the answer is not logical. If, how- interpretable from English to the individual’s
ever, the individual also has a significant knee or hip native language, so that an in-person interpreter
arthritis, and bilateral upper limb impairments pre- can provide an unequivocal oral interpretation.
clude the use of a cane, that patient’s answers about Because the functional assessment measure will
difficulty walking may be logical. be used to make important decisions, a method to
identify less than a full effort responding should
If an individual has multiple answers that are not
be built into the instrument. Because a paper and
logical or multiple answers that are not consistent,
pencil mode of administration will be used, a
the QuickDASH questionnaire should not be used to
method to accept reliable scores from incomplete
assign impairment ratings. In this case, Functional
data sets should be available. Because normative
History is not used as a Grade Modifier, and the
comparisons will be made, nonstandard modifi-
only grade modifiers that can potentially be used are
cations must be discouraged. The test-retest reli-
Physical Findings and Clinical Studies. The mini-
ability coefficient must be at least r .90.
mum impairment in that grade should be chosen to
represent the final impairment. • Validity: This is the degree to which evidence
and theories support the interpretation of func-
For the upper extremity section, the selection of a
tional assessment measure scores for its intended
self-report functional assessment measure began
purpose: “Does the score measure what it is
with development of criteria against which
TA B L E 15 -39
Comparison Between QuickDASH and ADL Questionnaires
QuickDASH question ADL Questionnaire correlate
1. “open a tight or new jar” Grasping
2. “heavy household chores (eg, wash walls, floors)” Grasping and lifting
3. “carry a shopping bag or briefcase” Grasping and lifting
4. “wash your back” Grasping and bathing
5. “use a knife to cut food” Grasping and eating (perhaps tactile feeling)
6. recreational activities” Grasping, tactile feeling, lifting
7. “social activities No correlate; upper limb impairments should not produce
social difficulty
Chapter 15
8. “work or ADLs” Writing, typing, tactile feeling, grasping, lifting, and/or

tactile discrimination
9. ”arm, shoulder, or hand pain” No direct correlate
10. “tingling” Tactile feeling and tactile discrimination
11. “sleeping” Sleep
Note: ADL indicates Activity of Daily Living.
Source: QuickDASH questions from Beaton et al, 2005.
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intended to measure?” The functional assess- the functional assessment measure must be useful
ment measure rating of severity of functional in clinical decision-making for the individual.
limitations must have good sensitivity and speci-
• Practicality: Materials must be low-cost, with
ficity. The rating must represent the severity of
easy replacement of expendable supplies. The
the functional limitations at the highest level of
functional assessment measure must be able to be
scaling, between the ordinal and interval levels.
administered by a trained clerk in 5 minutes or
The rating must focus on functional limitations
less, and scoring completed in 2 minutes or less.
that are caused by upper limb musculoskeletal
Typical interpretation by the physician must be
impairment, including the fingers, hand, wrist,
completed in 2 minutes or less, and reports of the
elbow, and shoulder. The functional assessment
results in 2 minutes or less.
measure must be diagnosis-neutral, gender-neu-
tral, and age-neutral. It must consider a wide • Forensic Defensibility: Formal reliability and
range of functional abilities. The functional validity studies of the functional assessment mea-
assessment measure must focus on the person’s sure must be undertaken and published in a peer-
ability to perform common and easily under- reviewed scientific journal.
stood activities that have a low skill component.
A number of self-report functional assessment mea-
Items must be simple with low cognitive demand.
sures that address upper extremity function were
These are more easily translated into various
considered and are listed in Table 15-40. A simple
languages and are more likely to be within
scoring rubric was used to compare the measures,
the repertoire of a broad range of individuals.
assigning a value of 1 to a “should” criterion that
Because the typical interface between the person
was met and a value of 3 to a “must” criterion that
and the activity is mediated by a tool, piece of
was met. A total score of 66 was possible. None of
equipment, or workstation, only those that are
the measures met all of the criteria. At this time,
universally designed and used in a standard or
the QuickDASH appears to be the most acceptable
invariant manner should be included. As much as
functional assessment measure. This instrument
possible, the application of the tool, equipment,
addresses the criteria adequately. Although it has
or workstation should be specified to minimize
a few deficiencies, none are considered so serious
ambiguity. Normative data should be available.
that it cannot be recommended. On this basis, the
Cross-references to widely used rating systems
QuickDASH has been selected as the functional
should be available. The information gained from
assessment measure for the upper extremity section.
TA B L E 15 - 4 0
Self-Report Functional Assessment Measures
Instrument Source Total Score
QuickDASH Beaton et al, 2005 61
Disabilities of the Arm, Shoulder and Solway et al, 2002; Upper Extremity 58
Hand (DASH) Collaborative Group, 1996
Hand Function Sort (HFS) Matheson et al, 1996, 2001 56
Multidimensional Task Ability Profile Mayer et al, 2005 55
(MTAP)
Functional Health Status Hart & Wright, 2002 54
Questionnaire (FHS)
Upper Extremity Function Scale Pransky et al, 1997 53
Short Form-36 Health Questionnaire McHorney et al, 1993, 1994; Ware, 49
Chapter 15
(SF-36) 2000; Ware & Sherbourne, 1992

Michigan Hand Outcomes Chung et al, 1998, 1999 48
Questionnaire (MHQ)
Sequential Occupational Dexterity Van Lankveld, 1998; Van Lankveld et 45
Assessment (SODA) al, 1996
Individual-Rated Wrist/Hand MacDermid, 1996; MacDermid & 41
Evaluation (PRWHE) Tottenham, 2004
Maximum Total Scorea 66
a
A value of 1 was assigned to a “should” criterion that was met and a value of 3 to a “must” criterion that was met.
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Appendix 15-B: Electrodiagnostic In bilateral studies, if the CMAP amplitude with

Evaluation of Entrapment wrist stimulation or the SNAP amplitude with
antidromic wrist stimulation is 50% lower on the
Syndromes involved side than on the contralateral normal side,
conduction block is present.
The following criteria are to be used in interpreting
electrodiagnostic testing for entrapment syndromes. If the CMAP with wrist stimulation is below 4 mV,
and the needle electromyogram (EMG) is still nor-
mal, motor conduction block is present.
Carpal Tunnel Syndrome Axon Loss

For impairment rating purposes, axon loss is con-
firmed either by needle EMG or by nerve conduction
Conduction Delay
testing. In carpal tunnel syndrome, axon loss will
For carpal tunnel syndrome, or CTS (median nerve),
usually be established by needle EMG findings of
criteria include:
“denervation.” Needle EMG should show fibrillations
• Distal motor latency longer than 4.5 milliseconds and positive waves in the thenar eminence (APB) and
for an 8-cm study. will typically show at least some high amplitude and
generally polyphasic motor unit potentials in chronic
• Distal peak sensory latency longer than 4.0 mil-
CTS. Recruitment must be reduced.
liseconds for a 14-cm distance.
On nerve conduction testing, axon loss is recognized
• Distal peak compound nerve latency of longer
by a CMAP of less than normal (generally less than
than 2.4 milliseconds for a transcarpal or midpal-
4 mV) recorded from the APB with palm stimula-
mar study of 8 cm.
tion. Care must be taken to ensure that palm stimula-
If different distances were used in testing, correction of the median nerve is supramaximal and that
tion to the distances stated above can be accom- other thenar intrinsic muscles (ulnar nerve) have not
plished by assuming each 1 cm of distance requires been stimulated by volume conduction; the CMAP
0.2 milliseconds. wave form should be similar in shape and should
not change when stimulation intensity is increased.
Conduction Block In many individuals the technical issues associated
For impairment rating purposes, the definition of with this method prevent a clear diagnosis of motor
median nerve conduction block at the carpal tunnel axon loss by nerve conduction testing in carpal tunnel
is a drop in the abductor pollicis brevis (APB) com- syndrome.
pound motor action potential (CMAP) amplitude of
at least 30% when wrist stimulation is compared with
palm stimulation. Care must be taken to ensure that Ulnar Neuropathy at the Wrist
palm stimulation of the median nerve is supramaxi- (Guyon’s Canal)
mal and that other thenar intrinsic muscles (ulnar
nerve) have not been stimulated by volume conduc-
tion; the CMAP wave form should be similar in shape Conduction Delay
and should not change when stimulation intensity is For ulnar tunnel syndrome at the wrist (ulnar nerve),
increased. In many individuals the technical issues criteria include:
associated with this method prevent a clear diagnosis • Distal motor latency longer than 4.5 milliseconds
of motor conduction block in carpal tunnel syndrome. for an 8-cm study.
If motor conduction block cannot be established • Distal peak sensory latency longer than
Chapter 15
because of technical issues, sensory conduction 4.0 milliseconds for a 14-cm distance.
block on an antidromic sensory study may be
present. If the 14-cm (or wrist stimulation, digit • Distal peak compound nerve latency longer than
recording) sensory nerve action potential (SNAP) 2.4 milliseconds for a transcarpal or midpalmar
amplitude is reduced by 50% or more compared with study of 8 cm.
the 7-cm (or palm to digit) SNAP amplitude study, If different distances were used in testing, correc-
sensory conduction block has been established for tion to the distances stated above can be accom-
the purpose of impairment rating. plished by assuming each 1 cm of distance requires
0.2 milliseconds.
Guides6e_15_383-492.indd 487 2/17/09 2:57:13 PM

Conduction Block interosseous (FDI) muscle. Recording from the FDI

For ulnar nerve conduction block, a drop of at least muscle may increase test sensitivity. With the concomi-
30% in the compound muscle action potential of tant presence of conduction delay by the above criteria,
either the abductor digiti minimi or the first dorsal a decrease in the CMAP amplitude greater than 40%
interosseous (FDI) muscle must be recorded when when the above-elbow (across-elbow) segment is com-
wrist stimulation is compared with palm stimulation. pared with the below-elbow segment, is consistent with
motor conduction block of the ulnar nerve at the elbow.
In bilateral studies, if the CMAP amplitude with
If the conduction velocity in both the above-elbow and
wrist stimulation or the SNAP amplitude with
the below-elbow ulnar nerve segments are less than
antidromic wrist stimulation is 50% lower on the
45 m/s, and the calculated conduction velocities in the
involved side than on the contralateral normal side,
median and radial nerves are all normal (greater than
conduction block is present.
50 m/s), at least ulnar nerve motor conduction block is
also present by these definitions.
Axon Loss
For impairment rating purposes, the diagnosis of
Axon Loss
axon loss is made either by needle EMG or by nerve
For ulnar neuropathy at the elbow, axon loss for
conduction velocity. Needle EMG should show fibril-
impairment rating purposes is usually diagnosed
lations and positive waves in the hypothenar eminence
by the needle EMG. Denervation changes (positive
(abductor digit minimi) or first dorsal interosseous
waves, fibrillations, and high-amplitude polyphasic
muscle. In chronic ulnar tunnel syndrome, it will typi-
motor units) must be present in muscles innervated
cally show at least some high-amplitude polyphasic
by the ulnar nerve distal to the site of entrapment.
motor unit potentials. Recruitment must be reduced.
The FDI muscle may be the muscle most sensitive to
On nerve conduction testing, axon loss is identified by
focal ulnar neuropathy. Neither changes limited to
a CMAP recorded from the abductor digiti minimi of
the FDI muscle nor sparing of the forearm muscles
well less than normal (generally less than 4 mV) with
exclude an elbow site of compromise.
palm stimulation.
Median Nerve Entrapment in

Ulnar Neuropathy at the Elbow the Proximal Forearm (Anterior
(Cubital Tunnel) Interosseous)
Conduction Delay Median nerve compromise in the proximal forearm,
Criteria for the diagnosis of ulnar neuropathy at the usually at the pronator teres muscle, is uncommon.
elbow, for the purpose of impairment rating, include Simultaneous entrapment of the median nerve both
motor conduction velocity less than 50 m/s for an 8- in the carpal tunnel and at the elbow is very rare, and
to 10-cm segment of nerve posterior to the elbow, or should be diagnosed with caution. Most often these
an above-elbow to below-elbow 8- to 10-cm segment cases are moderate carpal tunnel syndrome with
conduction velocity that is at least 10 m/s slower than proximal referral of symptoms. Conduction block of
the conduction velocity in the below elbow to wrist the fastest axons at the wrist may cause a delay in the
segment. calculated forearm conduction velocity.
For ulnar neuropathy at the elbow, the elbow should The forearm conduction velocity is computed by
be positioned at 70° to 90° of flexion for measure- recording from the APB in the palm and is thus
ment and stimulation. This position most accurately affected by carpal tunnel syndrome. If simultaneous
approximates surface measurements to the actual entrapments are suspected by both clinical examination
Chapter 15
length of the nerve. Conduction velocity should be and electrodiagnostic studies, the carpal tunnel syn-
calculated for an 8- to 10-cm segment of the ulnar drome is usually treated with surgical release and the
nerve, posterior to the elbow. Stimulation more electrodiagnostic studies and clinical exam for symp-
than 3 cm distal to the medial epicondyle should be tom severity are repeated 6 months postoperatively.
avoided, as the nerve becomes quite deep within the With this treatment, the “proximal entrapment” usually
flexor carpi ulnaris muscle, and there is substantial resolves and, therefore, was likely never present.
risk of submaximal stimulation. For the uncommon median nerve neuropathy near
the elbow, nerve conduction studies may not permit
Conduction Block the diagnosis to be made with enough certainty for
For these tests, the motor recording electrode can be impairment rating. Studies that fail to meet the defi-
over either the abductor digiti minimi or the first dorsal
Guides6e_15_383-492.indd 488 2/17/09 2:57:13 PM

nitions listed below are considered normal studies and the needle exam should not be consistent with a
for impairment rating purposes. more proximal lesion (plexopathy or radiculopathy).
Recruitment must be reduced.
Conduction Delay
A calculated forearm motor conduction velocity
(stimulation just proximal to the elbow flexion crease
and recording from the APB) that is less than 50 m/s Radial Nerve Entrapment
while the distal motor latency (wrist to APB) is nor-
mal (less than4.5 milliseconds) is consistent with Radial nerve entrapment near the elbow or axilla or
a proximal lesion causing motor conduction delay. in the spiral groove of the humerus is rare, and a suc-
Both a prolonged distal latency with wrist stimulation cessful result from surgical decompression of a “radial
and a slow forearm motor conduction velocity for nerve entrapment” at the elbow (posterior interosseous
the median nerve strongly suggest only carpal tunnel nerve entrapment) in a workers’ compensation patient
syndrome with conduction block of the fastest con- is even rarer. These diagnoses should be made with
ducting axons. This is not usually a sign of simulta- caution. Isolated trauma to the sensory branch, the
neous carpal tunnel syndrome and proximal median superficial radial nerve (“hand cuff neuropathy”), is
nerve compression neuropathy near the elbow. not an entrapment and should be rated from the acute
peripheral nerve injury section. This pure sensory
Conduction Block injury produces radial nerve sensory conduction slow-
With elbow stimulation and recording from the APB, a ing and/or SNAP amplitude loss with recording from
CMAP amplitude of less than 4 mV in the presence of the thumb, with a normal radial nerve motor study.
a calculated forearm motor conduction velocity of less For the very uncommon radial nerve entrapment just
than 50 m/s, with a distal motor latency at the wrist of below the elbow (posterior interosseous nerve at the
less than 4.5 milliseconds, is consistent with proximal supinator) bilateral studies are helpful, as this is very
or elbow entrapment of the median nerve, assuming rarely a bilateral process. There should be a normal
that ulnar testing has excluded a congenital anastomo- superficial radial nerve SNAP (greater than 7 V)
sis of the median and ulnar nerves. There will usually as the superficial radial nerve arises proximal to the
also be significant change in the configuration of the site of compression.
CMAP wave form. On bilateral testing with stimula-
tion just above the elbow flexion crease, a CMAP Conduction Delay
amplitude that on the involved side is 50% or less of the Absolute calculated conduction velocities for the
amplitude on the uninvolved side in either the APB or radial nerve are difficult to interpret, as it is difficult
the pronator quadratus qualifies as conduction block. to accurately measure the length of the radial nerve
by surface techniques. With stimulation at the elbow
Axon Loss and recording from the extensor indicis proprius, a
Denervation changes limited to muscles innervated by motor latency on the involved side that is 2 or more
the median nerve distal to the elbow entrapment must milliseconds longer than on the uninvolved side is
be present. For compression neuropathy in the pronator consistent with motor conduction delay.
teres muscle, the needle EMG should show denervation
changes (fibrillation potentials and positive waves and/ Conduction Block
or high-amplitude polyphasic potentials) in at least 2 of In conduction block lesions, the extensor indicis pro-
the distally innervated median nerve forearm muscles. prius (EIP) CMAP should be normal compared with
These muscles are the flexor carpi radialis, flexor digi- the contralateral side with stimulation in the mid-
torum sublimis, flexor digitorum profundus to digits 2 forearm (generally the normal side will be greater
and 3, flexor pollicis longus, and the pronator quadra- than 3 mV). It should be at least 30% lower with
tus. Abnormalities have been reported most often in the stimulation at or just above the elbow.
Chapter 15
flexor pollicis longus and flexor digitorum profundus to

digits 2 and 3. For compression neuropathy in the dis- Axon Loss
tal arm (at the ligament of Struthers) the needle EMG In axon loss lesions there should be a reduced CMAP
should, in addition to the just-mentioned criteria, show recorded from the EIP (generally less than 2 mV)
denervation changes (fibrillation potentials and positive and at least 30% less than the contralateral CMAP.
waves) in the pronator teres. Needle exam changes in The needle exam should show denervation changes
the ABP alone strongly suggest that carpal tunnel syn- in at least 2 of the following muscles: EIP, extensor
drome is present, rather than proximal median neuropa- carpi ulnaris, or extensor digitorum communis. In
thy at the elbow. Nerve conduction studies should not addition, radial nerve innervated muscles proximal to
be consistent with a generalized peripheral neuropathy,
Guides6e_15_383-492.indd 489 2/17/09 2:57:14 PM

Callahan AD. Sensibility assessment: prerequisites and

the origin of the posterior interosseous nerve should techniques for nerve lesions in continuity and nerve
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Chapter 15
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Chapter 16
CHAPTER 16
The Lower
Extremities
16.3 Adjustment Grid and Grade Modifiers–

Non-Key Factors

Impairment
16.6 Amputation Impairment

Introduction
16.7 Range-of-Motion Impairment
nent impairment due to impairments of the lower
extremities (limbs). For evaluation purposes, as illus-
16.8 Summary
trated in Figure 16-1, the lower extremity is divided
into 3 regions (distal to proximal):
16.9 Appendix 16-A Lower Limb
Questionnaire • Foot and ankle: from the midshaft of the tibia to
the tips of the toes.
• Knee: from the midshaft of the femur to the mid-
shaft of the tibia.
• Hip: from the articular cartilage of the acetabulum
to the mid shaft of the femur.
In prior editions of the Guides, the lower limb was
referred to as the lower extremity, and this usage has
become standardized. However, proper use of ter-
minology would require that the structure from the
hip to the foot be called the lower limb. In the Sixth
Edition both terms are used synonymously.
Assessment of the lower extremities requires evalu-
ation of soft tissue, skeletal structure, joints, and the
peripheral nervous system; vascular problems are
Note: All references to “radiographic” are to be rated per Section 4.8: Vascular Diseases Affecting
inclusive of other “imaging” studies. the Extremities.
493
Guides6e_16_493-556.indd 493 2/19/09 2:44:35 PM

Chapter 16

(1) International Classification of Functioning,
Disability, and Health (ICF) Model of Functioning
Hip and Disability is used to provide a common basis for
the description of human functioning and impair-
ments, (2) principles of assessment have been simpli-
fied and clarified, (3) specific diagnosis-based rating
tables for the most common injuries and diagnoses
have been added, (4) physical examination has been
simplified, (5) functional assessment is provided
Knee through focused history-taking including informa-
tion about activities of daily living (ADLs) and a
functional assessment tool, (6) criteria for diagnosis
of complex regional pain syndrome (CRPS) have
been updated for consistency with current standards
and other chapters, and (7) a Lower Extremity
Foot/ ankle Impairment Evaluation Record is provided as a tem-
plate to simplify making the assessment and record-
ing of the evaluation. As appropriate, impairment
values from prior editions are retained; some adjust-
ments were necessary to more appropriately reflect
F I G U R E 16 -1
the impairment or were required because of changes
Lower Extremity Regions
in the methodology.
The authors have made every effort to provide the
most current and comprehensive information for
In clinical situations and discussions regarding the the impairment scenarios likely to be encountered.
potential functional severity of an injury, there are Although the chapter and impairment rating method
typically 4 considerations: (1) what is the problem may seem complex at first, the chapter presents
(diagnosis), (2) what difficulties does the patient information useful and necessary for impairment
report, (3) what are the examination findings, and assessments. The reader is encouraged to read the
(4) what are the results of clinical studies. In a simi- entire chapter and review case examples prior to
lar manner, these are the steps used to assess most performing an assessment. The impairment rating
cases of musculoskeletal impairment. process has been simplified by providing a congru-
ent rating methodology among the 3 musculoskeletal
Musculoskeletal impairment rating is based primar-
chapters. Once the examiner masters the methodol-
ily upon a specific diagnosis, which, in the current
ogy in 1 chapter, that same methodology applies to
method, results in assignment to an Impairment
other chapters.
Class (IC) using grids designed for this purpose.
The impairment value within a class is further The authors of this chapter recognize that the pro-
refined by considering information related to func- cess described is still far from perfect with respect
tional status, physical examination findings and to defining impairment or the complexities of human
the results of clinical testing. The rationale for this function; however, the authors’ intention is to sim-
change from previous rating methods is to stan- plify the rating process, to improve interrater reli-
dardize and simplify the rating process, to improve ability and to provide a solid basis for future editions
content validity, and to provide a more uniform of the Guides.
methodology that promotes greater interrater reli-
ability and agreement.
This chapter has been updated with informa-
tion and research provided by the state and
medical specialty societies listed in the preface.
Impairment evaluations of the lower extremity
must be performed within the context of the direc-
tives in Chapters 1 and 2 and only performed
when conditions have reached maximum medical
improvement (MMI).
Guides6e_16_493-556.indd 494 2/19/09 2:44:40 PM

The Lower Extremities 495
Chapter 16
TA B L E 16 -1 In the event that a specific diagnosis is not included
Definition of Impairment Classes in the diagnosis-based regional grid, the examiner
Impairment Range
should use a similar listed condition as a guide to
determining an impairment value. In the report, the
Lower Whole
Class Problem Extremity (LEI) Person (WPI)
examiner must fully explain the rationale for the
analogy.
0 No objective 0% 0%
findings
1 Mild 1%–13% LEI 1%–5% WPI 16.1a Interpretation of Symptoms
2 Moderate 14%–25% LEI 6%–10% WPI and Signs
3 Severe 26%–49% LEI 11%–19% WPI The medical history must describe the chief com-
plaint and state the quality, frequency, and duration
4 Very severe 50%–100% LEI 20%–40% WPI
of symptoms such as pain, numbness, paresthesias,
and weakness, functional difficulties, and any
interference with daily activities. The evaluation
report should include the individual’s description
in impairment evaluation.
of how the symptoms and condition developed and
The impairment evaluation and report should include a the assumed cause. The evaluator should ask the
comprehensive, accurate medical history; a review and examinee about any perceived relationship between
summary of all pertinent records; and a comprehen- the current condition and any other musculoskel-
sive description of the individual’s current symptoms etal problems. The examiner should also clarify, to
and their relationship to daily activities. The examiner the extent possible, causation and apportionment,
should perform a careful and thorough physical exami- by documenting the mechanism of injury for the
nation and review all findings of relevant laboratory, condition being evaluated, and any prior problems.
imaging, and ancillary tests. A complete report will include discussion of previ-
ous evaluations and therapeutic interventions as
Anatomic, diagnostic, and functional bases for deter-
described in medical records, past medical history,
mining impairment are aspects of the ICF Model.
review of systems, personal and social history and
Diagnosis-based impairment (DBI) numbers are
family history. Available X rays and other imaging
provided for each of the 3 regions of the lower limb
studies or reports should be reviewed and com-
(Table 16-2 for foot/ankle, Table 16-3 for knee, and
mented on in the report.
Table 16-4 for hip). These regional Grids include
5 columns containing impairment classes, numbered Case history is based on information both pre-
from 0 to 4. These classes are designed to reflect sented by the patient and extracted from medical
the degree of impairment, and numerical ranges of records. The evaluating physician(s) should obtain
impairment have been assigned to each class and objective data through physical examination and
summarized in Table 16-1. appropriate clinical studies. If information pro-
vided by the patient or noted in previous medical
Most impairment values for the lower extremity are
records, or findings on physical examination are
calculated using the diagnosis-based impairment
inconsistent, the evaluator’s report should refer-
(DBI) method. Impairment class is determined by
ence the inconsistencies. The diagnosis used for
the diagnosis and specific criteria, considered the key
placement in an impairment class must be based
factor, and then adjusted by grade modifiers or non-
on reliable findings, reflective of the impair-
key factors that may include Functional History (FH),
ment that is being assessed, and supported by the
Physical Examination (PE), and relevant Clinical
clinical history, current examination, and clini-
Studies (CS). The grade modifiers, or non-key fac-
cal studies. Objective findings are always given
tors, are considered only if they are determined by the
the greater weight of evidence over subjective
examiner to be reliable and associated with the diag-
complaints.
nosis. The process for calculating impairment values
is described in detail in Section 16.3d. Functional history, physical examination and clini-
cal studies all contribute to better understanding of
Diagnoses for the lower extremity are defined in
the patient’s diagnosis and condition. Each of these
3 major categories:
“non-key factors” is described below. Adjustment
• Soft tissue. grids related to each of these factors, and for use in
the impairment calculation, are provided in Sections
• Muscle/tendon.
16.3b to 16.3d.
• Ligament/bone/joint.
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Chapter 16
Functional History (FH) as recorded in the medical records documenting

A proper functional history enables the physician previous treatment.
to assess the impact of a given condition on basic
Positive, negative, and nonphysiological findings
functioning of the limb for activities of daily liv-
must be assessed bilaterally and documented. If
ing (ADLs). The physician is expected to grade this
the opposite extremity is uninvolved, it should
impact, placing it in 1 of 5 broad categories of incre-
be used to define normal for that individual.
mental impairment. For a given diagnosis or condi-
Whenever possible, quantitative findings should
tion, the impact is defined as:
be reported as opposed to general descriptions;
• Grade modifier 0: no demonstrable interference ie, document specific measurements of lower limb
with function. girth as opposed to reporting extent of atrophy.
More objective findings, such as atrophy, are
• Grade modifier 1: interference with the vigorous
given greater relative weight over findings that
or extreme use of the limb only.
require patient participation, such as demonstra-
• Grade modifier 2: antalgic limp that limits ambulation of active range of motion or strength, and
tion distance; or regularly uses orthotic device (at reports of tenderness. Inconsistencies and dis-
least ankle-foot orthosis). crepancies between what is observed, what has
been previously reported, and what is otherwise
• Grade modifier 3: an antalgic limp; routine use of
expected should be noted. Examination findings
2 canes, or 2 crutches, or knee-ankle-foot orthosis.
that differ significantly from previously recorded
• Grade modifier 4: non-ambulatory. observations after the probable date of MMI
should be reported, with comments noting the
A functional assessment tool may be used as
discrepancy; these findings may be excluded from
described later in this chapter to further evaluate
the impairment calculation, as described later in
this parameter. The physician is expected to weigh
this chapter.
the patient’s subjective complaints and score on the
functional assessment tool, relative to the expected Neurologic examination of the lower extremities
severity for a given condition. The grade modifier includes measurement of knee and ankle reflexes
that reflects this analysis may be accepted or not as and motor and sensory functions. It is important to
a variable in the impairment calculation. ensure that lower extremity impairment discussed in
this chapter is not related to underlying spine pathol-
If multiple diagnoses are being rated, the examiner
ogy. If the neurologic exam points to an underly-
should consider the relative contribution of each of
ing spine disorder, the lower extremity impairment
these diagnoses to the functional complaints; for
would, in most cases, be accounted for in the spine
example, a patient may have an ankle and hip injury
impairment rating, assuming that there are no other
and have minimal difficulties with the hip, but
primary lower extremity diagnoses requiring a con-
the ankle injury may limit ambulation. Functional
comitant rating.
assessment is only considered for the limb impair-
ment with the highest rating, since it is expected that
Clinical Studies (CS)
this will encompass the functional limitations related
The physician needs to review and document
to other impairments in the same limb.
actual studies and findings from relevant diagnos-
tic studies, including laboratory tests, roentgeno-
Physical Examination (PE)
graphic (X ray) studies, computed tomographic
Guided by the history, an appropriate physical
(CT) scans, magnetic resonance images (MRIs),
examination is performed, documenting lower
nuclear medicine scans, ultrasound exams, and
extremity-related physical findings, such as gait,
electrodiagnostic testing. In some cases, only
limb length discrepancy, deformity, weakness,
reports may be available, and this should be
atrophy, instability, motion deficits and neurologic
noted in the record. While imaging and other
findings, including sensory and motor deficits.
studies may assist physicians in making a
The examiner should remove braces, orthotics and
diagnosis, they are not the sole determinants of
other external devices, as appropriate, to permit
a diagnosis. Clinical test results that do not cor-
adequate and thorough examination. The exam-
relate with the patient’s symptoms or support the
iner should consider the patient’s diagnosis, the
diagnosis should be mentioned.
reliability of findings on examination, and the
results of previous examinations and observations
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Chapter 16
16.2 Diagnosis-Based Impairment by adjusting the grade up or down from the default
value C, by the calculated net adjustment (2 to 2).
Most impairments are based on the Diagnosis-based The lowest possible grade is A, (adjustments less
Impairment (DBI) where impairment class is deter- than 2 from the default value C will automatically
mined by the diagnosis and specific criteria; this is be considered A) and the highest possible grade is E
then adjusted by non-key factors (grade modifiers) (adjustments greater than 2 will automatically be
and may include Functional History (FH), Physical considered E). The regional grid is then consulted
Examination (PE), and Clinical Studies (CS). The again to determine the appropriate impairment value
grade modifiers, or non-key factors, are considered for the selected class and grade. Grade modifiers
only if they are determined by the examiner to be allow movement within a class, but do not allow
reliable and associated with the diagnosis. Typically, movement into a different class.
these other factors will support the class and default
grade assignment; however in some circumstances
determine the most appropriate class for a specific
a lower or higher grade may be assigned, depending
regional diagnosis and (2) to determine the final
on the specifics of the case.
impairment after appropriate adjustments are made
Alternative approaches are also provided for calculat- using the grade modifiers.
ing impairment for peripheral nerve deficits, complex
There are 5 classes in the diagnosed-based regional
regional pain syndrome, amputation, and range of
grids:
motion. Range of motion is primarily used as a physi-
cal examination adjustment factor and is only used • Class 0: no objective problem.
to determine actual impairment values when it is not
• Class 1: mild problem.
possible to otherwise define impairment. Ratings
based on range of motion or for complex regional pain • Class 2: moderate problem.
syndrome cannot be combined with other approaches.
• Class 3: severe problem.
Figure 16-2, Lower Extremity Impairment
• Class 4: very severe problem approaching total
Evaluation Record, should be completed or all
function loss.
information on that record should be provided
in the impairment rating report. The terms class, Subjective complaints without objective physi-
default impairment, adjustments and assigned cal findings or significant clinical abnormali-
grade modifier and optional AAOS Lower Limb ties are typically assigned class 0 with no ratable
Score used in the evaluation record are described impairment.
in detail in this chapter. An example of a completed
This process is repeated for each separate diagnosis in
Lower Extremity Impairment Evaluation Record
each limb involved. In most cases, only 1 diagnosis in a
(Figure 16-13) is provided at the end of this chapter.
region (ie, hip, knee and/or foot/ankle) will be appropri-
Diagnosis-based impairment (DBI) is the primary ate. If a patient has 2 significant diagnoses, for instance,
method of evaluation for the lower limb. Three ankle instability and posterior tibial tendonitis, the
regional grids, listing relevant diagnoses, are pro- examiner should use the diagnosis with the highest
vided in this section, 1 for each region of the lower impairment rating in that region that is causally-related
extremity (foot/ankle, knee, and hip). An impairment for the impairment calculation. If an examiner is
will be defined by class and grade. The Impairment routinely using multiple diagnoses without objective
Class (IC) is determined first, by using the corre- supporting data, the validity and reliability of the evalu-
sponding diagnosis-based regional grid. The grade is ation may be questioned.
then determined using the adjustment grids.
Vascular conditions are rated per Section 4.8,
Once the impairment class has been determined, Vascular Diseases Affecting the Extremities,
based on the diagnosis, the grade is initially assigned and may be combined in the Lower Extremity
the default value, C. The final impairment grade, Worksheet using the Combined Values Chart in
within the class, is calculated using the grade modi- the Appendix. The diagnosis of complex regional
fiers, or non-key factors, as described in Section pain syndrome, CRPS I, previously known as
16.3. Grade modifiers include functional history, reflex sympathetic dystrophy (RSD), and CRPS II,
physical examination, and clinical studies. The grade known as causalgia, must be supported by consis-
modifiers are used in the net adjustment formula tent, objective findings, and is rated as explained
described in Section 16.3d to calculate a net adjust- in Section 16.5.
ment. The final impairment grade is determined
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FIGURE 16 -2 Lower Extremity Impairment Evaluation Record
Chapter 16
Name: Exam Date:

Table Diagnosis / Criteria Assigned Class Grade Modifier Adjustments Assigned Dx Final LEI
Grade
FA 0 1 2 3 4 Net
K GMFH 0 1 2 3 4 2 1 0 1 2
H GMPE 0 1 2 3 4
GMCS 0 1 2 3 4 A B C D E
(Optional: AAOS Lower Limb Score:)
Net Adjustment (GMFHCDX)(GMPE
CDX)(GMCSCDX)
FA 0 1 2 3 4 Net
K GMFH 0 1 2 3 4 2 1 0 1 2
H GMPE 0 1 2 3 4
GMCS 0 1 2 3 4 A B C D E

CDX)(GMCSCDX)
FA 0 1 2 3 4 Net
K GMFH 0 1 2 3 4 2 1 0 1 2
H GMPE 0 1 2 3 4
GMCS 0 1 2 3 4 A B C D E
CDX)(GMCSCDX)
Combined LEI
FA ⴝ Foot Ankle K ⴝ Knee H ⴝ Hip FH applied to single highest diagnosis
Peripheral Nerve/CRPS II
Impairments
Nerve Sensory and Motor Assigned Class Adjustments Assigned Combined
Grading Dx Grade LEI
Sensory Deficit Sensory Deficit FH 0 1 2 3 4 n/a Sensory:
A B C D E
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a
Motor Deficit Motor Deficit
FH 0 1 2 3 4 n/a Motor:
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a A B C D E
A B C D E
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a
Motor Deficit Motor Deficit
FH 0 1 2 3 4 n/a Motor:
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a A B C D E
Combined LEI
CRPS I Impairment Adjustment Abbreviations
Points Assigned Class Default Adjustments Assigned Final LEI FA ⴝ Foot / Ankle
LEI Grade K ⴝ Knee
H ⴝ Hip
0 1 2 3 4 FH 0 1 2 3 4 n/a A B C D E
GMFH ⴝ Functional History
PE 0 1 2 3 4 n/a
GMPE ⴝ Physical Exam
CS 0 1 2 3 4 n/a GMCS ⴝ Clinical Studies
Amputation
Level Assigned Class Default Adjustments Assigned Final LEI
LEI Grade
0 1 2 3 4 12% FH 0 1 2 3 4 n/a A B C D E
PE 0 1 2 3 4 n/a
CS 0 1 2 3 4 n/a
Motion Summary Final LEI

Joint Total LEI Assigned Class Diagnosis-based Impairment
Peripheral Nerve
0 1 2 3 4
CRPS
0 1 2 3 4 Amputation
0 1 2 3 4 Range of Motion (Stand-alone)
Combined LEI Final Combined Impairment LEI
Whole Person Impairment WPI
Signed: —————————————————————————
Evaluator (printed name): ———————————————— Date: ———————
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Chapter 16
Steps in Determining Impairment instability is resolved. That the joint has been treated
surgically does not result in an add-on value or addi-
1. Perform history and examination, and deter-
tional impairment percentage. Impairment ratings
mine if individual is at MMI.
are based on the patient’s condition at the time of the
2. Establish the appropriate diagnosis for each rating and do not anticipate or account for the pos-
part of the lower limb to be rated. sibility of future interventions.
3. Use the regional grid in the corresponding Selecting the optimal diagnosis requires judgment and
region to determine the associated class. experience. If assignment to a class is determined by
severity of ROM deficit (ie, normal, mild, moderate,
4. Use the adjustment grid and the grade modi-
severe, very severe), this severity is determined using
fiers, including functional history, physical
Sec. 16.7 ROM Impairment. If more than 1 diagnosis
exam, and clinical studies, to determine
in a region (ie, hip, knee and/or foot/ankle) can be
what grade of associated impairment should
used, the 1 that provides the most clinically accurate
be chosen within the class defined by the
and causally-related impairment rating should be
regional grid.
used; this will generally be the more specific diagno-
5. Use the regional grid to identify the appropri- sis. Typically, 1 diagnosis will adequately character-
ate impairment rating value for the impair- ize the impairment and its impact on ADLs. Certain
ment class, modified by the adjustments as diagnoses may span more than 1 class; therefore,
calculated. these diagnoses are associated with specific objective
findings on physical examination or clinical studies to
6. Combine lower extremity percentages using
ensure placement in the appropriate class.
the Combined Values Chart in the same
extremity as appropriate. If both lower In the event that a specific diagnosis is not listed in
extremities are involved, convert impairments the diagnosed-based impairment grid, the examiner
to whole person and combine. should identify a similar listed condition to be used
as a guide to the impairment calculation. The ratio-
nale for this decision should be described.
The regional grids have 1 column that includes diag-
16.2a Diagnosed-Based Class
noses and 5 columns reflecting impairment classes.
Assignment—Regional Grids
Identify the applicable diagnosis in the left-most
The first step in determining an impairment rating
column. The permissible class assignments (0–4)
is to choose the diagnosis that is most applicable for
are specified in the horizontal rows. Reference the
the region being assessed. Diagnoses are divided
specific criteria in the row for that diagnosis, to deter-
into 3 categories including soft tissue, muscle/
mine which class is appropriate. Above the criteria
tendon, and ligament/bone/joint. Typically, soft-
in each cell are 5 numbers reflecting the range of
tissue diagnoses are assigned the lowest impair-
impairment associated with those specific diagnostic
ments and ligament/bone/joint diagnoses the high-
criteria. Each of these numbers corresponds to grades
est impairments. As much as possible, impairment
A, B, C, D, and E, with A the mildest and E the most
values from prior editions were retained, unless
severe. The middle value is grade C and represents
adjustments were necessary to more appropriately
a default impairment value, which typically corre-
reflect the impairment or were required because
sponds with the impairment value assigned in prior
of changes in the methodology. On the basis of the
editions of the Guides. Grades and the corresponding
diagnosis and other specific differentiators that may
final impairment value are modified by the use of the
be associated with that diagnosis, the condition is
adjustment grids and the net adjustment formula, as
assigned to a specific class in the regional grid.
discussed above. The impairment calculation process
Reliability of the diagnosis is essential and the diag- is described in detail in Section 16.3d.
nosis should be consistent with the clinical history
and findings at the time of impairment assessment. General Considerations
Surgery does not necessarily result in an impairment Instructions for using the diagnosed-based impair-
rating, unless it is a factor that contributes to placing ment grids are provided in Section 16.3 Adjustment
a diagnosis within a class. Surgical intervention is Grid and Grade Modifiers—Non-Key Factors. The
only relevant if it alters the functional status of the evaluator should select the most accurate diagnosis
condition evaluated at MMI. For example, surgi- and identify the class containing that diagnosis. As
cal repair of a torn cruciate ligament can decrease previously described, the numerical value of the
the instability from a higher class to class 0 if the impairment associated with that diagnosis, located
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Chapter 16
above each diagnosis, may be increased or decreased based impairment grid, Table 16-2, the examiner
within an impairment class based upon grade should identify a similar listed condition to be used
modifiers, as determined using the adjustment grids as a guide to the impairment calculation. The ratio-
as described in Section 16.3. nale for this decision should be described.
Prior to using the regional grids, the examiner must
16.2c Knee
review Section 16.1, Section 16.2, and Section 16.3.
The knee is defined as the region from the mid
In some cases, the class will be defined by physi-
femur to the mid tibia and including all the bone,
cal examination findings or clinical studies results.
joint, ligamentous and soft tissue structures encom-
When this is the case, those same findings may
passing the joint. Diagnoses and classes are listed
not be used as grade modifiers to adjust the rating.
as previously described. In the event that a spe-
Range of motion will, in some cases, serve as an
cific diagnosis is not listed in the diagnosed-based
alternative approach to rating impairment. It is not
impairment grid, Table 16-3, the examiner should
combined with the diagnosis-based impairment, and
identify a similar listed condition to be used as a
stands alone as an impairment rating.
guide to the impairment calculation. The rationale
Clinical examples are provided in Section 16.3e. The for this decision should be described.
Guides’ user is encouraged to read the entire chapter
for a complete understanding of the impairment rating 16.2d Hip
method before attempting to interpret the ratings or to The hip area is defined as the region from the articu-
perform the calculations that accompany the examples. lar cartilage of the acetabulum to the mid shaft of
the femur, including all the bone, joint, ligamentous
16.2b Foot and Ankle and soft tissue structures. Diagnoses and classes
The foot and ankle is defined as the region from are listed as previously described. In the event that
below the mid-tibia to the toes, including all the a specific diagnosis is not listed in the diagnosed-
bone, joint, ligamentous and soft tissue structures based impairment grid, Table 16-4, the examiner
encompassing the joints. Diagnoses and classes are should identify a similar listed condition to be used
listed as previously described. In the event that a as a guide to the impairment calculation. The ratio-
specific diagnosis is not listed in the diagnosed- nale for this decision should be described.
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Chapter 16
TA B L E 16 -2 Foot and Ankle Regional Grid – Lower Extremity Impairments
Foot and Ankle Regional Grid (LEI)

DIAGNOSTIC
CRITERIA
CLASS Moderate Very severe

DEFINITIONS No problem Mild problem problem Severe problem problem
IMPAIRMENT
RANGES 0% LE 1%–13% LE 14%–25% LE 26%–49% LE 50%–100% LE
SEVERITY
SOFT TISSUE
Nail abnormali- 0 0 1 1 2 2
ties secondary to
No significant Significant con-
trauma
objective abnor- sistent palpatory
Callus/recurrent mal findings on findings and/or
healed plantar examination or radiographic
ulceration under radiographic findings
post traumatic studies at MMI
bony promi-
nence; contusion/
crush injury;
plantar fasciitis;
plantar fibroma-
tosis; symptom-
atic soft tissue
mass (ganglion,
etc); retrocalca-
neal bursitis
MUSCLE / Do not use PE

TENDON range of motion
if used for diag-
nostic criteria
Strain; tendonitis; 0 0 1 1 2 2 14 15 16 17 18 28 31 34 37 40
or h/o ruptured
No significant Palpatory find- Flexible defor- Fixed defor-
tendon, specifi-
objective abnor- ings and/or radio- mity and loss of mity and loss of
cally involving
mal findings of graphic findings specific tendon specific tendon
posterior tibial,
muscle or tendon function function
anterior tibial, 3 4 5 6 7
injury at MMI
achilles, or Mild motion
peroneal tendon deficits
(all other ten-
dons below) 7 8 10 12 13
Moderate motion
deficits and/or sig-
nificant weakness
Strain; tendonitis; 0 0 1 1 2 2
or h/o ruptured
No significant Palpatory findings
tendon
objective abnor- and/or radio-
All other tendons mal findings of graphic findings
muscle or tendon
1 2 2 2 3
injury at MMI
Mild motion
deficits
3 4 5 6 7
Moderate motion
nificant weakness
(continued)
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Chapter 16
TA B L E 16 -2 (C O N TI N U E D) Foot and Ankle Regional Grid – Lower Extremity Impairments

DIAGNOSTIC
CRITERIA

IMPAIRMENT
SEVERITY
LIGAMENT / BONE / JOINT
LIGAMENT Do not use with CS X ray stability
Joint instability / 0 0 1 1 2 2 14 15 16 17 18
ligamentous
No significant Clinical instability Severe ligamen-
laxity - traumatic
objective abnor- tous laxity on
3 4 5 6 7
Ankle (including mal findings of stress x-rays (AP
syndesmosis) muscle or tendon Mild ligamentous Stress radio-
injury at MMI laxity (AP Stress graphs: 6 mm.
(reference Table
radiograph: 2–3 excess opening
16-8)
mm. excess open- or 15 degrees
ing or 5–9 degrees varus opening
varus opening compared to
compared to nor- normal opposite
mal opposite side) side;
7 8 10 12 13 Lateral Stress
Moderate liga- radiograph: ante-
mentous laxity rior drawer 6
(AP Stress radio- mm excess open-
graph: 4–6 mm. ing compared to
excess opening normal side)
or 10–15 degrees
varus opening
compared to nor-
mal opposite side;
Lateral stress
radiograph: ante-
rior drawer 4–6
mm excess open-
ing compared to
normal side)
Joint instability/ 0 1 2 4 6 7
ligamentous
No significant Dorsal instability
laxity-traumatic
objective abnor- compared to
Metatarsal- mal findings of opposite side
phalangeal muscle or tendon
injury at MMI
FRACTURE / Do not use with CS X ray misalignment or PE ROM or align-

DISLOCATION ment if used in diagnostic criteria
Tibia 0 3 4 5 6 7 14 17 19 21 24 26 28 30 32 34 50 52 54 56 58
(extra-articular)
Healed, no objec- Non-displaced Moderate to Very severe Infected
tive deficits with minimal severe motion misalignment, nonunion
findings deficits and/ nonunion with
or moderate angulation
5 7 9 11 13
misalignment or rotational
Mild motion defi- deformity or
cits and/or mild union with
misalignment osteomyelitis
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Chapter 16
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
Tibia (intra- 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
articular – pilon /
plafond)
tive deficits with minimal severe motion malalignment, nonunion
7 8 10 12 13
malalignment or rotational
malalignment osteomyelitis
Ankle (malleo- 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
lar, bimalleolar,
trimalleolar)
7 8 10 12 13
malalignment or rotational
malalignment osteomyelitis
Talus 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
7 8 10 12 13
malalignment; or rotational
Mild motion defi- avascular necrosis deformity or
cits and/or mild with talar body union with
malalignment; collapse osteomyelitis
avascular necrosis
without talar
body collapse
Calcaneus 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43
Healed, no objec- Non-displaced Moderate to Very severe
tive deficits with minimal severe motion malalignment or
7 8 10 12 13
malalignment /
Mild motion defi- angulation
cits and/or mild
malalignment /
angulation
Navicular / 0 2 3 3 3 4 14 15 16 17 18 26 28 30 32 34
cuboid (transtar-
sal) / charcot
5 6 7 8 9
malalignment /
Mild motion defi- angulation
cits and/or mild
malalignment /
angulation
(continued)
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Chapter 16

DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY

Metatarsal – 0 2 3 3 3 4 14 15 16 17 18 26 28 30 32 34
tarsal fracture /
dislocation
(Lisfranc)
or moderate angulation, or
5 6 7 8 9
malalignment / involvement of
Mild motion defi- angulation 4th and 5th tarsal -
cits and/or mild metatarsal joints
14 15 16 17 18
malalignment /
angulation Very severe
malalignment or
nonunion with
angulation, with-
out involvement
of 4th and 5th tarsal
- metatarsal joints
Metatarsal(s) 0 2 3 3 3 4
Healed, no objec- 1 metatarsal
st
tive deficits - Non-displaced

with minimal
findings
7 8 10 12 13
1 metatarsal
st
– with angulation
and metatarsalgia
0 1 1 2 2
Other metatarsal
- non-displaced
with abnormal
examination
findings
3 4 5 6 7
Other metatarsal
– with angulation
and metatarsalgia
7 8 10 12 13
Multiple meta-
tarsals with
angulation and
metatarsalgia
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Chapter 16
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
GRADE A B C D E A B C D E A B C D E

Sesamoid(s) 0 0 1 1 2 2
Healed, no objec- Non-displaced
tive deficits with abnormal
examination
findings
3 4 5 6 7
Displaced or
fragmented
Phalanx 0 0 1 1 2 2
Healed, no objec- Non-displaced
tive deficits with abnormal
examination
findings
3 4 5 6 7
Displaced or
fragmented
Deformity
Midfoot – cavus 1 2 2 2 3
Mild
5 6 7 8 9
Moderate
Midfoot – 3 4 5 6 7 16 18 20 22 24
“rocker bottom”
Mild Severe
7 8 10 12 13
Moderate
Arthritis Do not use with Do not use with Do not use with Do not use with
CS X ray arthritis CS X ray arthritis CS X ray arthritis CS X ray arthritis
Degenerative 0
condition:
unrelated and
symmetric
Pan-Talar 26 28 30 32 34 52 56 60 64 68
(Tibial-talar, 1–2 mm cartilage 0–1 mm cartilage
talar-calcaneal, interval all 3 interval all 3
talar-navicular) joints joints or severe
loss of motion in
all 3 joints
(continued)
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Chapter 16

DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
Ankle 0 1 2 2 2 3 14 15 16 17 18 26 28 30 32 34
3 mm cartilage Mild osteophytes 2 mm cartilage No cartilage
interval with impinge- interval, cystic interval
ment, full- changes on both
thickness articular sides of joint,
cartilage defect, large area of
cystic changes on avascular necrosis
one side of joint,
16 18 20 22 24
focal area of avas-
cular necrosis or 1 mm cartilage
ununited osteo- interval
chondral fracture
3 4 5 6 7
3 mm cartilage
interval
Subtalar 0 0 1 1 2 2 14 15 16 17 18
2 mm cartilage Mild osteophytes 1 mm cartilage
interval with impinge- interval
ment, full-
19 20 22 24 25
thickness articular
cartilage defect, No cartilage
cystic changes on interval
one side of joint,
focal area of avas-
cular necrosis or
ununited osteo-
chondral fracture
3 4 5 6 7
2 mm cartilage
interval
Talonavicular 0 0 1 1 2 2 16 18 20 22 24
1 mm cartilage Mild osteophytes No cartilage
interval with impinge- interval
ment, full-
thickness articular
cartilage defect,
cystic changes on
one side of joint,
focal area of avas-
cular necrosis or
ununited osteo-
chondral fracture
7 8 10 12 13
1 mm cartilage
interval
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Chapter 16
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
Calcaneocuboid 0 3 4 5 6 7
1 mm cartilage 1 mm cartilage
interval interval
7 8 10 12 13
No cartilage
interval
First metatarso- 0 3 4 5 6 7
phalangeal joint
interval interval
7 8 10 12 13
No cartilage
interval
Other metatar- 0 1 2 2 2 3
sophalangeal
joint
interval interval
5 6 7 8 9
No cartilage
interval
Interphalangeal 0 0 1 1 2 2
joints
Asymptomatic Symptomatic
osteochondral osteochondral
lesion lesion 5 mm
3 4 5 6 7
Symptomatic
osteochondral
lesion 5 mm or
multiple lesions
Arthrodesis Do not use Do not use Do not use Do not use

(Joint Ankylosis, with CS X ray with CS X ray with CS X ray with CS X ray
Fusion) malalignment malalignment malalignment malalignment
Pan-talar 50 56 60 64 64
(Tibial-talar, Neutral position
talar-calcaneal,
59 67 75 75 75
talar-navicular)
Malalignment
(continued)
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Chapter 16
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
Arthrodesis Do not use Do not use Do not use Do not use

(Joint Ankylosis, with CS X ray with CS X ray with CS X ray with CS X ray
Fusion) malalignment malalignment malalignment malalignment
Tibial to calca- 37 40 43 46 49 50 56 60 64 64
neal fusion
Neutral Malalignment
(Tibial-talar and
talar-calcaneal)
Ankle 7 8 10 12 13 16 18 20 22 24 26 28 30 32 34 52 56 60 64 68
Neutral position Mild Moderate Severe malalign-
malalignment malalignment ment (plantar
(dorsiflexion (dorsiflexion flexion varus
10–19°, plantar 19°, plantar position >19°,
flexion 10–19°, flexion 20–29°, valgus position
varus position varus position >19°, internal
5–9°, valgus posi- 10–19°, valgus malrotation
tion 5–9°, interposition 10-19°, >29°, or exter-
nal malrotation internal malrota- nal malrotation
0–9°, or external tion 10–29°, or >39°) or infected
malrotation external malrota- non-union
15–19°) tion 20–39°) or
non-union
Subtalar 7 8 10 12 13 16 18 20 22 24 26 28 30 32 34 52 56 60 64 68
Neutral position Mild malalign- Moderate Severe malalign-
(equal to oppo- ment (varus malalignment ment (varus posi-
site normal side) position, 1°–3° (varus position, tion, 6° greater
greater than the 4°–6° greater than the opposite
opposite normal than the opposite normal or valgus
or valgus 5–9° normal or valgus 14° greater)
greater) 10–14° greater)
Double or triple 7 8 10 12 13 14 15 16 17 18 26 28 30 32 34 52 56 60 64 68
arthrodesis
Neutral position Mild malalign- Moderate Severe malalign-
(talar-calcaneal, ment (varus malalignment ment (varus
talar-navicular, position, 1°–3° (varus position, position, 4°–6°
calcaneal- greater than the 4°–6° greater greater than the
cuboid) opposite normal than the opposite opposite normal
or valgus 5–9° of normal or valgus or valgus 10–14°
normal) 10–14° of normal) of normal)
Toes 7 8 10 12 13 14 15 16 17 18
Great toe only Great and minor
toes
0 1 1 2 2
Minor toe
(per toe)
Total ankle 21 23 25 25 25 31 34 37 40 43 59 63 67 71 75
replacement
Good result Fair result (fair Poor result (poor
(good posi- position, mild position, mod-
tion, stable, instability and/ erate to severe
functional) or mild motion instability, and/or
deficit) moderate to
severe motion
deficit)
67 71 75 79 83
Poor result with
chronic infection
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Chapter 16
TA B L E 16 -3 Knee Regional Grid – Lower Extremity Impairments
Knee Regional Grid (LEI)

DIAGNOSTIC
CRITERIA (KEY
CLASS Very severe

DEFINITIONS No problem Mild problem Moderate problem Severe problem problem
IMPAIRMENT
SOFT TISSUE
Bursitis, plica, 0 0 1 1 2 2
h/o contusion,
or other soft
objective sistent palpa-
tissue lesion
abnormal find- tory findings
ings on exami- and/or radiographic
nation or findings
radiographic
1 2 2 2 3
studies at MMI
Consistent motion
deficits
MUSCLE / Do not use with PE

TENDON range of motion
Strain; ten- 0 1 2 2 2 3
donitis; or
No significant Palpatory findings
ruptured
objective and/or radiographic
tendon
abnormal find- findings
ings of muscle
5 6 7 8 9
or tendon
injury at MMI Mild motion deficits
7 8 10 12 13
Moderate motion
nificant weakness
Myositis 0 1 1 2 2
ossificans
Small
(hypertrophic
ossification) 3 4 5 6 7
Large, palpable
mass with decreased
knee motion
LIGAMENT / Do not use with PE Do not use with

BONE / JOINT stability PE stability
Meniscal 1 2 2 2 3 19 20 22 24 25
injury
Partial (medial or lat- Total (medial and
eral) meniscectomy, lateral)
meniscal tear, or
meniscal repair
5 6 7 8 9
Total meniscectomy
(medial or lateral) or
meniscal transplant
(allograft)
7 8 10 12 13
Partial (medial and
lateral)
(continued)
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Chapter 16
TA B L E 16 -3 (C O N TI N U E D) Knee Regional Grid – Lower Extremity Impairments

DIAGNOSTIC
CRITERIA (KEY
CLASS Very severe

IMPAIRMENT
LIGAMENT / Do not use with PE Do not use with PE

BONE / JOINT stability stability
Cruciate or 0 7 8 10 12 13 14 15 16 17 18
collateral liga-
No instability Mild laxity Moderate laxity
ment injury;
Surgery not
rating factor
Cruciate and 0 7 8 10 12 13 19 20 22 24 25 31 34 37 40 43
collateral liga-
No instability Mild laxity Moderate laxity Severe laxity
ment injury;
Surgery not
rating factor
Patellar Lesion Do not use with PE Do not use with PE
stability stability
Patellar sub- 0 5 6 7 8 9 14 15 16 17 18
luxation or
No instability Mild instability Moderate
dislocation
instability
19 20 22 24 25
Severe instability
Patellectomy 5 6 7 8 9 19 20 22 24 25
Partial Total
Fracture Do not use with CS Do not use with Do not use with
x ray alignment CS x ray alignment CS x ray alignment
Femoral shaft 0 5 6 7 8 9 14 15 16 17 18 31 34 37 40 43 52 56 60 64 68
fracture
Non-displaced, Abnormal examina- 10°–19° angulation 20° angulation Non-union and/or
with no signif- tion findings and infected
icant objective 10° angulation
abnormal find-
ings at MMI
Supracondylar 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
or intercondy-
Non-displaced, Non-displaced with 10°–19° angulation 20° angulation Non-union and/or
lar fracture
with no signif- abnormal examina- or 2 mm articu- infected
icant objective tion findings lar surface step off
abnormal find-
7 8 10 12 13
ings at MMI
5°–9° angulation
Patellar 0 5 6 7 8 9 14 15 16 17 18
fracture
Non-displaced, Non-displaced with Displaced with
with no signif- abnormal examina- nonunion
icant objective tion findings
abnormal find-
7 8 10 12 13
ings at MMI
Articular surface dis-
placed 3 mm or less
Tibial plateau 0 3 4 5 6 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
fracture
Non-displaced, Non-displaced with 10°–19° angulation 20° angulation Non-union and/or
with no signif- abnormal examina- or 2 mm articu- or 2 mm articu- infected, or severe
icant objective tion findings lar surface step off lar surface step off comminuted,
abnormal find- displaced
7 8 10 12 13
ings at MMI
9° angulation
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Chapter 16
TA B L E 16 -3 (C O N TI N U E D) Knee Regional Grid – Lower Extremity Impairments
DIAGNOSTIC
CRITERIA (KEY
CLASS Very severe
IMPAIRMENT
Fracture Do not use with CS Do not use with Do not use with
x ray alignment CS x ray alignment CS x ray alignment
Proximal tibial 3 4 5 6 7 14 17 19 21 24 26 28 30 32 34 50 52 54 56 58
shaft fracture 0
Non-displaced with 10°–19° angulation 20° angulation Non-union and/or
Non-displaced, abnormal examina- infected
with no signif- tion findings
icant objective
7 8 10 12 13
abnormal find-
ings at MMI 10° angulation
Arthritis Do not use with CS

x ray arthritis
Primary knee 5 6 7 8 9 16 18 20 22 24 26 28 30 32 34 50 50 50 54 58
joint arthritis
3 mm cartilage 2 mm cartilage 1 mm cartilage No cartilage
interval, full- interval interval interval
thickness articular
cartilage defect,
or ununited osteo-
chondral fracture
Patellofemoral 1 2 3 4 5 14 14 15 16 17
arthritis
Full-thickness articu- 1 mm cartilage
lar cartilage defect interval
or ununited osteo-
16 18 20 22 24
chondral fracture
No cartilage
7 8 10 12 13
interval
2 mm cartilage
interval
Arthrodesis
Arthrodesis 59 63 67 71 75
(joint ankylo-
10°–15° flexion
sis, Fusion)
contracture and
good alignment
67 71 75 79 83
15° flexion or
poor alignment
Osteotomy /
Knee
Replacement
s/p tibial 21 23 25 25 25 31 34 37 40 43
osteotomy
Fair or good result Poor result
(effusion, lim-
ited motion,
instability)
Total knee 21 23 25 25 25 31 34 37 40 43 59 63 67 71 75
replacement
Good result (good Fair result (fair Poor result (poor
position, stable, position, mild position, moder-
functional) instability and/ ate to severe
or mild motion instability, and/or
deficit) moderate to severe
motion deficit)
67 71 75 79 83
Poor result with
chronic infection
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Chapter 16
TA B L E 16 - 4 Hip Regional Grid – Lower Extremity Impairments
Hip Regional Grid (LEI)

DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SOFT TISSUE
Bursitis, h/o con- 0 0 1 1 2 2

tusion, or other
soft tissue lesion
objective abnor- sistent palpatory
mal findings on and/or radio-
examination or graphic findings
radiographic
1 2 2 2 3
studies at MMI
Consistent
motion deficits
5 6 7 8 9
Chronic trochan-
teric bursitis with
documented,
chronically
abnormal gait
Muscle / Tendon
Strain; tendon- 0 0 1 1 2 2
itis; or h/o rup-
No significant Palpatory and/or
tured tendon
objective abnor- radiographic
mal findings of findings
muscle or tendon
1 2 2 2 3
injury at MMI
Mild motion
deficits
3 4 5 6 7
Moderate motion
deficits and/or
significant
weakness
Myositis ossifi- 0 1 1 2 2
cans (hypertro-
Small
phic ossification)
3 4 5 6 7
Large, palpable
mass with
decreased motion
(continued)
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Chapter 16
TA B L E 16 - 4 (C O N TI N U E D) Hip Regional Grid – Lower Extremity Impairments
DIAGNOSTIC
CRITERIA (KEY

No problem Mild problem Severe problem
DEFINITIONS problem problem
IMPAIRMENT
0% LE 1%–13% LE 14%–25% LE 26%–49% LE 50%–100% LE
RANGES
LIGAMENT /
BONE / JOINT
Hip dislocation 3 4 5 6 7 14 15 16 17 18 26 28 30 32 34
Hip dislocation Hip dislocation Hip dislocation,
with relocation with relocation recurrent
and no avascular and avascular
necrosis or joint necrosis
surface injury
7 8 10 12 13
Hip dislocation
with relocation
and findings
of joint surface
injury
Avascular 7 8 10 12 13 14 15 16 17 18 26 28 30 32 34
necrosis
Avascular necrosis Avascular necrosis Avascular necrosis
of hip with mild of hip with mod- of hip with severe
range of motion erate range of range of motion
deficit motion deficit deficit
Acetabular 1 2 2 2 3
labral tear
Unoperated tear,
tear treated with
partial labrec-
tomy or repair
3 4 4 4 5
Tear treated with
total labrectomy
Fracture
Osteochondral 3 4 5 6 7 14 15 16 17 18
fracture
1 cm osteo- 1 cm osteo-
chondral fracture chondral fracture
(arthroscopically (arthroscopically
or MRI verified) or MRI verified)
Osteochondritis 3 4 5 6 7
dissecans
Osteochondritis
dissecans with
stable osteochon-
dral fragment
6 7 8 9 10
Osteochondritis
dissecans with
unstable osteo-
chondral frag-
ment, in situ or
removed
(continued)
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Chapter 16

DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
Fractures about 0 5 6 7 8 9 16 18 20 22 24 26 28 30 32 34 50 50 50 54 58
the hip joint
No significant Femoral neck, Femoral neck, Femoral neck, Infected
(acetabulum and
objective abnor- intertrochanteric, intertrochanteric, intertrochanteric,
proximal femur)
mal findings or subtrochan- or subtrochan- or subtrochan-
teric fracture teric fracture with teric fracture with
with mild motion moderate motion severe motion
deficits and/or deficits and/or deficits and/or
malalignment malalignment malalignment
(malunion)
5 6 7 8 9 14 15 16 17 18
31 34 37 40 43
Nondisplaced Acetabular frac-
acetabular ture with 1–2 mm Acetabular frac-
fracture displacement of ture with 5 mm
articular surface displacement of
7 8 10 12 13
articular surface
19 20 22 24 25
Fracture of
greater or lesser Acetabular frac-
trochanter with ture with 3–4 mm
non-union or displacement of
malunion articular surface
Arthritis
(Arthrosis)
Degenerative 0 1 2 2 2 3
conditions
Unrelated and Loose bodies
symmetrical with accompany-
ing symptoms
but not physical
findings
3 4 5 6 7
Loose bodies with
accompanying
symptoms and
abnormal physi-
cal findings
Hip arthritis 5 6 7 8 9 16 18 20 22 24 26 28 30 32 34 50 50 50 54 58
(arthrosis)
3 mm cartilage 2 mm cartilage 1 mm cartilage No cartilage
interval or full- interval interval interval
thickness articular
cartilage defect
Arthrodesis
Hip Joint 50 50 50 54 58
arthrodesis
Fused in 25–40°
(ankylosis,
flexion and neu-
fusion)
tral rotation,
adduction and
abduction
67 71 75 79 83
Moderate
malposition
80 85 90 95 100
Severe
malposition
(continued)
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Chapter 16
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
Osteotomy /
Joint
Replacement
s/p Femoral 19 20 22 24 25 31 34 37 40 43
osteotomy
Fair or good Poor result
result (effusion, lim-
ited motion,
instability)
Partial or total 21 23 25 25 25 31 34 37 40 43 59 63 67 71 75
hip replacement
Good result Fair result (fair Poor result (poor
(good posi- position, mild position, mod-
tion, stable, instability and/ erate to severe
functional) or mild motion instability, and/or
deficit) moderate to
severe motion
deficit)
67 71 75 79 83
Poor result with
chronic infection
permits modification of the default value, grade C,

16.3Adjustment Grid and Grade up or down within a given class adjustment. When
Modifiers—Non-Key Factors determining the grade modifier, assess each of
the components of the adjustment (eg, soft tissue
The adjustment grids, as described in the introduc- findings, stability, and alignment, etc) and use the
tion, are used to assign a grade within the class highest class modifier as the value for that adjust-
defined by the regional grid. The grade for a given ment in the net adjustment calculation. For example,
class is determined by considering functional his- on physical examination, soft tissue findings may
tory, physical examination findings and the results of be characterized as grade modifier 0 and stability
relevant clinical studies (See Table 16-5). findings may be grade modifier 2. The class modi-
fier for physical examination would then be grade
The grade modifiers associated with functional
modifier 2, because it is the higher of the 2 grades.
history, physical examination and clinical stud-
If a grade modifier, or non-key factor, was used for
ies will be used to calculate a net adjustment, that
TA B L E 16 - 5
Specific
Adjustment Grade Grade Grade Grade Grade
Grid Modifier 0 Modifier 1 Modifier 2 Modifier 3 Modifier 4
FUNCTIONAL Table 16-6 No problem Mild problem Moderate Severe problem Very severe
HISTORY problem problem
PHYSICAL Table 16-7 No problem Mild problem Moderate Severe problem Very severe
EXAMINATION problem problem
CLINICAL Table 16-8 No problem Mild problem Moderate Severe problem Very severe
STUDIES problem problem
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Chapter 16
primary placement in the regional grid, it may not impairment (DBI) or not considered at all as a
be used again in the impairment calculation. For grade modifier.
example, if a diagnostic class was determined using
The need for assistive devices is based on objective
range of motion as a factor, then range of motion is
medical reasons and not for pain or alleged inse-
not considered again when determining the physical
curity. The evaluating physician may use outcome
examination adjustment factor. The non-key factors
instruments and inventories as part of the process
must be consistent, reliable and associated with the
of evaluating functional symptoms. Further infor-
diagnosis.
mation on inventories for the lower extremity is
If any of these factors are determined by the exam- provided on the Web site of the American Academy
iner to be unreliable or inconsistent, they should be of Orthopedic Surgeons. Inventories must be widely
disregarded in the grading adjustment. The examiner accepted and have documented reliability and valid-
should explain in the evaluation report the basis for ity. The American Academy of Orthopaedic Surgery
grade assignment or discounting of a specific adjust- Lower Limb Instrument is 1 inventory that may be
ment for lack of reliability. used; information and scoring is provided at the
AAOS Web site. An inventory is used only to assist
16.3a Adjustment Grid— the examiner in defining the grade for functional
Functional History history and does not serve as a basis for defining fur-
Grade assignment for functional symptoms is ther impairment nor does the score reflect an impair-
based on subjective reports that are attributable ment percentage (see Table 16-6).
to the impairment. Grading is based on the extent
The examiner must assess the reliability of the func-
to which functional symptoms interfere with dif-
tional reports recognizing the potential influence of
ferent levels of activities, as summarized in Table
behavioral and psychosocial factors. Therefore, the
16-6, Functional History Adjustment. As explained
examiner must use appropriate clinical judgment in
in Section 1.8e History of Clinical Presentation,
interpreting subjective reports. Gait abnormalities
in general, individuals with no symptoms will be
must be observed and consistent. If the grade for
assigned grade modifier 0, and those who are non-
functional history differs by 2 or more grades from
ambulatory will be assigned grade modifier 4.
that defined by physical examination or clinical stud-
Functional history grade modifier should be ies the functional history should be assumed to be
applied only to the single, highest diagnosis-based unreliable. If the functional history is determined to
impairment (DBI). Specific jurisdictions may be unreliable or inconsistent with other documenta-
modify this process such that functional history tion, it is excluded from the grading process.
adjustment is considered for each diagnosis-based
TA B L E 16 - 6
Functional History Adjustment – Lower Extremities
Grade Grade Grade Grade Grade
Modifier 0 Modifier 1 Modifier 2 Modifier 3 Modifier 4
CLASS DEFINITIONS No Mild problem Moderate problem Severe problem Very severe
problem problem
GAIT DERANGEMENT None Antalgic limp Antalgic limp (in the Antalgic/unsta- Nonambulatory
with asym- presence of objectively ble transfers
metric short- defined significant and ambulation
ened stance, pathology) with asymmet- requires rou-
corrects with ric shortened stance; sta- tine use of gait
footwear modi- ble with use of external aids (2 canes
fications and/or orthotic device (eg, ankle- or crutches) or
orthotics foot orthosis), routine use KAFO bracea
of single gait aid (cane
or crutch), or positive
Trendelenburg test
AAOS LOWER LIMB Normal Mild deficit Moderate deficit Severe deficit Near-total to
INSTRUMENT (OR total deficit
OTHER INVENTORY)
a
KAFO indicates knee, ankle, foot orthosis; AAOS, American Academy of Orthopaedic Surgeons.
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Chapter 16
16.3b Adjustment Grid—Physical the grading process. The physician must explain, in
Examination the report, the rationale for the choice of grade.
When performing a physical examination, the cli-
Table 16-7, Physical Examination Adjustment, sum-
nician needs to determine the significance of the
marizes the grading process. Specific parameters are
findings related to the impairment being evaluated.
provided in the adjustment grid for the appropriate
For the purposes of this evaluation, greater weight is
region.
given to those findings that are more objective. Some
parameters described in the adjustment grid may be Stability, alignment and deformity are determined
region-specific. clinically and/or on the basis of radiographic studies;
specific parameters may vary by region.
If multiple diagnoses are rated, the examiner should
determine the appropriate impairment class for each Range of motion is graded according to the process
diagnosis, and the examiner must distinguish which and the criteria specified in Section 16.7. Lower
physical examination findings are associated with extremity impairment can be evaluated by assessing
each specific ratable condition. If a physical finding, the range of motion of its joints, recognizing that
for example, range of motion, has been used to deter- pain and motivation may affect the measurements.
mine class placement, that specific finding should If it is clear to the evaluator that a restricted range of
not be used to select a grade modifier. If physical motion has an organic basis, 3 measurements should
examination findings are determined to be unreliable be obtained and the greatest range measured should
or inconsistent, or they are for conditions unrelated be used for the determination of impairment. If mul-
to the condition being rated, they are excluded from tiple previous evaluations have been documented,
TA B L E 16 -7
Physical Examination Adjustment – Lower Extremities
CLASS DEFINITIONS No Mild problem Moderate problem Severe problem Very severe
problem problem
OBSERVED AND No Minimal palpa- Moderate palpatory Severe palpatory Very severe pal-
PALPATORY consistent tory findings, findings, consistently findings, con- patory findings,
FINDINGS findings consistently documented, and sup- sistently docu- consistently
(tenderness, swell- documented, ported by observed mented, and documented,
ing, mass, or without abnormalities supported by and supported
crepitance) observed abnor- observed moder- by observed
malities ate or greater severe
abnormalities abnormalities
STABILITY Stable Grade 1 (slight) Grade 2 (moderate) Grade 3 (serious) Gross instability
instability instability instability
KNEE Grade 1 Grade 2 Lachman’s test; Grade 3 Multi-

Lachman’s moderate laxity patellar Lachman’s directional
test; slight mechanism test; severe instability
laxity patellar laxity patellar
mechanism mechanism
ALIGNMENT/ Normal for Mild Moderate Severe Very severe

DEFORMITY individual
with sym-
metry to
opposite
side
RANGE OF MOTION None Mild or arthrod- Moderate Severe Very severe

(reference Section esis in position
16.7) of function
MUSCLE ATROPHY 1 cm 1.0–1.9 cm 2.0–2.9 cm 3.0–3.9cm 4.0 cm

(asymmetry compared
to opposite normal)
LIMB LENGTH 1.9 cm 2.0–2.9 cm 3–4.9 cm 5.0–5.9 cm 6.0 cm

DISCREPANCY
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Chapter 16
and there is inconsistency in a rating class between parallel to the joint surface. Evaluation of the foot
the findings of 2 observers, or in the findings on joints requires a lateral view for the hindfoot and an
separate occasions by the same observer, the results anteroposterior view for the midfoot and forefoot. An
are considered invalid. Range of motion restrictions oblique view taken with internal rotation will assist
in multiple directions do increase the impairment. in viewing the metatarsal and metatarsophalangeal
The total values for the foot/ankle, knee, or hip are joints. The ankle X ray must be taken in a mortise
compared to the criteria in Section 16-7, Range of view, which is 10° internal rotation; 10° flexion or
Motion Impairment, to define the range of motion extension is permissible. The estimate for the patel-
grade modifier. Range of motion impairment is not lofemoral joint is based on a “sunrise view” taken
combined with the diagnosed-based impairment. at 40° flexion or on a true lateral view. In the case
of the knee, the joint should ideally be in neutral
The evaluation of neurologic deficits is explained in
flexion-extension position (0°) to evaluate the X
Section 16.4, Peripheral Nerve Impairments.
rays. Impairments of individuals with knee flexion
For muscle atrophy, the limb circumference should contractures should not be estimated using X rays
be measured and compared to the opposite limb at because measurements are unreliable. X rays of the
equal distances from either the joint line or another hip joint are taken in the neutral position. The carti-
palpable anatomic structure. For example, thigh lage interval (joint space) of the hip is relatively con-
circumference may be measured 10 cm above the stant in the various positions; therefore, positioning is
patella and compared a similar measure on the other not as critical as for the knee X rays (see Table 16-8).
thigh. Calf circumference is compared at the level
of maximum circumference bilaterally. Neither limb
should have swelling or varicosities that would inval-
tion, training, and experience in these procedures.
idate the measurements.
Typically, these studies are performed by board
To determine limb length discrepancy, place the indi- certified neurologists and physical medicine special-
vidual supine on the examination table with the legs in ists. Some jurisdictions allow others to perform such
the same position. Measure the distance between the studies. The studies must be performed in accor-
anterior superior iliac spine and the medial malleolus dance with established standards.
on the involved side, and compare it with the opposite
side. Teleroentgenography is recommended. If surface 16.3d Impairment Calculation
measurements with a tape measure from the anterior Methodology
superior iliac spine to medial malleolus are used, they As described in the preceding parts of this chapter,
should be repeated 3 times and averaged to reduce impairment is calculated by identifying an impair-
measurement error. ment class that reflects the diagnosis, and a grade
that considers functional, physical and clinical
16.3c Adjustment Grid—Clinical Studies facets of the condition. The impairment class (IC)
The patient may have undergone a variety of special is determined first, by using the corresponding
tests including imaging studies and electromyographic diagnosis-based regional grid. The grades are then
studies. The physician should review these studies, determined using the adjustment grids.
and note their interpretations. Whenever possible, the
Each regional grid provides a range of impairment
physician should personally review the studies and
values for each specific diagnosis. Each cell within
report agreement or disagreement with previous inter-
a regional grid contains a range of impairment
pretations. Studies must be reliable and pertinent. For
values, represented by a series of 5 numbers that
adjustment purposes, findings at MMI are used.
correspond to grades A- E. Once the impairment
Imaging studies are used to grade arthritis. Cartilage class is determined according to diagnostic crite-
interval or joint space is the best roentgenographic ria, the final impairment grade within a particular
indicator of disease stage and impairment for a class is determined by the non-key factors, or grade
person with arthritis of the lower extremity. The modifiers, identified in the adjustment grids. The
hallmark of all types of arthritis is thinning of the first grade (A) is the lowest impairment rating that
articular cartilage; this correlates well with disease could be assigned for the class; the last grade (E) is
progression. The impairment estimates in a person the highest. For most impairment rating scenarios,
with arthritis of the lower extremity are based on the middle grade (C) and the correlating numeri-
standard X rays taken with the individual standing, cal impairment value in that class will serve as the
if possible. The ideal film-to-camera distance is 90 default impairment value, which is adjusted to reflect
cm (36 in), and the beam should be at the level of and the non-key factors.
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Chapter 16
TA B L E 16 - 8
Clinical Studies Adjustment – Lower Extremities a
CLASS No Mild problem Moderate problem Severe problem Very severe

DEFINITIONS problem problem
IMAGING No avail- Clinical studies con- Clinical studies Clinical studies Clinical studies con-
STUDIES able clinical firm diagnosis; mild confirm diag- confirm diagnosis; firm diagnosis; very
studies or pathology nosis; moderate severe pathology severe pathology
relevant pathology
findings
X RAYS
ARTHRITIS Cartilage interval Cartilage interval Cartilage interval No cartilage inter-

normal or less than present; however, present; however, val; radiographic
Note: Do not
25% loss compared 25% to 50% loss 50% lost com- evidence of severe
use when
to opposite unin- compared to oppo- pared to opposite posttraumatic
X-ray carti-
jured side; cystic site uninjured side; uninjured side; arthrosis or avascu-
lage interval
changes on 1 side cystic changes on radiographic evi- lar necrosis
is used in
of joint; loose body both sides of joint; dence of moder-
diagnostic
5 mm loose body 5 mm or ate posttraumatic
impairment
greater or multiple arthrosis or avascu-
definition
loose bodies; radio- lar necrosis
graphic evidence of
mild posttraumatic
arthrosis or avascu-
lar necrosis
STABILITY AP stress radio- AP stress radio- AP stress radio-

Foot/Ankle graph: 2- to 3-mm graph: 4- to 6-mm graphs: 6-mm
excess opening or excess translation excess translation or
Note: Do not
5°–9° varus opening or 10–15° varus 15° varus opening
use when
compared to normal opening compared compared to normal
X-ray stress
opposite side to normal opposite opposite side
opening
side
is used in Lateral stress radio-
diagnostic Lateral stress radiograph: anterior
impairment graph: anterior drawer 6-mm
definition drawer 4- to 6-mm excess translation
excess translation compared to nor-
compared to normal mal side
side
ALIGNMENT Syndesmosis nor- Syndesmosis laxity Healed, angular or Severe multiplanar

Foot/Ankle mal; healed angula- with separation rotational defor- deformity
tion or rotational demonstrated mity 15° in any
Note: Do not
deformity 5° in on foot external plane
use when
any plane rotation AP ankle
X-ray angula-
radiograph com-
tion is used
pared to opposite
in diagnostic
normal ankle
impairment
definition Healed, angular or
rotational defor-
mity 5°–15° in any
plane
KNEE 10° angulation/ 10°–20° angulation/ 20° angulation/ Severe multiplanar

rotational defor- rotational defor- rotational defor- deformity
Note: Do not
mity single plane mity single plane mity 1–2 planes
use when
X-ray angula-
tion is used
in diagnostic
impairment
definition
(continued)
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Chapter 16
TA B L E 16 - 8 (C O N TI N U E D) Clinical Studies Adjustment – Lower Extremities

HIP Femoral osteotomy Femoral osteotomy
in good position in suboptimal
Note: Do not
position
use when
X-ray angula-
tion is used
in diagnostic
impairment
definition
NERVE Normal Conduction Delay Motor Conduction Partial Axonal Loss Total Axonal
CONDUCTION (sensory and/or Block Loss/Denervation
TESTING motor)
ELECTRO-DIAG- Normal Needle EMG done Needle EMG done Needle EMG done Needle EMG done
NOSTIC (EMG) at least 3 weeks but at least 3 weeks but at least 3 weeks but at least 3 weeks but
TESTING less than 9 months less than 9 months less than 9 months less than 9 months
Note: If the after injury shows after injury shows after injury shows after injury shows
test results at least 1 fibrilla- at least 2 fibrilla- at least 3 fibrilla- at least 4 fibrilla-
meet some of, tion potentials and tion potentials and tion potentials and tion potentials and
but not all of positive waves in positive waves in positive waves in positive waves in
the criteria for at least 2 muscles at least 2 muscles at least 3 muscles at least 3 muscles
a specific class, innervated by the innervated by the innervated by the innervated by the
the next lower injured nerve. If injured nerve. If injured nerve. If injured nerve. If
class is the class the EMG study is the EMG study is the EMG study is the EMG study is
to be used first done more first done more first done more first done more
in rating the than 9 months post- than 9 months post- than 9 months post- than 9 months post-
impairment injury, the exam injury, the exam injury, the exam injury, the exam
shows high ampli- shows high ampli- shows high ampli- shows no motor
tude polyphasic tude polyphasic tude polyphasic units (fibrofatty
muscle potentials muscle potentials muscle potentials replacement of
in at least 1 muscle in at least 2 muscles in at least 3 muscles muscle) in at least
and recruitment and recruitment in and recruitment 2 muscles.
in that muscle those muscles is at in those muscles is
is at least mildly least moderately severely decreased.
reduced. decreased.
DIAGNOSTIC
CRITERIA (KEY
IMPAIRMENT
RANGES a 0% LE 1%–13% LE 14%–25% LE 26%–49% LE 50%–100% LE
EXAMPLE 3 4 5 6 7 16 18 20 22 24 26 28 30 32 34 50 52 54 56 58
RATING

a
LE indicates lower extremity.
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Chapter 16
Once the class is determined, the grade is initially from the numerical value of the grade modifier
assigned to the default impairment (C) rating. for each component (functional history, physical
This initial default value may be modified up or examination and clinical studies) and add those
down within a class by calculating a net adjust- values. That net adjustment value will determine
ment, based upon the grade modifiers. Using the how many places up or down from the default
Net Adjustment Formula, the assigned value for value “C’ the rating should move and the corre-
each grade modifier (0 to 4) is compared with the sponding numerical value for the impairment.
number of the impairment class (0 to 4) using the
Net Adjustment Formula, described in the box
entitled: Net Adjustment Formula: Mathematical Net Adjustment Formula: Mathematical
Explanation. The net adjustment value is used to Explanation
move up a grade ( net adjustment value) or down a
Net adjustment may be obtained by a mathemati-
grade ( net adjustment value) within a class. If all
cal formula and then use of the resultant value to
of the grade modifier numbers are the same as the
define the grade. The following abbreviations are
impairment class number, the net adjustment will be
used:
0 and the default value (C) will be the impairment
rating value for that diagnosis. Grade adjustments do CDX Class of Diagnosis (Regional Grid)
not permit a change in class, regardless of the mag- GMFH Grade Modifier for Functional History
nitude of the net adjustment. GMPE Grade Modifier for Physical
Examination
Method
GMCS Grade Modifier for Clinical Studies
1. Determine the class first, using the relevant
regional grid, by choosing the appropriate
diagnosis for the condition in the left-most col-
umn. Select the class for that diagnosis based Grade Assignments
on the criteria specified in the columns for
Net Adjustment Grade
classes 0 to 4.
(from default C)
2. Using the adjustment grids for functional history,
2
physical examination and clinical studies, iden-
1
tify the appropriate grade for each, using grade

0 C
modifiers:
1 D
a. If there are multiple components to a grade 2 E
modifier, such as physical examination (which
For example, if the diagnosis is in impairment
may include palpatory findings, alignment,
class 2, then CDX 2. If net adjustment value is
instability), choose the most objective grade
2, then the Grade is A.
modifier with the highest value, associated
with the diagnosis being rated. If a grade
modifier is found to be unreliable or inconsis-
tent, it should be disregarded and eliminated To further illustrate this process, if the key factor
from the calculation. identifies class 3, and non-key factors identify grade
modifier 1 and grade modifier 4 with the third non-
b. If a particular criterion such as range of
key factor determined to be unreliable, this would
motion was used to determine impairment
produce differences of 2 (1 3) and 1 (4 3),
respectively. These (2 1) add to a net adjustment
the grade and is disregarded in the impair-
of 1, moving the rating to 1 lower grade within that
ment calculation.
class (ie, 1 position to the left) and the correspond-
c. Functional history grade modifier should ing impairment percentage. In this example, if the
be applied only to the highest diagnosed- non-key factors both identified grade modifier 1 the
based impairment. Specific jurisdictions may differences would total 4 [net adjustment (13)
modify this process such that functional his- (13) 4]. Since this procedure does not allow
tory adjustment is considered for each diag- jumping from 1 class to a lower (or higher) class, the
nosed-based impairment or not considered at rating would move to the lowest grade within a class.
all as a grade modifier. In this example, if all non-key factors identified grade
3 you would remain at the default mid position.
3. Applying the Net Adjustment Formula, as shown
in the box, calculate the net adjustment value by As explained in other chapters, a modification of
subtracting the numerical value of the class (CDX) this process is required for class 4 impairments;
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Chapter 16
these impairments are uncommon. If the key fac- Physical Exam: He displays antalgic gait in the
tor is class 4, and both non-key factors were grade examination room, however on leaving the office his
modifier 4, the differences would summate to zero, gait appeared normal. He reported severe tenderness
and placement in a grade above the default value C on palpation of the dorsum of his right foot; however
in class 4 would not be possible. In order to correct there were no objective findings. There were no find-
this deficiency, if the key factor is class 4, automati- ings to support a diagnosis of CRPS.
cally add 1 to the value of each non-key factor.
Clinical Studies: X rays of the right foot were
For example, if the key factor is class 4, and the first
normal.
non-key factor was grade 3, the second was grade 4,
the differences are 1 and zero. Adding 1 to each Diagnosis: h/o contusion right foot with ongoing
of these yields zero and 1; this summates to 1. pain complaints unsupported by objective findings.
Consequently, the final class 4 and the final impair-
Comment: There are no objective findings clini-
ment is class 4 grade D.
cally or radiographically of an ongoing physical
problem. His subjective complaints are not sup-
Example: Meniscectomy ported and the gait inconsistency suggests significant
behavioral overlay or the potential of purposeful
The use of the adjustment process can be illus-
misrepresentation.
trated by the rating of a partial medial meniscec-
tomy. According to the knee regional grid, this Impairment Rating: Regional impairment:
results in class 1 impairment. If on the basis of Diagnosis: “contusion, resolved” and per criteria of
the use of the adjustment table, it was determined “soft tissue” and “contusion/crush injury” assigned
that the non-key factors were normal functional to class 0 with 0% lower extremity impairment. With
history, unremarkable examination (grade modi- class 0 adjustment is not required, however the physi-
fier 0), and MRI study that confirmed the meniscal examination and clinical studies also support class
cal tear (grade modifier 1), the net adjustment is 0. The functional history was determined to be unreli-
calculated NA GMPE CDX GMCS able. Regional impairment: 0% LEI or 0% WPI.
CDX or (01) (0 1) (1 1) 2, and
moves the grade within the class 2 positions to
the left of the default value (1% lower extremity).
For this diagnosis, it would remain at 1% lower CLASS 1
extremity. 1% to 13% Impairment of the Lower Extremity
16.3e Lower Extremity Examples EXAMPLE 16-2: PLANTAR FASCIITIS
Foot and Ankle Impairment Examples (see Subject: 45-year-old woman.

Table 16-2, Foot and Ankle Regional Grid)
History: Has developed the new onset of plantar fas-
ciitis of the right heel after 6 months on her new job
that requires standing on her feet all day on a con-
CLASS 0 crete floor. She is 160 cm (5 ft 4 in) tall and weighs
0% Impairment of the Lower Extremity 45 kg (100 lb). She wears a comfortable shoe, is not
athletic, does not attend a gym or jog, denies hob-
bies, is in excellent health and takes no medication.
EXAMPLE 16-1: CONTUSION
She reports that she is currently unable to work at
Subject: 25-year-old man. her usual job because of her chronic heel pain, which
persists in spite of 6 months off. She is able to walk
History: Dropped a concrete block on his right
10 blocks, although she is symptomatic. Her pain is
foot. X rays revealed no fracture and he was treated
worse in the morning when she first gets out of bed.
conservatively for a “contusion.” He continued to
She uses a cushioned heel insert. She has failed non-
have complaints of severe pain and was diagnosed
operative treatment and does not want surgery.
by a consultant physician as having reflex sympa-
thetic dystrophy. The patient declined recommended Physical Exam: Severe focal tenderness over the
treatment. medial calcaneal tuberosity of the right foot where the
plantar fascia inserts. Negative percussion sign over
Current Symptoms: One year later he is being seen
the posterior tibial nerve and no tenderness over the
for an impairment evaluation reporting that he has
medial heel. She has no atrophy and her motor strength
severe right foot pain (averaging 9 on scale of 0 to
10) and significant difficulty walking and standing.
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Chapter 16
is normal. Her range of motion is equal and normal EXAMPLE 16-3: ANKLE INSTABILITY
bilaterally, including 20° of ankle dorsiflexion. She
Subject: 22-year-old male.
does not use a walking aid. She has a mild limp.
History: Twisted his left ankle and had recurrent
Clinical Studies: Labs normal. On lateral radio-
problems with it feeling “weak”. His physician diag-
graph there is a 3-mm plantar heel spur. An MRI
nosed a tear of the anterior talofibular ligament and
demonstrates inflammatory changes and thickening
recommended conservative therapy. He reported
of the plantar fascia of 4-mm.
difficulties walking on uneven surfaces and was cau-
Diagnosis: Plantar fasciitis with objective chronic tious. He is evaluated 1 year later.
changes on MRI.
Physical Exam: He reports mild tenderness over the
Comment: She has reached MMI and is ratable. In anterior talofibular ligament, and there appears to be
general, absent systemic disease, there are 3 estab- mild laxity. Motion and muscle evaluation is normal.
lished predisposing factors for plantar fasciitis: BMI
Clinical Studies: Stress X rays reveal 3-mm excess
25, ankle dorsiflexion 10°, and standing for the
opening on the left compared with the right.
majority of the work day. This woman has no medical
problems, is of normal BMI, and has ankle dorsiflex- Diagnosis: Ligamentous instability of the anterior
ion 10°. Patients with chronic plantar fasciitis will talofibular ligament mild.
invariably demonstrate changes on MRI, with thicken-
Impairment Rating: Regional impairments:
ing of the plantar fascia which is normally 2 to 3 mm.
Diagnosis: “ligamentous instability” and per criteria of
Impairment Rating: Regional impairment: “mild instability on stress X rays (2–3 mm excess open-
Diagnosis: “plantar fasciitis” and per criteria of ing)” assigned to class 1 with midrange default value of
“significant consistent palpatory findings and/or 5% LEI. Adjustment grids: Functional history: Grade
radiographic findings” assigned to class 1 with mid- modifier 1; Physical exam: grade 1, either by tenderness
range default value of 1% LEI. Adjustment grids: or by instability; Clinical studies: not applicable, used
Functional history: Grade modifier 1 (“functional in class assignment. Net adjustment compared to diag-
difficulties, such as significant limp, that occurs only nostic class is 0, remains grade C. Therefore remains at
with strenuous activity, routine use of orthotic inserts the default of 5% LEI or 2% WPI.
and/or occasional use of a cane”); Physical examina-
tion: Grade modifier 1 (“minimal palpatory findings,
consistently documented, without observed abnor-
malities”); Clinical studies: Grade modifier 1 (MRI CLASS 2
confirms diagnosis and provide no additional infor- 14% to 25% Impairment of the Lower Extremity
mation). All adjustments consistent with the assigned
class for the diagnosis. Net adjustment compared
EXAMPLE 16- 4: BIMALLEOLAR FRACTURE
to diagnostic class is 0, remains grade C. Regional
impairment: 1% LEI or 1% WPI. Subject: 38-year-old woman.
History: Fell from a ladder injuring her left ankle.
Class 1 Example Calculation X rays revealed a bimalleolar fracture which was
CDX GMFH GMPE GMCS treated conservatively. Subsequent X rays docu-
1 1 1 1 mented healing and 1 year later she was seen for
Net adjustment permanent impairment assessment. She reports an
occasional limp, particularly after walking more
(GMFH CDX) (1 1) 0
than a few blocks.
(GMPE CDX) (1 1) 0
(GMCS CDX) (1 1) 0 Physical Exam: Remarkable for reduced range of
motion with plantar flexion of 5° and extension of
Net adjustment 0
5°. Strength of plantar flexion was diminished at 4/5
Result is class 1 adjustment 0 which equals class 1 with calf atrophy of 1 cm.
default grade C 1%
Clinical Studies: X rays confirmed fracture of distal
CDX Class of diagnosis tibia and fibula with subsequent healing, without
GMFH Grade modifier for functional history deformity.
GMPE Grade modifier for physical examination
Diagnosis: Bimalleolar fracture, healed, with mod-
GMCS Grade modifier for clinical studies
erate motion deficits.
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Chapter 16
Comment: The impairment is based on regional CLASS 3

impairment diagnosis, however first the classifi- 26% to 49% Impairment of the Lower Extremity
cation for the range of motion deficit is required.
Range of motion deficits consistent with “moderate”
EXAMPLE 16-5: ANKLE ARTHRITIS
deficit. The range of motion findings per Section
16.7, Range of Motion Impairment, were consistent Subject: 60-year-old man.
with class 2 classification. Per Table 16-22, Ankle
History: Evaluated for right ankle arthritis which is
Motion Impairments – Lower Extremity Impairment,
attributed to prior trauma. He reported significant
the findings of plantar flexion 5° resulted in a clas-
problems with pain and a limp occurring with walk-
sification of a moderate deficit (15% LEI) and
ing. He often made use of a cane.
extension of 5° resulted in findings of mild deficit
(7% LEI). This results in 22% LEI, and per Table Physical Exam: Remarkable for reduced range of
16-25, Range of Motion, a class modifier 2, and thus motion with plantar flexion of 10° and extension
per Table 16-7, physical examination adjustment of of 10°. He reports diffuse tenderness on movement
class 2 modifier. The finding of atrophy of 1 cm are of the ankle. Diffuse 4/5 weakness about the ankle,
consistent with a class modifier 1. The greater (ie, however this also appears to relate to difficulties
higher) class modifier is selected, thus per Table 16- with pain. 2.0 cm atrophy of right calf compared to
7, class modifier 2. the left.
Impairment Rating: Regional impairment: Clinical Studies: X rays reveal total loss of the ankle
Diagnosis: “fracture/dislocation”and “ankle” and per joint space interval on the right with a normal 4 mm
criteria of “moderate to severe motion deficits and/or joint space interval on the left.
moderate malalignment” assigned to class 2 with
Diagnosis: Ankle arthritis
midrange default value of 22% LEI. Adjustment grids:
Functional history: Grade modifier 1 (“functional Impairment Rating: Regional impairment:
difficulties, such as significant limp, that occurs only Diagnosis: “arthritis” and per criteria of “no car-
with strenuous activity, routine use of orthotic inserts tilage interval” assigned to class 3 with midrange
and/or occasional use of a cane”); Physical examina- default value of 30% LEI. Adjustment grids:
tion: Grade modifier 2 “moderate to severe motion Functional history: Grade modifier 2 (“functional
deficits and/or moderate malalignment”); Clinical difficulties, such as significant limp, that occurs
studies: Grade modifier 2 (clinical studies confirm with normal activity, regular use of cane; and/or
diagnosis, moderate pathology “). Numerical adjust- occasional use of crutches or a walker”); Physical
ment: 1. Moved 1 position to the left (grade B). examination: Grade modifier 2, range of motion
Regional impairment: 20% LEI or 8% WPI. findings consistent with moderate motion deficits
and/or moderate malalignment, refer to Table 16-22,
Class 2 Example Calculation Ankle Motion Impairments and Table 16-25, Range
CDX GMFH GMPE GMCS of Motion; Clinical Studies: Unable to use since
2 1 2 2 used in defining the diagnosed-based impairment;
Numerical adjustment: 2. Grade A. Regional
(1 2) 1 impairment: 26% LEI or 10% WPI.
(2 2) 0
(2 2) 0
Class 3 Example Calculation
Net adjustment 1
CDX GMFH GMPE GMCS
Adjustment of 1 equals 1 position to the left of
default grade C resulting in grade B 3 2 2 n/a
Class 2, grade B 20% (2 3) 1

(2 3) 1
(n/a 3) n/a
Net adjustment 2
Adjustment of 2 equals 2 positions to the left of
default grade C resulting in grade A
Class 3, grade A 26% LEI
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Chapter 16
CLASS 4 Knee Impairment Examples (see Table 16-3,
50% to 100% Impairment of the Lower Extremity Knee Regional Grid)
EXAMPLE 16-6: S/P TOTAL ANKLE

REPLACEMENT WITH POOR RESULT CLASS 0
0% Impairment of the Lower Extremity
History: Underwent a total ankle replacement and
EXAMPLE 16-7: KNEE STRAIN
when evaluated 1 year later reports disappointment
with the surgical result. She reports minimal activity Subject: 35-year-old man.
and regular use of a cane.
History: Twisted his knee and was diagnosed as
Physical Exam: Reduced range of motion with plan- having a “knee strain”. He was treated conservatively
tar flexion of 10° and extension of 10°. She reports by his primary care physician, however continued
diffuse tenderness on movement of the ankle. She to complain of difficulties. He was evaluated by an
has diffuse 4/5 weakness about the ankle, however orthopedic surgeon who reported a normal examina-
this also appears to relate to difficulties with pain. tion. Due to ongoing complaints, an MRI was per-
She has 3.5 cm atrophy of her right calf compared formed; the MRI was unremarkable. One year later
with the left. The ankle is stable without deformity. he reports continued problems with discomfort in his
knee and a sense that it gives way.
Clinical Studies: X rays show ankle replacement
in good position, but heterotopic bone which limits Physical Exam: Normal, including gait, palpation,
ankle motion. motion, stability, and strength.
Diagnosis: s/p total ankle replacement. Clinical Studies: MRI was normal.
Comment: For ankle replacement the class is Diagnosis: h/o knee strain, resolved.
determined by findings of position (good), stabil-
Impairment Rating: Regional impairment:
ity (normal), and range of motion (moderately
Diagnosis: Category “muscle/tendon,” “strain” and
reduced), which results in a poor result, and a class 4
per criteria of “no significant objective abnormal find-
assignment.
ings of muscle or tendon injury at MMI” assigned to
Impairment Rating: Class 4 results in a midrange class 0 with 0% lower extremity impairment. With
default impairment value of 67% LEI. Since class class 0, adjustment is not required; however, the physi-
4 is being used, each adjustment is increased by +1. cal examination and clinical studies also support class
Adjustments: Functional history; regular use of a cane 0. The functional history was determined to be unreli-
is grade 2, which is increased to grade 3. Physical able. Regional impairment: 0% LEI or 0% WPI.
exam: Range of motion is the same as in Example 16-5,
but was used in class placement. Calf atrophy is grade
2, which is increased to grade 3. Clinical studies:
X ray at MMI showing heterotopic bone limiting motion CLASS 1
is grade 3, which is increased to grade 4. Numerical 1% to 13% Impairment of the Lower Extremity
adjustment: –2. Moved 2 positions to the left (grade A).
Regional impairment: 59% LEI or 24% WPI.
EXAMPLE 16-8: MENISCAL TEAR
Class 4 Example Calculation Subject: 45-year-old man.
CDX GMFH GMPE GMCS
History: Sustained twisting injury to left knee result-
4 3 3 4
ing in pain and swelling. MRI 1 month post injury
(3 4) 1 confirmed a medial meniscal tear. He declined sur-
(3 4) 1 gery and was treated conservatively. Six months later
(4 4) 0 he denied any symptoms or functional limitations.
Net adjustment 2
default grade C resulting in grade A Clinical Studies: MRI showed medial meniscal tear,
Class 4, grade A 59% and mild patellofemoral chondromalacia.
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Chapter 16
Diagnosis: Medial meniscal tear, treated conserva- instability diagnosis was chosen, and the effect of the
tively, asymptomatic. meniscal tear is reflected in the adjustments.
Impairment Rating: Regional impairment: Impairment Rating: Diagnosis: “cruciate or col-
Diagnosis: “meniscal injury” and per criteria of “par- lateral ligament injury” with mild instability assigned
tial (medial or lateral) meniscectomy, meniscal tear, to class 1 with a default value of 10% LEI. Functional
or meniscal repair” assigned to class 1 with mid-range history judged unreliable in the presence of only mild
default value of 2% LEI. Adjustment grids: Functional instability and no atrophy, and thus not used in rating.
history: Grade modifier 0; Physical examination: Physical exam instability not used as a grade modifier
Grade modifier 0; Clinical studies: Grade 1 (chondro- since stability was used in class assignment. No atrophy
malacia). With 2 grade modifier 0, adjustments moved would be grade 0, but 5° flexion contracture would
2 to the left of midrange default resulting in grade A be rated at 10% LEI by Table 16-23, and Table 16-25
and final rating of 1% LEI and converts to 1% WPI. indicates a 10% LEI rating would be a mild degree of
problem, or a grade 1 modifier from Table 16-7. The
Class 1 Example Calculation anterior cruciate reconstruction, in good position with-
CDX GMFH GMPE GMCS out joint space narrowing on current weight-bearing
1 0 0 1 X rays, by itself would be a grade 1, mild pathology
adjustment. The presence of the meniscal tear and
(0 1) 1 subsequent repair (documented in the operation report)
(0 1) 1
(1 1) 0 would justify moving up a grade to grade 2 for the final
clinical studies adjustment. The net adjustment is +1, so
Net adjustment 2
class 1, grade D, or 12% LEI is the final rating.
default grade C resulting in grade A
Class 1, grade A 1%
CLASS 2
14% to 25% Impairment of the Lower Extremity
EXAMPLE 16-9: S/P ANTERIOR CRUCIATE
RECONSTRUCTION AND MEDIAL MENISCUS
REPAIR EXAMPLE 16-10: SUBLUXING PATELLA
Subject: 52-year-old man. Subject: 30-year-old female.

History: Sustained twisting injury to right knee History: Notes that her left knee has been “giving-
on a slippery surface while carrying sheet rock. He out” when squatting to change the arm on equip-
heard a “pop” and had swelling of joint over next ment she operated. She underwent a rehabilitation
day and examination revealed hemarthrosis, positive program that has decreased the pain, but she still
Lachman’s test, and medial joint line tenderness. remains symptomatic when not maintaining her
An MRI revealed a torn anterior cruciate ligament exercise program. She was found to be at MMI fol-
and bucket handle tear of the medial meniscus. The lowing 6 months of rehabilitation. She says that her
patient underwent arthroscopic anterior cruciate knee hurts in the front most of the time, especially
reconstruction and repair of the torn medial menis- when climbing stairs. She has an antalgic limp despite
cus 1 year ago. He reported severe ongoing pain and use of a patellar tracking brace.
nearly total functional loss of his extremity.
Physical Exam: She has valgus deformity (knocked-
Physical Exam: 5° flexion contracture, normal flexion knees) and severe laxity of the patellar mechanism
and no effusion. “Give way” weakness of his quadri- with an apprehension sign on palpating the patella
ceps and no atrophy. There is mild laxity of the ACL. and checking for stability. She has significant crepi-
His gait was unremarkable when exiting the examina- tus in the patellofemoral (P-F) joint. Her knee is
tion room. otherwise slightly lax to valgus and varus stress with
the knee flexed. No effusion is palpable. There is 2.5
Clinical Studies: Current weight-bearing X rays show
cm of thigh atrophy.
bioabsorbable fixation of the ACL in good position
with a normal 5 mm joint space in all 3 compartments. Clinical Studies: X rays reveal a “lateral tilt” of
the patella in the femoral groove with a shallow
Diagnosis: s/p anterior cruciate ligament reconstruc-
groove, and she has a positive “Q angle.” The MRI
tion and medial meniscus repair.
is otherwise without new lesions except for the pres-
Comment: The methodology requires the examiner ence of the structural abnormalities of the P-F joint
to pick one diagnosis for the region. The anterior and moderate “chondromalacia patella.”
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Chapter 16
Diagnosis: Subluxing patella. Comment: Her right knee difficulties were found to
be work-related. Her left knee osteoarthritis is asso-
ciated with her obesity and age. Apportionment was
Diagnosis: “patellar subluxation or dislocation”
requested by the client.
and per criteria of “moderate instability” assigned
to class 2 with midrange default value of 16% LEI. Impairment Rating: Right Knee: Regional impair-
Adjustment grids: Function: Grade 2 (antalgic limp ments: Diagnosis “s/p total knee replacement” and
despite bracing); Exam: Grade 2 (atrophy); Clinical per criteria of “fair result” assigned to class 3 with
studies: Grade 2 (chondromalacia). Adjustments are midrange default value of 37% LEI. Adjustment grids:
consistent with the class 2 assignment for diagnoses, Functional history: Grade modifier 2 difficulty on
midrange default used resulting in final rating of 16% stairs; Physical examination: Grade modifier 1 (based
LEI which converts to 6% WPI. on either atrophy or weakness; ROM would be grade
modifier 2, but motion was used in assigning class);
Class 2 Example Calculation Clinical studies: Grade modifier 2 (implant in good
CDX GMFH GMPE GMCS position). Net adjustment is minus 4, thus, grade A.
2 2 2 2 Regional impairment 31% LEI.
(2 2) 0 Left knee: Regional Impairments: Diagnosis: “knee

(2 2) 0 arthritis” and per criteria of “2 mm cartilage interval”
(2 2) 0 assigned to class 2 with midrange default value of
Net adjustment 0 20% LEI. Adjustment grids: Functional history: Grade
Adjustment of 0 results in default grade C modifier 1; Physical examination: Grade modifier 0;
Class 2, grade C 16% Clinical studies: Not applicable, used to assign class.
Net adjustment compared to diagnostic class 2 is 3
(ie, functional history was 1 less than the diagnosis
class 2, physical examination was 2 less, and clinical
CLASS 3 studies not applicable). Therefore, moved 2 to the left
26% to 49% Impairment of the Lower Extremity resulting in 16% LEI or 6% WPI.
Apportionment: Using the left knee as her normal, the
EXAMPLE 16-11: S/P TOTAL KNEE 16% LEI is subtracted from the right knee impairment
REPLACEMENT, WITH APPORTIONMENT of 31% LEI resulting in 15% LEI, which is attributed to
her work-related injury. This converts to 6% WPI.
Subject: 60-year-old female.
History: Had a “severe” right knee injury years Class 3 Example Calculation
ago, however details are unavailable. Over the past CDX GMFH GMPE GMCS
5 years she had progressive difficulties with osteoar- 3 2 1 2
thritis and ultimately had total loss of her cartilage Right knee
interval. She underwent a right total knee replace-
(2 3) 1
ment 1 year ago. She reports improvement, however (1 3) 2
does have mild pain that occurs on climbing stairs (2 3) 1
and walking. She reports her left knee that has never Net adjustment 4
been injured occasionally aches. Adjustment of 4 results in default grade A
Physical Exam: Weight is 101.2 kg (225 lb) and height Class 3, grade A 31%
is 157.5 cm (5 ft 2 in). She can flex her right knee to 80° CDX GMFH GMPE GMCS
and has an extension lag of 5°. Her right knee is stable, 2 1 0 N/A
quadriceps strength is 4+/5 and there is 2 cm atrophy
Left knee (1 2) 1
of the quadriceps on the right compared with the left.
(0 2) 2
Exam of the left knee is normal.
Net adjustment 3
Clinical Studies: X rays on the right show a well- Adjustment of 3 equals 2 positions to the left of the
aligned knee replacement without loosening. X rays default grade C which equals grade A
performed on the left at the time of the examination Class 3, grade A 16%
revealed 2 mm cartilage interval.
Apportionment: 31% (right knee) 16% (left knee)
Diagnosis: s/p right total knee replacement for 15%
osteoarthritis and left knee osteoarthritis.
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Chapter 16
CLASS 4 Hip Impairment Examples (see Table 16-4, Hip

50% to 100% Impairment of the Lower Extremity Regional Grid)
EXAMPLE 16-12: KNEE ARTHRITIS

CLASS 0
0% Impairment of the Lower Extremity
History: Evaluated for left knee arthritis which is
attributed to prior trauma. He reports significant
EXAMPLE 16-13: CONTUSION, RESOLVED
problems with pain and a limp occurring during nor-
mal activity. He often makes use of a cane. Subject: 48-year-old woman.
Physical Exam: Knee motion is decreased with flex- History: Struck in her lateral right hip region by a
ion limited to 90° with a flexion contracture of 10°. falling box. Three days later her primary care physi-
There is 4/5 weakness on extension of the knee and 3 cian noted ecchymosis. Hip X rays were normal. She
cm atrophy of the left thigh compared to the right. did not seek further care but when evaluated a year
later complains of continued pain.
Clinical Studies: X rays reveal total loss of the knee
joint space interval on the left with a normal 4 mm Physical Exam: Normal, including gait, palpation,
joint space interval on the right. motion, stability, and strength.
Diagnosis: Knee arthritis. Clinical Studies: X ray normal.
Comment: The range of motion deficits are assessed Diagnosis: Contusion lateral right hip, resolved.
using Section 16.7. Per Table 16-23, Knee Motion
Impairments, flexion of 90° results in mild impair-
Diagnosis “soft tissue” and “contusion”. With no sig-
ment (10% LEI) and the flexion contracture of 10°
nificant objective abnormal findings on examination
results in moderate impairment (20% LEI), a total
or radiographic studies at MMI she is assigned to
of 30% LEI. Per Table 16-25, Range of Motion ICF
class 0 with 0% lower extremity impairment.
Classification, this is consistent with class 3, severe.
Diagnosis: “arthritis” and per criteria of “no cartilage
interval” assigned to class 4 with midrange default CLASS 1
value of 50% LEI. Adjustment grids: Functional history 1% to 13% Impairment of the Lower Extremity
grade 2 modifier (frequent use of cane), with +1 added
since class is 4. Physical exam grade modifier 3 (range
EXAMPLE 16-14: HIP DISLOCATION AND
of motion is grade 3, atrophy is grade 2, weakness is
RELOCATION
grade 1) with +1 added because class 4 impairment.
Clinical studies not applicable, used in class assign- Subject: 40-year-old man.
ment. Numerical adjustment: –1 position moved 1 to
History: Had a documented hip dislocation and relo-
the left, at grade B; however, the minimum LEI for
cation 2 years ago. He denies any ongoing problems
class 4 is 50% (see grid) and therefore impairment is
other than occasional hip discomfort.
unchanged. Regional impairment: 50% LEI or 20%
WPI. Physical Exam: Normal, including gait, palpation,
motion, stability, and strength.
Clinical Studies: X ray normal.
CDX GMFH GMPE GMCS
4 3 4 N/A Diagnosis: Hip dislocation, status post relocation.
(3 4) 1 Impairment Rating: Regional impairment:

(4 4) 0 Diagnosis: “ligament/bone/joint” and “hip dis-
Net adjustment 1 location.” Per criteria of “hip dislocation with
Adjustment of 1 equals 1 position to the left of relocation and no avascular necrosis or joint sur-
default grade C resulting in grade B face injury” he is assigned to class 1 with a mid-
Class 4, grade B 50% range default value of 5% LEI. Adjustment grids:
Functional history: Grade modifier 0; Physical
examination: Grade modifier 0; Clinical studies:
Grade modifier 0. Numerical adjustment: 3. The
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Chapter 16
rating is moved the maximum 2 positions to the Class 3 Example Calculation
left resulting in grade A. Regional impairment: 3%
CDX GMFH GMPE GMCS
LEI or 1% WPI.
3 2 4 3
Class 1 Example Calculation (2 3) 1
CDX GMFH GMPE GMCS (4 3) 1
(3 3) 0
1 0 0 0
Net adjustment 0
(0 1) 1
No adjustment remains 30% LEI
(0 1) 1
(0 1) 1 Class 3, grade C 30% LEI
Net adjustment 3
Adjustment of 3 equals 3 positions to the left of 16.3f Combining and Converting
default grade C resulting in grade A. The maximum Impairments
number of places that can be moved is 2, and there- If there are multiple diagnoses at MMI, the exam-
fore, this becomes grade A.
iner should determine if each should be considered
Class 1, grade A 3%
or the impairments are duplicative. If there are
multiple diagnoses within a specific region, then
the most impairing diagnosis is rated, because it
is probable this will incorporate the functional
CLASS 3 losses of the less impairing diagnoses. In rare
26% to 49% Impairment of the Lower Extremity cases of complex injury or occupational exposure,
the examiner may combine multiple impairments
within a single region, if the most impairing diag-
EXAMPLE 16-15: HIP FRACTURE
nosis does not adequately reflect the losses. When
Subject: 68-year-old man. uncertain about which rating method to choose (eg,
diagnosed-based impairment or range of motion)
History: Male executive fell at work and sus-
or whether diagnoses are duplicative, the evaluator
tained a comminuted subtrochanteric fracture of
should calculate the impairment using the alterna-
left femur, treated with open reduction internal
tive methods and choose the method or combi-
fixation. When evaluated 1 year postoperatively he
nation of methods that gives the most clinically
has returned to work and golf, but routinely uses
accurate impairment rating. The evaluating physi-
a cane in right hand and must use a cart for the
cian must explain in writing the rationale for the
latter.
rating methodology that is used.
Physical Exam: He walks with a noticeable limp
If two conditions in a limb are being rated, the
and has a 2.5 cm lift on his left shoe. There is a 30°
examiner will need to determine the grade modi-
external rotation contracture.
fiers for each. Functional history is only used for the
Clinical Studies: X ray reveals the fracture has single, highest diagnosed-based impairment.
healed with 3.3 cm of shortening.
If there are multiple lower extremity impairments,
Diagnosis: Comminuted subtrochanteric fracture they are combined at the lower extremity level. The
left femur. combined value determination is based on the fol-
lowing formula: A% B% (100% A%) the
combined value of A% and B%. The Combined
Diagnosis: “hip fracture” and per criteria of “hip
Values Chart (in the Appendix) is used to determine
fracture (neck or inter/sub-trochanteric) malunion”
the combined value of 2 impairment percentages.
he is assigned to class 3 with midrange default
All percentages being combined must be expressed
value of 30% LEI. Adjustment grids: Functional
using a common denominator or same unit relative
history: Grade modifier 2; Physical examination:
value. Multiple impairments are successively com-
Grade modifier 4; Clinical studies: Grade modi-
bined by first combining the largest number with
fier 3. Net adjustment compared to diagnostic
the next largest remaining number, and then further
class is 0. Therefore placement remains at 30%
combining it with the next largest remaining number,
LEI or 12% WPI.
and then further repeating the process until all given
impairment numbers are combined.
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Chapter 16
Tables in this chapter show the impairment percent- TA B L E 16 -1 0 (C O N T I N U E D)

ages at the lower extremity level. The conversion fac- % Impairment
tors for the lower extremity are: Whole Lower Foot and Great Lesser
Person Extremity Ankle Toe Toe
• 40%: Lower extremity to whole person.
Severe
• 70%: Foot and ankle to lower extremity. 10 26 37
• 17%: Great toe to ankle/foot. 11 27 39
11 28 40
• 3%: Lesser toe to ankle/foot.
12 29 41
These values are shown in Table 16-10. An excep- 12 30 43
tion for conversion is made for 1% lower extremity;
12 31 44
this is equated to 1% whole person. The examiner
should report values at the level appropriate for the 13 32 46
jurisdiction. 13 33 47
14 34 49
14 35 50
TA B L E 16 -1 0
14 36 51
Impairment Values Calculated From Lower
Extremity Impairment 15 37 53
% Impairment 15 38 54
Whole Lower Foot and Great Lesser 16 39 56

Person Extremity Ankle Toe Toe 16 40 57
0 0 0 0 0 16 41 59
Mild 17 42 60
1 1 1 8 48 17 43 61
1 2 3 17 95 18 44 63
1 3 4 25 18 45 64
2 4 6 34 18 46 66
2 5 7 42 19 47 67
2 6 9 50 19 48 69
3 7 10 59 20 49 70
3 8 11 67 Very Severe
4 9 13 76 20 50 71
4 10 14 84 20 51 73
4 11 16 92 21 52 74
5 12 17 100 21 53 76
5 13 19 22 54 77
Moderate 22 55 79
6 14 20 22 56 80
6 15 21 23 57 81
6 16 23 23 58 83
7 17 24 24 59 84
7 18 26 24 60 86
8 19 27 24 61 87
8 20 29 25 62 89
8 21 30 25 63 90
9 22 31 26 64 91
9 23 33 26 65 93
10 24 34 26 66 94
10 25 36 (continued)
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Chapter 16
TA B L E 16 -1 0 (C O N T I N U E D) 16.4Peripheral Nerve
% Impairment Impairment
Whole Lower Foot and Great Lesser
Person Extremity Ankle Toe Toe
This section presents a method of evaluating lower
Very Severe (continued) extremity peripheral nerve impairment. Peripheral
27 67 96 nerve impairment may be combined with diagnosed-
27 68 97 based impairments at the lower extremity level,
28 69 99 when the diagnosed-based impairment does not
28 70 100
already include the nerve impairment. Impairment
due to chronic pain is discussed in Chapter 3, Pain.
28 71
Motivation and behavioral concerns are considered
29 72 in Chapter 14, Mental and Behavioral Disorders.
29 73
Neurologic impairment is assessed only for objec-
30 74
tive involvement of specific nerve(s). The user should
30 75 first identify the structure(s) involved; this identi-
30 76 fication is based on the clinical history, presenting
31 77 complaints, specific neurologic findings, and clinical
31 78 studies. The principles described in Section 16.4a,
32 79
Clinical Assessment and Grading Deficits, must be
followed.
32 80
32 81 Complex Regional Pain Syndrome – Type II (also
33 82
referred to as causalgia) is rated using Section 16.5,
since a specific sensory or motor nerve structure is
33 83
involved. However, probability and severity must be
34 84 determined as explained in Section 16.5, Complex
34 85 Regional Pain Syndrome Impairment, first.
34 86
Accurate diagnosis of peripheral nerve disorders is
35 87 based on a detailed history, a thorough neurologic
35 88 examination and appropriate diagnostic tests, includ-
36 89 ing electrodiagnostic studies when required. Precise
36 90 knowledge of the anatomy and physiology of the ner-
36 91
vous system is a prerequisite. Underlying causes of
neuromuscular dysfunction that may mimic specific
37 92
regional defects must be detected and may include
37 93 diabetes mellitus, chronic alcohol abuse, systemic
38 94 neurologic disorders, hypothyroidism, and other
38 95 systemic diseases. Failure to recognize a preexisting
38 96 alteration of sensory or motor nerve function can
39 97
lead to erroneous conclusions about impairment after
nerve injury.
39 98
40 99 It is important to determine the anatomic distribution
40 100
and loss of function resulting from (1) sensory defi-
cits or pain and (2) motor deficits and loss of power.
Characteristic deformities and manifestations result-
ing from peripheral nerve lesions, such as restricted
motion, atrophy, and vasomotor, trophic, and reflex
changes, have been taken into consideration in the
impairment values shown in this section. Therefore,
when impairment results strictly from a peripheral
nerve lesion, no other rating method is applied to this
section to avoid duplication or unwarranted increase
in the impairment estimation.
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Chapter 16
16.4a Clinical Assessment and Grading All clinical studies used to examine the degree of
Deficits functional loss of sensibility are related to cutaneous
Sensory and motor deficits must be accurately graded touch-pressure sensation. The examiner’s fingertip
to define the potential range of impairments associ- or a cotton tipped applicator can be used to assess
ated with the nerve lesion. Since sensory and manual light touch. Sharp/dull recognition and protective
muscle testing may be influenced by several neuro- sensation can be assessed using a disposable pin.
logic findings, only unequivocal and permanent defi- The pinprick test can be useful to determine whether
cits are given permanent impairment ratings. protective sensation is intact and to identify discrep-
ancies between dermatomal findings and reported
Sensory Deficits symptoms. More accurate assessment is obtained by
Sensation is the awareness of stimulation, while sen- using the sharp and dull sides of the pin at random.
sibility is the conscious appreciation and interpreta- Vibration testing has yet to be associated with func-
tion of the stimulus that produced the sensation. tional levels of sensibility.
Sensory deficits are evaluated according to the fol- The sensory exam results should conform to the
lowing criteria: cutaneous distribution of a peripheral nerve, or a
branch of a peripheral nerve. The sensory exam
1. How does the sensory deficit or pain interfere
should be classified into one of five categories.
with the individual’s performance of daily
Severity grade 0 is normal sensibility and sensation.
activities?
Severity grade 1 is subjectively altered sensory per-
2. To what extent does the sensory deficit or pain ception but retained light touch and sharp/dull recog-
follow the defined anatomic pathways of the nition. In this grade the patient correctly reports each
peripheral nerve? time he/she is touched, but stimuli are perceived
as subjectively abnormal (paresthesia-like), but in
3. To what extent is the description of the sensory
only the distribution of a particular cutaneous nerve.
deficit or pain consistent with characteristics of
Severity grade 2 is impaired light touch, but retained
peripheral nerve disorders?
sharp/dull recognition. This means several of the
4. To what extent does the sensory deficit or pain light touch stimuli are not felt by the patient, but
correspond to other disturbances (motor, trophic, sharp and dull stimuli are consistently recognized
vasomotor, etc) of the involved nerve structure? correctly. Severity grade 3 is impaired sharp/dull
recognition, but retained protective sensibility.
Sensory deficits can be challenging to grade, since
In this grade, light touch recognition is severely
the clinical examination is based on subjective
impaired, and sharp/dull discrimination is absent,
reports by the patient. Grading is based on the results
but the sharp side of the pin is recognized as touch-
of sensibility testing by light touch and sharp/dull
ing the patient, and protective sensation is still pres-
discrimination.
ent, as recognized by the absence of blisters, burns,
The subjective nature of sensibility testing can abrasions, scars, etc from unrecognized trauma
relate to a number of variables involving the testing or repetitive activity. Severity grade 4 sensation is
environment, the individual being tested, the test absent sensation and no protective sensibility. There
instruments and methods of administration, and the should be no recognition of light touch and no rec-
examiner. Tests should be administered in a quiet ognition of touch with the sharp side of the pin, and
environment, void of extraneous noises that distract there will usually be signs of skin injury (blisters,
the individual and the tester. Patient-related variables scars, burns, abrasions, etc).
can include attitude, concentration, and anxiety.
If nerve conduction testing has been done, there
Abnormal skin texture, such as calluses, also influ-
should be at least major sensory conduction block if
ences the test results. Instrument-related variables
the physical exam is consistent with sensory severity
include manufacturing quality control, recalibra-
grade 3, and there should be axon loss or no record-
tion as needed over time, and the weight of various
able sensory nerve action potential (SNAP) if the
instruments. Important method-related variables
physical exam is consistent with sensory grade
include rate and duration of stimulus application, the
4 severity. Individuals with severe deficits have
amount of pressure exerted on the skin, and whether
decreased protective sensibility, which is defined
the stimulus is moving or constant. The examiner’s
as a conscious appreciation of pain, temperature, or
experience, attention to detail, and adherence to
pressure before tissue damage results from the stim-
methods of administration can minimize the effects
ulus. Individuals with very severe or complete deficit
of the above variables.
have no protective sensibility.
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Chapter 16
Motor Deficits is reflected in a level of severity as illustrated in
Motor deficits are based on muscle strength testing. Table 16-11.
The manual grading of muscle strength is based on
16.4c Peripheral Nerve Rating Process
the ability of a normal muscle to contract and to
Impairment from traumatic injury to peripheral
move a bone-joint lever arm through range of motion
nerves is defined by the specific nerve(s) involved,
with full resistance. Palpation of the muscle-tendon
and the associated severity of sensory and motor def-
unit helps evaluate muscle contractility. Both lower
icits. This section is NOT used for nerve entrapments
extremities should be tested and the results com-
since nerve entrapments are not isolated traumatic
pared. Muscle strength testing is voluntary in that it
events.
requires full individual concentration and coopera-
tion. It remains somewhat subjective until precise 1. Identify the injured nerve. The distribution of
methods of measuring muscle contractions become peripheral nerves is presented in Figure 16-3,
generally available. Muscle atrophy, although not Sensory Nerves of the Lower Extremity and Figure
rated separately, can be a more objective sign of 16-4, Motor Nerves of the Lower Extremity.
motor dysfunction. Electromyographic studies can
2. Grade the sensory and motor deficit using Table
help confirm motor function of specific muscles or
16-11, Sensory and Motor Severity; the deficits
groups of muscles.
are: none, mild, moderate, severe, or very severe
Manual muscle testing, which typically involves based on the results of the physical examination.
groups of muscles, depends on the patient’s coop-
3. Use Table 16-12, Peripheral Nerve Impairment
eration and is subject to his or her conscious and
– Lower Extremity Impairments to define the
unconscious control. To be valid, the results should
impairment.
be concordant with other observable pathologic signs
and medical evidence. Measurements can be made by a. In the left column identify the nerve involved
1 or 2 observers. If the measurements are made by 1 and then identify the severity of the sensory
examiner, they should be consistent on different occa- and/or motor deficit.
sions. If made by 2, they should be consistent between
b. Adjust the impairment as described in 16.3 non-
examiners. Even in a fully cooperative individual,
key factors for grade adjustment – adjustment
strength may vary from 1 examination to another, but
grid; excluding Table 16-7, Physical Examination
not by more than 1 grade. If findings vary by more
Adjustment since these neurologic examination
than 1 grade between observers or by the same exam-
findings define the impairment values in Table
iner on separate occasions, the measurement should
16-12. Adjustments are made only for functional
be considered invalid. Individuals whose performance
history (Table 16-6) and clinical studies (Table
is inhibited by pain or the fear of pain are not good
16-8) (ie, electrodiagnostic studies).
candidates for manual muscle testing.
c. Combined motor and sensory impairments are
16.4b Neurologic Grading and Severity the lower extremity value.
Determination
The results of the sensory and motor examination
are used to define the severity of the deficits. This
TA B L E 16 -11 S E N S O R Y A N D M O T O R S E V E R I T Y
Severity 0 Severity 1 Severity 2 Severity 3 Severity 4

Severity Normal Mild Moderate Severe Very Severe or
Complete Loss
Sensory Deficit Normal sen- Subjectively altered Impaired light touch, Impaired Absent sensation and
sibility and sensory perception but retained sharp/ sharp/dull no protective sensibility
sensation but retained light dull recognition recognition,
touch and sharp/dull but retained
recognition protective
sensibility
Motor Deficit Normal Grade 4 / 5 (Against Grade 3 / 5 (Against Grade 2 / 5 Grade 0–1 / 5 (No evi-
gravity with some gravity only without (Movement dence of contractility or
resistance), mild resistance), more with gravity no joint movement), no
weakness than 50% of strength eliminated) motion
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Chapter 16
TA B L E 16 -12 Peripheral Nerve Impairment – Lower Extremity Impairments
Peripheral Nerve Impairment (LEI)

Note: Classification of degree of deficit must be based on results of specific evaluation as explained in Section 16.4b and
the use of Table 16.11 Sensory and Motor Severity. The examiner must document specific results of sensory testing (sen-
sibility) and motor assessment.
DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
SENSORY
NERVES
Lateral Femoral 0 1 2 3 4 5
Cutaneous
No objective sen- Sensory deficit or
sory deficit CRPS II
Superficial 0 1 2 3 4 5
Peroneal
Sural 0 1 2 3 4 5
Saphaneous 0 1 2 3 4 5
MOTOR NERVES
Obturator 0 0 1 1 2 2
No objective Mild motor or
motor deficits sensory deficit
2 3 3 3 4
Moderate motor
or moderate or
greater sensory
deficit
4 4 5 5 5
Severe motor
deficit
6 6 7 7 7
Very severe
motor deficit
Superior Gluteal 0 2 5 8 11 13 14 19 24 25 25 31 36 40 45 49 50 53 56 59 62
No objective Mild motor Moderate motor Severe motor Very severe
motor deficits deficit deficit deficit motor deficit
(continued)
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Chapter 16
TA B L E 16 -12 (C O N T I N U E D) Peripheral Nerve Impairment – Lower Extremity Impairments
DIAGNOSTIC
CRITERIA

IMPAIRMENT
SEVERITY
Inferior Gluteal 0 1 3 5 7 9 14 14 14 17 19 28 30 33 35 37
No objective Mild motor Moderate motor Very severe
motor deficits deficit deficit motor deficit
19 21 23 25 25
Severe motor
deficit
MIXED NERVES
Femoral 0 1 1 1 2 2 14 14 14 17 19 28 30 33 35 37
No objective Sensory deficit Moderate motor Very severe
sensory or motor or CRPS II (objec- deficit motor deficit
deficits tively verified)
19 21 23 25 25
1 3 5 7 9
Severe motor
Mild motor deficit
deficit
Sciatic 0 2 3 4 6 9 14 15 16 17 17 38 43 47 48 49 56 61 66 72 75
No objective Mild to moderate Very severe sen- Severe motor Very severe
sensory or motor sensory deficit sory deficit or deficit motor deficit
deficits or CRPS II very severe CRPS
(objectively II (objectively
verified) verified)
10 11 12 13 14 20 23 25 25 25
Severe sensory Moderate motor
deficit or severe deficit
CRPS II (objectively
verified)
5 7 9 11 13
Mild motor deficit
Common 0 1 2 3 4 5 14 15 16 19 21 26 26 26 29 32
Peroneal
No objective Sensory deficit Moderate motor Severe motor
sensory or motor or CRPS II (objec- deficit deficit
deficits tively verified)
33 35 37 39 42
Very severe
motor deficit
(continued)
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Chapter 16
TA B L E 16 -12 (C O N T I N U E D) Peripheral Nerve Impairment – Lower Extremity Impairments

DIAGNOSTIC
CRITERIA (KEY

IMPAIRMENT
SEVERITY
Tibial 0 1 1 2 3 4 14 14 14 14 15 26 28 31 33 35
No objective Mild sensory defi- Very severe sen- Very severe
sensory or motor cit or mild CRPS II sory deficit or motor deficit
deficits (objectively CRPS II; or very (above knee)
verified) severe motor defi-
cit (below midcalf)
1 2 2 3 4
14 14 14 16 18
Mild motor
deficit (below Moderate motor
midcalf) deficit (above
knee)
Moderate sensory
deficit or moder- 18 20 22 24 25
ate CRPS II (objec-
Severe motor
tively verified); or
deficit (above
moderate motor
knee)
deficit (below
midcalf)
1 3 5 7 9
Mild motor defi-
cit (above knee)
9 9 10 11 11
Severe sensory
deficit or severe
CRPS II; or severe
motor deficit
(below midcalf)
Medial Plantar 0 1 1 1 1 1
or Lateral
No objective Mild sensory defi-
Plantar
sensory or motor cit, mild motor
deficits deficit or mild
CRPS II (objec-
tively verified)
2 2 2 3 3
Moderate sensory
deficit, moderate
motor deficit or
moderate CRPS II
(objectively
verified)
3 3 3 4 4
Severe sensory
deficit, severe
motor deficit
or severe CRPS
II (objectively
verified)
4 4 4 5 5
Very severe sen-
sory deficit, very
severe motor def-
icit or very severe
CRPS II (objec-
tively verified)
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Chapter 16
FIGURE 16 -3
Sensory Nerves of the Lower Extremity
Dorsal ramus
Lateral and anterior of T12
branches (T11, T12)
Iliohypogastric Ventral ramus
(L2, L3) of T12
Dorsal rami L1-L3

Dorsal rami (superior cluneal nn.)
of S1-S3
Lateral femoral Perforating cutaneous
cutaneous (S2, S3)
Medial
(L2, L3) plantar
Ilioguinal Inferior cluneal nn.
(L1) (S1, S3) (L4, L5)
Genitofemoral
(L1, L2) Lateral
Lateral femoral
Femoral (anterior plantar
cutaneous
cutaneous muscle (L4, L5)
(L2, L3)
(L2, L3)
Posterior femoral Saphenous
Obturator (L3, L4)
cutaneous Medial
(L3, L4) (S1, S3) calcaneal Sural
Saphenous (L4, L5) (S1, S2)
(L3, L4)
Lateral sural
cutaneous
(L4, L5, S1, S2)
Superficial peroneal
(L4, L5, S1)
Sural
(S1, S2)
Deep peroneal
(L4, L5)
FIGURE 16 - 4
Motor Nerves of the Lower Extremity
Femoral Obturator Sciatic

L2 L2 (tibial and peroneal)
L3 L3
L4 L4 L4
Psoas major
and minor L5
S1
Orientation S2
levels Iliacus S3
Ischial Rectus
tuberosity femoris
Pectineus
Sartorius Obturator Semitendinosus
externus Biceps femoris
Vastus Adductor brevis Biceps femoris (long head)
lateralis Adductor longus (short head) Semitendinosus
Vastus Gracillis Adductor magnus
intermedius Common peroneal
Adductor nerve Semimembraneous
tubercle Adductor magnus
Articularis genu Tibial nerve
Plantaris
Gastrocnemius
Gastrocnemius
Tibialis Soleus
anterior
Popliteus
Soleus Flexor digitorum
Peroneus longus longus
Tibialis
Extensor hallucis longus Peroneus posterior
brevis
Tibial
malleolus Extensor digitorum longus Flexor hallucis longus
Peroneus Abductor hallucis

tertius Flexor digitorium brevis
Extensor All other
digitorum muscles in Flexor hallucis brevis
longus the sole Lumbricals to
second digit
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Chapter 16

CLASS 1
CDX GMFH GMPE GMCS
1% to 13% Impairment of the Lower Extremity
1 2 n/a n/a
EXAMPLE 16-16: FEMORAL NEUROPATHY (2 1) 1

Net adjustment 1
Adjustment of 1 equals 1 position to the right of default
History: Sustained a shrapnel-type injury at work grade C resulting in grade D
when a part in his lathe broke and a sharp metal
Class 1, grade D 2% sensory deficit
fragment struck him near the groin. The wound
Motor deficit 7%
was surgically explored, and he was found to have a 7% 2% 9%
totally transected femoral nerve. The femoral ves-
sels were not injured. The nerve was repaired, with
return of significant function. Two years post-injury,
walks without a cane or brace but with an abnormal 16.5Complex Regional Pain
gait, minimally hyperextending his knee by using Syndrome Impairment
hip extensors, just prior to weight-bearing.
Physical Exam: Decreased light touch perception Complex regional pain syndrome (CRPS) is a
in leg in the distribution of the saphaneous nerve challenging and controversial concept, difficult to
(the distal sensory branch of the femoral nerve) with diagnose accurately, with epidemiological studies
intact sharp/dull perception. The area of skin along indicating that most such diagnoses are made within
the medial leg has retained sharp/dull perception. a workers’ compensation context. Therefore, this
Quadriceps strength is grade 4/5. is a particularly challenging diagnosis to rate. The
hallmark of this condition is a characteristic burning
Clinical Studies: Vascular studies show normal
pain that is present without stimulation or movement,
flow in the femoral artery. No electrodiagnostic
that occurs beyond the territory of a single peripheral
studies were performed.
nerve, and that is disproportionate to any suspected
Diagnosis: Femoral neuropathy, mild. inciting event. The pain is associated with specific
clinical findings, including signs of vasomotor and
sudomotor dysfunction and, later, trophic changes of
Nerve involvement: “femoral nerve”, for the sen-
all tissues from skin to bone.
sory involvement, per criteria of “mild to moderate
sensory” assigned to class 1 with midrange default The International Association for the Study of Pain
value of 1% LEI. For the motor involvement, per (IASP) created the diagnoses of CRPS type I to
criteria of “mild motor deficit” (based on finding replace the diagnosis of reflex sympathetic dystro-
of grade 4/5 motor strength) assigned to class 1 phy (RSD), and CRPS type II to replace causalgia.
with midrange default value of 5% LEI. Adjustment Historically, sympathetic nervous system dysfunc-
grids: Functional history: Class 2; Physical exami- tion was thought to be a cause of symptoms, and the
nation: not relevant (neurologic findings used to term RSD reflects that. Causalgia was considered
define impairment ranges); Clinical studies: not similar to RSD except it followed an unambiguous
relevant (no electrodiagnostic testing). Net adjust- lesion of a peripheral nerve, either a major mixed
ment compared to diagnostic class is 1. Therefore, nerve in the proximal extremity (major causalgia) or
moved 1 to the right of the default for both motor of a purely sensory branch more distally (minor cau-
and sensory. For sensory deficit the impairment is 2% salgia). CRPS I is presently considered when clini-
LE and for the motor deficit the impairment is 7% LEI. cally appropriate signs and symptoms are present in
The combined impairment is 9% LEI which is equiva- the limb without nerve injury. CRPS II is considered
lent to 4% WPI. in when appropriate signs and symptoms are present
in the clinical setting of an unambiguous injury to a
specific peripheral nerve.
Since a subjective complaint of pain is the hallmark
of this diagnosis, and since all of the associated
physical signs and radiologic findings can be the
result of disuse, an extensive differential diagnostic
process is necessary. Differential diagnoses which
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Chapter 16
must be ruled out include disuse atrophy, unrec- to permit adequate time to achieve maximum medi-
ognized general medical problems, somatoform cal improvement), (3) the diagnosis has been verified
disorders, factitious disorder, and malingering. A by more than 1 physician, and (4) a comprehensive
diagnosis of CRPS may be excluded in the presence differential diagnostic process (which may include
of any of these conditions, or any other conditions psychological evaluation and psychological testing)
which could account for the presentation. This exclu- has clearly ruled out all other differential diagnoses.
sion is necessary due to the general lack of scientific Emphasis is placed on the differential diagnostic
validity for the concept of CRPS, and due to the process, because accurate diagnosis of CRPS is dif-
reported extreme rarity of CRPS (any of the differ- ficult, and because even objective findings have been
entials would be far more probable). demonstrated to lack diagnostic validity.
Because accurate diagnosis of CRPS is difficult, the The taxonomy and criteria, which were adopted by
diagnostic approach should be conservative, and sup- the Committee for Classification of Chronic Pain
ported by objective findings. The diagnosis of CRPS of the International Association for the Study of
has not been scientifically validated as representing a Pain (IASP), have contributed to progress in under-
specific and discrete health condition. The diagnostic standing the syndrome; these substantial efforts
process is itself unreliable, as competing diagnostic finally provided standardized diagnostic criteria,
protocols and definitions are continuously being intro- improved clinical communication and homogeneity
duced and utilized. There is no gold standard diagnos- of research, and provided the promise of results that
tic feature which reliably distinguishes the diagnosis could be compared across studies. These criteria
of CRPS from presentations which clearly are not have been examined, both in terms of external and
CRPS. Scientific findings have actually indicated internal validation. The IASP criteria, while sensi-
that whenever this diagnosis is made, it is probably tive, lack specificity, and thus would identify patients
incorrect. A diagnosis of CRPS may create a dilemma as having CRPS when they do not. As a result of
for the evaluator with regard to a specific injury. validation studies, proposed modified research diag-
Specifically, a lack of proportionality between a clini- nostic criteria were developed.
cal presentation and any suspected inciting event is
Signs are objective evidence of disease perceptible
inherent to the concept of CRPS. Therefore an evalu-
to the examiner, as opposed to symptoms, which are
ator must determine if there is relationship between
subjective sensations of the individual. The examiner
CRPS and the injury in question.
should provide objective evidence of the reported
CRPS may be rated only when: (1) the diagnosis findings (ie, photographic documentation, tempera-
is confirmed by objective parameters (specified in ture measurements, etc.) whenever possible. The
Table 16-13), (2) the diagnosis has been present for at presence or absence of the following objective fac-
least 1 year (to assure accuracy of the diagnosis and tors should be noted (see Table 16-14):
TA B L E 16 -13
Diagnostic Criteria for Complex Regional Pain Syndrome
1) Continuing pain, which is disproportionate to any inciting event.
2) Must report at least one symptom in three of the four following categories:
____ Sensory: Reports of hyperesthesia and/or allodynia.
____ Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry.
____ Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry.
____ Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin).
3) Must display at least one sign* at time of evaluation in two or more of the following categories:
____ Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure
and/or joint movement).
____ Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry.
____ Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry.
____ Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nail, skin).
4) There is no other diagnosis that better explains the signs and symptoms.
*A sign is counted only if it is observed and documented at time of the impairment evaluation.
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Chapter 16
TA B L E 16 -14 4 points is required for a class 1 rating, 6 points

Objective Diagnostic Criteria Points for Complex for a class 2 rating, and 8 points for a class 3 or 4
Regional Pain Syndrome rating. If there are 3 points or less the rating for
Local Clinical Signs Points pain complaints may be based on Chapter 3, as
Vasomotor changes: applicable.
• Skin color: mottled or cyanotic 1 5. Using Table 16-6, Functional History Adjustment
• Skin temperature: cool 1 Modification, Table 16-7, Physical Examination
• Edema 1 Adjustment Modification, and Table 16-8, Clinical
Sudomotor changes:
Studies Adjustment Modification, identify the grade
modifier number for each adjustment factor that
• Skin dry or overly moist 1
is determined to be reliable. The process differs
Trophic changes: from that used for diagnosed-based impairments.
• Skin texture: smooth, nonelastic 1 Average the grade modifier numbers and use this
• Soft tissue atrophy: especially digit tips 1 information to define the class number in Table 16-
• Joint stiffness and decreased passive motion 1 15, Complex Regional Pain Syndrome (Type I)
• Nail changes: blemished, curved, talonlike – Lower Extremity Impairments. If that class num-
1
• Hair growth changes: fall out, longer, finer
ber is not supported by the objective diagnostic cri-
1
teria points then the highest class specified by those
Radiographic Signs points is selected, for example, if an individual has
• Radiographs: trophic bone changes,
1
grade modifiers that ultimately resulted in assign-
osteoporosis ment to class 2, however the objective diagnostic
• Bone scan: findings consistent with CRPS 1 criteria points were only 4, the individual would be
assigned to class 1. Using clinical judgment, select
the appropriate grade within the class. Since the
adjustment factors are used to define the class they
In CRPS I, neither the initiating causative factor nor
cannot be used to determine the grade within the
the symptoms involve a specific peripheral nerve
class. The physician may use clinical judgment to
structure, therefore impairment is based on Table
decrease or increase the grade within the assigned
16-15. In CRPS II a specific sensory or mixed nerve
class and must explain in detail the rationale for any
structure is involved, therefore the rating is based on
adjustments.
Table 16-12 Peripheral Nerve Impairment – Lower
Extremity Impairments. With CRPS II the sever- The rating for CRPS is a “stand alone” approach.
ity of CRPS is first determined using Table 16-14 If impairment is assigned for CRPS, no additional
Complex Regional Pain Syndrome (Type I). impairment is assigned for pain from Chapter 3
nor is the CRPS impairment combined with any
The steps in assessing CRPS type I impairment are:
other approach for the same extremity from this
1. Determine if CRPS is a ratable diagnosis (ie, chapter.
the diagnosis has been confirmed), (Table 16-13,
Diagnostic Criteria for Complex Regional Pain
Syndrome), the diagnosis has been present for at
least 1 year, the diagnosis has been verified by CLASS 3
more than 1 physician, and a comprehensive dif- 26% to 49% Impairment of the Lower Extremity
ferential diagnostic process has clearly ruled out
all other differential diagnoses.
EXAMPLE 16-17: COMPLEX REGIONAL PAIN
2. Determine the number of objective diagnostic SYNDROME, TYPE I
criteria points (Table 16-14, Objective Diagnostic
Criteria for Complex Regional Pain Syndrome.)
History: Developed problems consistent with
3. Assess adjustment factors, as described in
complex regional pain syndrome. Two years later
Section 16.3.
despite a myriad of interventions she continued to
4. The classification of severity is based on the have significant difficulties. She underwent exten-
number of objective diagnostic criteria points and sive diagnostic evaluation, both physical and psy-
assessment of adjustment factors, as described chological, and no other diagnoses were identified.
in Section 16.3, Non-Key Factors for Grade
Adjustment – Adjustment Grid. A minimum of
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Chapter 16
TA B L E 16 -15 Complex Regional Pain Syndrome (Type I) – Lower Extremity Impairments
Complex Regional Pain Syndrome (LEI)

Note: Prior to using Table, examiner must review Sections 16.3 and 16.4. The diagnosis of CRPS must be defined by Table
16-13 Diagnostic Criteria for Complex Regional Pain Syndrome and specified points threshold must be met as defined
by Table 16-14 Objective Diagnostic Criteria for Complex Regional Pain Syndrome. The default value for impairment is
grade C and modified by reliable findings and use of Adjustment Grids.
DIAGNOSTIC
CRITERIA
IMPAIRMENT
OBJECTIVE 4 points 6 points 8 points 8 points

FINDINGS
(POINTS
THRESHOLD)
SEVERITY Mild Moderate Severe Very Severe
GRADE 0 A B C D E A B C D E A B C D E A B C D E
CRPS diagnosis 1 3 7 11 13 14 17 20 23 25 26 32 38 44 49 50 60 70 80 90
not supportable
Current Symptoms: She reports problems with a logical testing), failed to reveal any psychological
significant limp, which occurs with normal activity, differentials.
and regular use of a cane. Also, she reports her most
Work-relatedness Considerations:
serious problem is that of pain. States her leg will
Administratively, it was determined that her complex
swell, change colors, and feel cool. Complains her
regional pain syndrome was attributable to the injury
knee motion and strength are decreased.
2 years prior.
Physical Exam: Right leg is mildly edematous and
Diagnosis: Complex regional pain syndrome, type I.
feels cool when compared with the opposite limb.
Reports significant tenderness on palpation. Skin Comment: She meets the standards defined in Table
texture is smoother and the hair on her right leg 16-13, Diagnostic Criteria for Complex Regional
is fine compared with the opposite leg. Motion is Pain Syndrome: (1) continuing pain which is dispro-
normal except for her right knee that has flexion portionate to any inciting event; (2) reports at least
reduced to 100° and a flexion contracture of 5°. 1 symptom in 3 of the 4 following categories: sen-
Antalgic gait with asymmetric shortened stance. sory (allodynia), vasomotor (temperature and color
asymmetry), sudomotor (edema), and motor/trophic
Clinical Studies: Radiographs reveal moderately
(decreased motion and weakness); (3) displays at least
severe trophic bone changes and bone scan is consis-
1 sign at time of evaluation in 2 or more of the follow-
tent with CRPS.
ing categories: sensory (allodynia), vasomotor (tem-
Differential Diagnosis: A comprehensive medi- perature asymmetry), sudomotor/edema (edematous),
cal investigation, including a review of the patient’s and motor/trophic (decreased motion, weakness, and
records from her entire life, failed to reveal any trophic changes); and (4) there is no other diagnosis
general medical differentials. A comprehensive that better explains the signs and symptoms. Table
psychological evaluation (including a review of the 16-14, Objective Diagnostic Criteria Points for
patient’s records from her entire life, diagnostic eval- Complex Regional Pain Syndrome has 8 objective
uation in accordance with the American Psychiatric diagnostic criteria points: (1) skin color mottled,
Association’s diagnostic manual (Axes I and II), (2) skin temperature cool, (3) edema, (4) skin texture
collateral input, and scientifically credible psycho- smooth and nonelastic, (5) hair fine, (6) joint stiff-
Guides6e_16_493-556.indd 541 3/3/09 6:59:39 PM

Chapter 16
ness and decreased passive motion, (7) trophic bone 16.6 Amputation Impairment
changes and (8) bone scan consistent with CRPS.
Amputation impairment is based on the level of the
Impairment Rating: Her condition is ratable since
amputation with adjustments for proximal problems
the diagnosis has been confirmed, it has been present
reflected by functional history, physical examination,
for a least 1 year, and it has been verified by more than
and clinical studies, unless the proximal problems
1 physician. A comprehensive differential diagnostic
qualify for separate impairments (diagnosis, range
process has clearly ruled out all other differential diag-
of motion, or nerve injury). Table 16-16, Amputation
noses. She has 8 objective diagnostic criteria points.
Impairment, specifies the class and magnitude of
Table 16-15, Complex Regional Pain Syndrome impairment based on the level of the amputation. The
(Type I) – Lower Extremity Impairments, is appli- default mid-grade value and values to the left are con-
cable since her diagnosis is confirmed by Table 16-14, sistent with the impairment values in prior editions.
Objective Diagnostic Criteria for Complex Regional It is not possible to decrease impairment below the
Pain Syndrome. Based on her average of the reliable value associated with the amputation level, however
functional history (grade modifier 2), physical exami- proximal problems may increase the impairment, and
nation (grade modifier 4), and clinical studies (grade thus may result in assignment to grade D or grade E.
modifier 3) findings, she is assigned to class 3 with These adjustments are performed as outlined in Section
a mid-range default of 38% LEI. Using clinical judg- 16.3. The amputation impairment may be combined
ment, the physician determined that this did not require with proximal diagnosed-based impairments or proxi-
adjustment within the class and used this as the basis mal range of motion impairments; the examiner must
for the final rating. Her impairment was 38% LEI or explain the rationale for combining. Impairment for
15% WPI. amputation can never exceed 100% lower extremity.
TA B L E 16 -16 Amputation Impairment
Amputation
DIAGNOSTIC
CRITERIA
(KEY
IMPAIRMENT
SEVERITY
GRADE 2 2 2 3 4 20 20 20 22 24 45 45 45 47 49 62 62 62 68 70
Lesser toes at First metatarsal Midfoot Syme (hindfoot)
MTP joint
22 22 22 24 25 40 40 40 42 44 70 70 70 72 74
5 5 5 6 7
All toes at metatar- Transmetatarsal Below knee, 3
Greater toe at sophalangeal (MTP)
80 80 80 82 84
interphalangeal joint
joint Below knee, 3
Metatarsal (other Knee disarticulation
than First) Above knee - distal
12 12 12 13 13 90 90 90 92 94
Great toe at MTP Above knee
joint – Midthigh
100 100 100 100 100
Above knee
– Proximal
Hip disarticulation
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Chapter 16
CLASS 3 Section 16.2, Diagnosed-Based Impairment, is
26% to 49% Impairment of the Lower Extremity the method of choice for calculating impairment.
Range of motion is used principally as a factor in
the Adjustment Grid—Physical Examination, as
EXAMPLE 16-18: MIDFOOT AMPUTATION
explained in Section 16.3b. Some of the diagnosis-
Subject: 40-year-old woman. based impairment grids refer to the range of motion
section when that is the most appropriate mechanism
History: Involved in a motor vehicle accident and
for grading the impairment. This section is to be
sustained severe trauma to her foot. Ultimately she
used as a stand-alone rating when other grids refer
underwent a midfoot amputation. She reports that
you to this section or no other diagnosis-based sec-
she needs to use a cane to ambulate, but otherwise is
tions of this chapter are applicable for impairment
doing reasonably well.
rating of a condition. The final impairment may be
Physical Exam: Well-healed midfoot amputation, adjusted for functional history, in certain circum-
with no abnormalities proximally. stances. Figure 16-12, Lower Extremity Range of
Motion Record, is used to record motion findings
Clinical Studies: None relevant.
and document impairments. Examples of the lat-
Diagnosis: Midfoot amputation. ter include burns or other severe scarring causing
permanent passive and active range of motion losses,
complex flexor or extension tendon or multiple
Amputation “midfoot” and assigned to class 3 with
tendon laceration injuries, severe crush injuries,
midrange default value of 45% LEI. Adjustment
residual compartment syndrome, or other condi-
grids: Functional history: Grade modifier 2. Net
tions not addressed in the regional grids but having
adjustment compared to diagnostic class is 1.
significant functional loss.
Therefore, moved 1 position to the left. Impairment
remains at 45% LEI or 18% WPI. There are additional exceptions when using ROM as
the primary impairment is accepted.
1) For amputation ratings, deficits of motion for the
CDX GMFH
remaining portion of the limb may be combined
3 2
with the amputation impairment.
(2 3) 1 2) In very rare cases, severe injuries may result in
Net adjustment 1 passive range of motion losses qualifying for
Adjustment of 1 equals 1 position to the left of default class 3 or 4 impairment. If the active range of
grade C resulting in grade B motion impairment percentage is greater than the
Class 3, grade B45% percentage impairment derived from the diag-
nosis-based class, then the impairment is rated
by range of motion as a stand-alone rating. This
range of motion for the impairment may only
16.7 Range of Motion Impairment be used if the active range of motion is within
10°s of the passive range of motion measured.
Range of motion (ROM) determination is an essen-
The active range of motion measurement is what
tial component of LE impairment ratings with a
determines the final impairment rating.
strong historical precedent. Although the procedure
may be time consuming, valuable objective informa- Examples include complex flexor or extension ten-
tion concerning joint function can be ascertained. don or multiple tendon laceration injuries, severe
Surface goniometry can be carried out reliably and crush injuries, residual compartment syndrome, or
effectively on the joints of the extremities, so that other conditions having significant functional loss.
range of motion can be objectively determined.
The conventional ROM goniometric procedures 16.7a Range of Motion Measurement
previously advocated in the Guides should be fol- Range of motion (ROM) is measured on the basis
lowed. However, certain procedural modifications, of the neutral position of a joint being zero. The
described below, have been implemented to enhance “extended anatomic position” is therefore accepted as
simplicity and reproducibility of results, and the 0° rather than 180°, and the degrees of joint motion
tables have been reformatted and simplified consid- increase in the direction the joint moves from the zero
erably to conform more effectively to the requisite starting point. The term extension describes motion
ICF Approach. opposite to flexion. Incomplete extension from a
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Chapter 16
flexed position to the neutral starting point is defined muscle or tendon that holds back the motion because it
as extension lag. Extension exceeding the zero start- is adherent or too short. Sound clinical knowledge and
ing position, as can be seen in normal knee joints, measurement techniques are necessary for appropriate
is referred to as hyperextension. Ankylosis refers to impairment evaluation and rating.
complete absence of motion of a joint. For ease of
notation, a plus sign () is used to indicate joint hyper- 16.7b Range of Motion Impairment
extension and a minus sign (–) to indicate extension Assessment
lag. These signs have no mathematical significance. If it is clear to the evaluator that a restricted range of
motion has an organic basis, 3 measurements should
Knee extension lag and flexion contracture are differ-
be obtained and the greatest range measured should be
ent concepts, the former is dynamic and the latter is
used. If multiple evaluations exist, and there is incon-
static. A patient lying supine, with his heel on the bed,
sistency of a rating class between the findings of 2
fully relaxed, who cannot fully extend his knee, even
observers, or in the findings on separate occasions by
with external force applied, has a flexion contracture
the same observer, the results are considered invalid.
of the knee. A seated patient who cannot fully extend
Figures 16-5 to 16-11 illustrate measuring range of
her knee the last few degrees has an extension lag.
motion in the lower extremity. The ranges listed in
The arc of motion represents the total number of Tables 16-18 to 16-24 define the severity of impair-
degrees traced between the 2 extreme positions of ment (mild, moderate, severe) for lower extremity
movement in a specific plane of motion. When a joints. Figure 16-12, Lower Extremity Range of Motion
joint has more than 1 plane of movement, each type Record, is used to record motion findings and docu-
of motion is referred to as a unit of motion. The term ment impairments. All impairments are expressed as
functional position of a joint denotes the optimum lower extremity impairments; conversion to other units
angle(s) recommended for joint fusion. When a joint is performed using Table 16-10, Impairment Values
has more than 1 unit of motion, each separate unit is Calculated From Lower Extremity Impairment.
assigned a functional position.
Adjustments for functional history may be made if:
Both extremities should be compared. If the contralat- (1) range of motion impairment is the only approach
eral joint is uninjured it may serve as defining normal used to rate the extremity, (2) there are reliable
for the individual. In determining the range of motion findings of motion impairment, (3) the evaluator
of individual joints, the examiner must evaluate both determines that the resulting impairment does not
active and passive motion. Active or voluntary motion adequately reflect interference the functional loss, and
is performed by the active contraction of the govern- (4) functional reports are determined to be reliable.
ing muscles and is evaluated first. When a person has The adjustment is a percentage add-on to total range
full active joint excursion, passive motion values need of motion impairment; this add-on is based on the rel-
not be taken because a joint that has full active excur- ative difference between the range of motion impair-
sion will have a full passive range as well. However, ment class and the functional history grade modifier.
if the active arc of motion is incomplete, assisted
Based on the motion deficits the physician will deter-
active and/or passive motion measurements are neces-
mine the appropriate impairment class in Table 16-25,
sary to evaluate the joint motion. Passive motion is
Range of Motion ICF Classification. The physician will
that produced by an external force to determine the
identify the grade modifier from Table 16-6, Functional
freedom and range of motion existing at a joint when
History Adjustment. The functional history net modi-
all muscles are relaxed. Assisted active motion is the
fier, specified in Table 16-17, is based on the relative
result of active muscle contraction and an external
difference between the grade modifier number and
force applied to the joint; it allows for stabilization
the range of motion impairment class; this number is
of a segment to improve the mechanical advantage
determined by subtracting the impairment class num-
of the muscles that move the joint being measured.
ber from the functional grade number (see Table 16-17).
Measurements of active motion take precedence in
For example, if the functional history adjustment was
the Guides. The actual measured goniometer read-
grade modifier 3 and the impairment class from Table
ings or linear measurements are recorded.
16-25, Range of Motion ICF Classification, was class
Many different factors can limit the normal range of 1, the functional history net modifier is 3 1 or 2. The
motion of the joints of the lower extremities. Limitation impairment is increased by multiplying the functional
of active motion can be due to failure of the nerve, history net modifier 10% by the total motion impair-
muscle, or tendon to execute the motion. Limitation ment. With the above example, if the range of motion
of passive motion can be from involvement of the impairment was 10% LEI (class 1), the functional
joint itself, a fixed contracture, or the antagonistic grade (class 3) and the net modifier 2, the increase is
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Chapter 16
TA B L E 16 -17
Functional History Net Modifier
Net Modifier 0 1 2 3
Functional History Grade Adjustment Equal 1 Higher 2 Higher 3 Higher
compared to Range of Motion ICF Class
Increase to Total Range of Motion No change Total Range Total Range Total Range
Impairment of Motion of Motion of Motion
Impairment 5% Impairment Impairment
10% 15%
FIGURE 16 -5
Evaluating the Range of Motion of a Toe: The Metatarsophalangeal (MTP) Joint of the Great Toe
(a) The examinee is seated in the position for evaluation of the toes. The knee is flexed to 45 , and the foot and MTP joint
are in the neutral position.
(b) Extension: The goniometer is under the MTP joint, and its angle is read as a baseline. The examinee extends
(dorsiflexes) the toe maximally, and the angle subtending the maximum arc of motion is read; the baseline angle is
subtracted.
(c) Flexion: the goniometer is placed over the MTP joint. The baseline angle is read. The examinee plantar flexes the MTP
joint maximally. The angle subtending the maximum arc of motion is read, and the baseline angle is subtracted.
45°
90°
a.
c.
b.
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Chapter 16
FIGURE 16 - 6 FIGU R E 16 -7
Measuring Inversion and Eversion Measuring Ankle Dorsiflexion (Extension) and
Plantar Flexion
The patient should be seated on the examination table
in front of the examiner who is seated at foot level. The Ankle motion should be measured with the knee in
heel (calcaneous) is placed inline with the long axis of the flexion at 90° to eliminate any effect of gastrocnemius
leg (tibia). With the ankle joint in neutral the calcane- or soleus contratures. The goniometer’s pivot is centered
ous is held with 1 hand and the forefoot with the other over the ankle and 1 arm parallels the tibia. The exam-
hand. The sub-talar joint is moved to inversion and then iner reads the angles subtending the maximum arcs of
the heel is brought into eversion with the angle mea- motion for dorsiflexion and plantar flexion. The averages
sured between the tibia and calcaneous. Note: There is of the maximum angles represent dorsiflexion (exten-
usually twice as much inversion as eversion. sion) and plantar flexion ranges of motion.
15˚
30˚
Eversion
Inversion
FIGURE 16 - 8
Measuring Knee Flexion
(a) The examinee is supine and the goniometer is next to the knee joint; 1 goniometer arm is parallel to the lower leg,
and the other is parallel to the femur. Any deviation from 0° is recorded.
(b) The examinee exerts maximum effort to flex the knee. The flexion angle is obtained from the goniometer.
a. b.
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Chapter 16
FIGURE 16 -9
Using a Goniometer to Measure Flexion of the Right Hip*
(a) Goniometer is placed at the right hip, and the pelvis is blocked in the neutral position by flexing the left hip until the
lumbar spine is flat.
(b) Examinee flexes the right hip until the anterior superior iliac spine begins to move, when the angle is recorded.
(c) To measure loss of extension of the right hip, the left hip is flexed until the lumbar spine is flat on the examining table,
as determined by the examiner’s hand, which is placed between the lumbar spine and table surface. The right thigh
should rest flat on the table; any right hip flexion is recorded as a flexion contracture.
a. b.
c.
*Accurate measurements of the lower extremity can also be obtained using a proper inclinometer (see Appendix).
F I G U R E 16 -1 0
Neutral Position (a), Abduction (b), and Adduction (c) of Right Hip
The examinee is supine on a flat surface. To improve consistency, flex the knee to stabilize the pelvis.
a. b. c.
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Chapter 16
F I G U R E 16 -11
Measuring Internal and External Hip Rotation*
The examinee is prone on a flat surface, and the knee is flexed 90°. One part of the goniometer is parallel to the flat
surface, and the other is along the tibia. While testing, the examiner should place the hand on the knee to determine
whether there is significant laxity of the knee joint. Keep the pelvis flat on the table.
*Adapted from American Orthopaedic Association, Manual of Orthopedic Surgery.

Rosemont, Il: American Orthopaedic Association, 1966.
10% (modification percentage) 10% LEI (the cal- for each motion component and the correspond-
culated range of motion impairment) or 1% LEI. ing lower extremity impairment value.
Therefore, the final adjusted range of motion impair-
3. Add all impairment values at a joint. If more
ment is 11% LEI. Note the 5% is not an add-on of
than 1 joint involved and being rated, combine
5%, rather it is a multiplier used in conjunction with
the motion measurements of the separate joints.
the functional history net modifier and the total
impairment. 4. Using the total impairment for the joint refer-
ence, Table 16-25 to classify the severity of the
The steps in assessing range of motion impairment are:
lower extremity motion measurements in the ICF
1. Perform active range of motion measurements, format. Note the impairment values specified in
bilaterally, using a goniometer, as described the sub-grids are those corresponding to the total
above and illustrated in Figures 16-5 to 16-11. impairment identified for each joint rather than
the impairments associated with different grades.
2. Compare results to criteria in Tables 16-18 to
16-24. If opposite extremity is uninjured, use this 5. If functional history grade modifier exceeds the
as baseline for the individual and adjust individ- impairment class and requirements stated above
ual components accordingly. Classify impairment are met, modify the final impairment.
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Chapter 16
TA B L E 16 -18 TA B L E 16 -22
Lesser Toe Impairments Ankle Motion Impairments
Note: The maximum LEI of 2 or more lesser toes is 6% LEI.
Severity Mild Moderate Severe
Severity Mild Moderate Severe Impairment 7% LEI 15% LEI 30% LEI
Impairment 2% LEI Motion
Motion Plantar flexion 11°–20° 1°–10° None
capability
Metatarsophalangeal, 0°–10°
extension Flexion Contracture 10°–19° 19°
(Equinus deformity)
Extension 10°–0°
(Dorsiflexion) (neutral)
TA B L E 16 -19
Greater Toe Impairments TA B L E 16 -23
Severity Mild Moderate Severe Knee Motion Impairments
Impairment 2% LEI 5% LEI Note: If multiple deficits of motion the values are added.
Varus/valgus Deformity measured by femoral-tibial
Motion angle; 3° to 10° valgus is considered normal.
Metatarsophalangeal, 15°–30° 0°–9°
extension Severity Mild Moderate Severe
Impairment 10% LEI 20% LEI 35% LEI
Interphalangeal, 20°
flexion Motion
Flexion 80°–109° 60°–79° 60°
Flexion Contracture 5°–9° 10°–19° 19°
TA B L E 16 -20
Hindfoot Motion Impairments TA B L E 16 -2 4
Severity Mild Moderate Severe Hip Motion Impairments – Lower Extremity
Impairment 2% LEI 5% LEI Impairment
Motion Severity Mild Moderate Severe
Inversion 10°–20° 0°–9° Impairment 5% LEI 10% LEI 20% LEI
Motion
Eversion 0°–10°
Flexion 80°–100° 50°–79° 50°
Extension 10°–19° 20–19° 30°

flexion flexion flexion
TA B L E 16 -21 contracture contracture contracture
Ankle or Hindfoot Deformity Impairments Internal 10°–20° 0°–9°
rotation
Severity Mild Moderate Severe
External 20°–30° 0°–19°
Impairment 12% LEI 25% LEI 50% LEI rotation
Motion Abduction 15°–25° 5°–14° 5°
Varus 10°–14° 15°–24° 24°
Adduction 0°–15°
Valgus 10°–20° Abduction 0°–5° 6°–10° 11°–20°
Contracture
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Chapter 16
TA B L E 16 -25 Range of Motion ICF Classification
Range of Motion ICF Classification

DIAGNOSTIC
CRITERIA
(KEY
LOWER
EXTREMITY Very Severe or
SEVERITY Normal Mild Moderate Severe Complete
IMPAIRMENT
CLASS 3 and perform a thorough and careful physical exami-

26% to 49% Impairment of the Lower Extremity nation, then follow the steps suggested below.
1. Record process and results using Lower
EXAMPLE 16-19: KNEE MOTION DEFICIT Extremity Impairment Evaluation Record
(Figure 16-2).
2. Obtain detailed history and perform an appro-
History: Sustained a right knee injury which was
priate physical examination, as explained in
treated with prolonged immobilization. Subsequent
Section 16.1.
evaluation failed to reveal internal derangement or
other significant pathology, other than reproducible 3. Review clinical studies, as explained in Section
marked deficits of motion. Two years later her only 16.1.
complaint is that her knee is stiff.
4. Determine the diagnoses and those that are to be
Physical Exam: Examination is only remarkable for rated.
her motion deficits with knee flexion limited to 90°
5. Determine the diagnosed-based impairment for
and a flexion contracture of 15°.
each ratable diagnosis, using the regional grids,
Clinical Studies: Unremarkable. as explained in Section 16.2.
Diagnosis: Knee motion deficit, presumed second- 6. Assess the results of the functional history,
ary to prolonged immobilization. physical examination, and clinical studies to
determine reliability and severity, as explained
Impairment Rating: According to Table 16-23,
in Section 16.3c. For those factors that are deter-
Knee Motion Impairments – Lower Extremity
mined to be reliable, define the grade modifier
Impairment, for the finding of flexion of 90°, she
for each factor. Functional history adjustment is
has a mild impairment corresponding with 10%
performed only for the single most significant
LEI and for the flexion contracture of 15°, she has a
diagnosis, unless otherwise specifically stated
moderate impairment corresponding with 20% LEI.
by a jurisdiction.
These values are added resulting in 30% LEI which
is consistent with a class 3 impairment. Regional 7. Adjust the diagnosed-based impairment values,
impairment: 30% LEI or 12% WPI. Her functional as explained in Section 16.3.
history difficulties are grade modifier 1, less than
8. If more than 1 ratable diagnosis, combine the
the assigned class 3 impairment; therefore the final
final impairment value at the lower extremity
impairment was not modified.
level.
9. Identify and calculate impairment related to the
peripheral nerve impairment, as explained in
16.8 Summary Section 16.4.
10. Identify and calculate impairment related to
When evaluating an individual with lower extremity
complex regional pain syndrome, as explained
impairment, first obtain the person’s detailed history
in Section 16.5.
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Chapter 16
F I G U R E 16 -12
Lower Extremity Range of Motion Record
Name Date _________________________________

Injured Side ___ Right ___ Left ___ Bilateral
File No.
Right ___ Injured Left ___ Injured Impaired ___ Right

___ Uninjured ___ Uninjured ___ Left
Motion Normal Motion Impairment Motion Impairment Impairment
Toe, Lesser
Second MP Extension 10º % LEI % LEI % LEI
Third MP Extension 10º % LEI % LEI % LEI
Fourth MP Extension 10º % LEI % LEI % LEI
Fifth MP Extension 10º % LEI % LEI % LEI
Add (Maximum 6% LEI) % LEI % LEI % LEI
Toe, Greater Motion Normal Motion Impairment Motion Impairment Impairment
IP Flexion 20º % LEI % LEI % LEI
MP Extension 30º % LEI % LEI % LEI
Add % LEI % LEI % LEI
Ankle or Hindfoot Deformity absent % LEI % LEI % LEI

Deformity
Hindfoot Motion Normal Motion Impairment Motion Impairment Impairment
Inversion 20º % LEI % LEI % LEI
Eversion 10º % LEI % LEI % LEI
Ankle Motion Normal Motion Impairment Motion Impairment Impairment
Plantar Flexion 20º % UE % UE % UE
Flexion Contracture absent % LEI % LEI % LEI
Extension 10º % UE % UE % LEI
Add % UE % UE % LEI
Knee Motion Normal Motion Impairment Motion Impairment Impairment
Flexion 110º % LEI % LEI % LEI
Flexion Contracture 5º % LEI % LEI % LEI
Hip Motion Normal Motion Impairment Motion Impairment Impairment
Flexion 100º % LEI % LEI % LEI
Extension <10º Flex % LEI % LEI % LEI

Contracture
Internal rotation 20º % LEI % LEI % LEI
External rotation 30º % LEI % LEI % LEI
Abduction 25º % LEI % LEI % LEI
Adduction 15º % LEI % LEI % LEI
Abduction Contracture absent % LEI % LEI % LEI
Combined Combine LE Joints % LEI % UE % LEI
Convert to Whole % WP % WP % WP
Person
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Chapter 16
11. Identify and calculate impairment related to 1.5 cm calf atrophy compared to the opposite side.
amputation, as explained in Section 16.6. Examination of her right knee reveals a grade 1
Lachman’s test.
12. Only if no other approach is available to rating,
calculate impairment based on range of motion, Clinical Studies: MRI confirmed partial tear of her
as explained in Section 16.7. anterior cruciate ligament. X rays reveal good heal-
ing of her fibular fracture with normal alignment.
13. Typically, only a single approach is used and in
the vast majority of cases this will be the diag- Diagnosis: Amputation great toe at MTP joint;
nosed-based impairment assessment. However, ankle (fibula) fracture, healed; anterior cruciate
if multiple approaches are applicable, combine ligament tear, with mild laxity.
the impairments at the lower extremity level.
Comment: Three separate factors need to be con-
14. As appropriate convert the final impairment to sidered in the rating, the fracture and knee injury
regional or whole person impairment. being evaluated by the diagnosed-based impairment
approach. No single problem adequately reflects her
15. If more than 1 leg is involved, each lower
combined impairment. Functionally, her difficul-
extremity is rated separately and converted
ties relate primarily to the amputation of a moderate
to whole person; then both whole person rat-
severity, with her knee difficulties a mild severity
ings (right and left leg) are combined using the
and her fibula not being functionally significant.
Combined Values Chart.
Her examination reveals atrophy which likely more
relates to her reported sequelae from her amputation,
Report Example
although may also relate to her ankle fracture.
The following case example demonstrates the
process of rating multiple impairments and the Impairment Rating: There are 3 components to the
use of Figure 16-2, Lower Extremity Impairment rating which are then combined at the lower extrem-
Evaluation Record Example. ity impairment level prior to conversion to whole
person permanent impairment. Of the 2 diagnosed-
based impairments, the impairment for the knee is
EXAMPLE: AMPUTATION OF GREAT TOE higher.
Subject: 40-year-old woman. 1. Regional impairment for the ankle based on
the use of Table 16-2, Foot and Ankle Regional
History: Involved in a motor vehicle accident
Grid – Lower Extremity Impairments and fac-
2 years ago and sustained trauma to her right lower
tors of “fracture,” “ankle,” and “non-displaced
extremity, including crush injury to her right great
with minimal findings,” this results in a class
toe, an ankle fracture (distal fibula, undisplaced)
1 (mild problem) impairment with a mid-range
and a torn right anterior cruciate ligament. She
default value of 5% LEI. She reports no func-
underwent amputation of her great toe at the meta-
tional problems as a result of the ankle fracture
tarsal-phalangeal joint, and otherwise was treated
and therefore per Table 16-6, Functional History
conservatively. She declined surgery to repair her
Adjustment, there is a grade modifier 0 (no
torn anterior cruciate ligament.
problem); however since this is not the single
Current Symptoms: She reports problems with a most significant impairment it is disregarded in
limp, occurring with normal activity and frequent the adjustment process. Providing her with the
use of a cane. She attributes her functional difficul- benefit of the doubt and attributing some of the
ties primarily to her problems with the amputation. atrophy to the fracture per Table 16-7, Physical
If it were not for the amputation she feels that she Examination Adjustment, there is a grade modi-
would have only minor difficulties due to her knee. fier 1 (mild problem). Clinical studies (X rays)
She reports her fracture has healed well and is not a confirmed the fracture therefore a grade modi-
problem. Her functional reports are consistent with fier 1 (mild problem). Thus, all factors except the
her medical reports. functional history (class 0) are consistent with
the class 1 diagnosis impairment (mild problem),
Physical Exam: Gait is antalgic limp with asymmet-
and since functional history is used for another
ric shortened stance, however accomplished without
greater impairment it is not used in the adjust-
assistant device. There is a well-healed amputation
ment process. Thus the impairment remains at
of her great toe at the level of the MTP joint. Range
5% LEI.
of motion is intact for the hindfoot, ankle and knee.
There is no significant weakness, however there is
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553 Guides to the Evaluation of Permanent Impairment The Lower Extremities 553
Chapter 16
2. Regional impairment for the knee based the 3. Amputation impairment is based Table 16-16,
use of Table 16-3, Knee Regional Grid – Lower An amputation of the great toe at the MTP joint
Extremity, impairments and factors of “liga- results in class 1 (mild problem) assignment and
ment/bone/joint,” “cruciate or collateral liga- 12% LEI. Per Table 16-6, Functional History
ment injury,” and “mild laxity.” This results Adjustment, she would be classified as grade
in a class 1 (mild problem) impairment with a modifier 2 (Moderate). Her examination (atro-
midrange default value of 7% LEI. Her functional phy and gait) is consistent with class 1 (mild
reports are most consistent with grade modi- problem) assignment per Table 16-7, Physical
fier 1 (mild problem) per Table 16-6, Functional Examination Adjustment. Clinical studies are
History Adjustment. Her examination finding not relevant. Thus the net adjustment is 1 and
was limited to mild laxity, but this is also the the assignment is moved 1 to the right, resulting
finding that defined the class impairment; tech- in the same 13% LEI.
nically this could be excluded, however it only
The 2 diagnostic-based impairments are combined,
reaffirms a class 1 placement per Table 16-7,
resulting in 12% LEI. This is combined with the 13%
Physical Examination Adjustment. Clinical stud-
LEI for amputation, resulting in 24% LEI, which
ies (X rays) confirmed the tear, therefore a class
converts to 10% WPI per Table 16-10, Impairment
modifier 1. Thus, all factors are consistent with
Values Calculated from Lower Extremity
the class 1 (mild problem) diagnosis impairment
Impairment.
and the default value of 7% LEI.
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F I G U R E 16 -13
Chapter 16
Lower Extremity Impairment Evaluation Record Example
Name: Jane Doe Exam Date: 8/8/07

ID Number: Sex: F M Side: R L Birth Date: 11/9/73
Diagnosis: Ankle Fracture, ACL Tear, Amputation Great Toe Injury Date: 7/1/05
Table Diagnosis / Criteria Assigned Class Grade Modifier Adjustments Assigned Dx Final LEI
Grade
FA Ankle (Fibula) Fracture, healed 0 1 2 3 4 Net
K GMFH 0 1 2 3 4 A B C D E 5%
H
GMPE 0 1 2 3 4 0
GMCS 0 1 2 3 4 0
(Optional: AAOS Lower Limb Score: )
FA Anterior cruciate ligament tear, 0 1 2 3 4 Net

K with mild laxity
GMFH 0 1 2 3 4 A B C D E 7%
H
GMPE 0 1 2 3 4 0
GMCS 0 1 2 3 4 0
FA 0 1 2 3 4 Net
K GMFH 0 1 2 3 4 A B C D E
H
GMPE 0 1 2 3 4
GMCS 0 1 2 3 4
Combined LEI 12%

FA ⴝ Foot Ankle K ⴝ Knee H ⴝ Hip FH applied to single highest diagnosis
Peripheral Nerve/CRPS II
Impairments
Nerve Sensory and Motor Assigned Class Adjustments Assigned Combined
Grading Dx Grade LEI
A B C D E
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a
Motor Deficit Motor Deficit FH 0 1 2 3 4 n/a Motor:
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a A B C D E

A B C D E
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a
Motor Deficit Motor Deficit FH 0 1 2 3 4 n/a Motor:
0 1 2 3 4 na 0 1 2 3 4 CS 0 1 2 3 4 n/a A B C D E
CRPS I Impairment Adjustment Abbreviations
Points Assigned Class Default Adjustments Assigned Final LEI FA ⴝ Foot / Ankle
LEI Grade K ⴝ Knee
H ⴝ Hip
A B C D E
0 1 2 3 4 FH 0 1 2 3 4 n/a GMFH ⴝ Functional History
PE 0 1 2 3 4 n/a GMPE ⴝ Physical Exam
CS 0 1 2 3 4 n/a GMCS ⴝ Clinical Studies
Amputation
Level Assigned Class Default Adjustments Assigned Final LEI
LEI Grade
Amputation great 0 1 2 3 4 12% FH 0 1 2 3 4 n/a A B C D E 13%
toe at MTP PE 0 1 2 3 4 n/a
CS 0 1 2 3 4 n/a
Motion Summary Final LEI

Joint Total LEI Assigned Class
Diagnosis-based Impairment 12%
0 1 2 3 4 Peripheral Nerve
0 1 2 3 4 CRPS
0 1 2 3 4 Amputation 13%
Combined LEI Range of Motion (Stand-alone)

Final Combined Impairment 24 % LEI
Whole Person Impairment 10 % WPI
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Chapter 16
16.9 Appendix 16-A: Lower Limb Questionnaire
Lower Limb Questionnaire
Instructions
Please answer the following questions for the lower limb being treated or followed up. If it is BOTH lower
limbs, please answer the questions for your worse side. All questions are about how you have felt, on aver-
age, during the past week. If you are being treated for an injury that happened less than one week ago,
please answer for the period since your injury.
1. During the past week, how stiff was your lower limb? (Circle one response.)
1 Not at all 2 Mildly 3 Moderately 4 Very 5 Extremely
2. During the past week, how swollen was your lower limb? (Circle one response.)
1 Not at all 2 Mildly 3 Moderately 4 Very 5 Extremely
During the past week, please tell us about how painful your lower limb was during the following activities. (Circle ONE
response on each line that best describes your average ability.)
Could not
Could not
Not Mildly Moderately Very Extremely do because
do for other
painful painful painful painful painful of lower
reasons
limb pain
3. Walking on flat surfaces? 1 2 3 4 5 6 7

4. Going up or down stairs? 1 2 3 4 5 6 7
5. Lying in bed at night? 1 2 3 4 5 6 7
6. Which of the following statements best describes your ability to get around most of the time during the past week?
(Circle one response.)
1 I did not need support or assistance at all.
2 I mostly walked without support or assistance.
3 I mostly used one cane or crutch to help me get around.
4 I mostly use two canes, two crutches or a walker to help me get around.
5 I used a wheelchair.
6 I mostly used other supports or someone else had to help me get around.
7 I was unable to get around at all.
7. How difficult was it for you to put on or take off socks/stockings during the past week? (Circle one response.)
1 Not at all difficult 2 A little bit difficult 3 Moderately difficult 4 Very difficult 5 Extremely difficult 6 Cannot do it at all
Courtesy of AAOS, Rosemont, Illinois. For more information, go to http://www.aaos.org/research/outcomes/Lower_Limb.

pdf. Scoring information is available at http://www.aaos.org/research/outcomes/Lower_LimbScoring.xls.
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Chapter 16
Gross AE, McDermott AGP, Lavoie MV, et al. The use of

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Feagin JA. Principles of diagnosis and treatment. In: Feagin
of limb-length discrepancy: full-length standing
JA, Applewhite LB, eds. The Crucial Ligaments:
anteroposterior radiograph compared with scanogram.
Diagnosis and Treatment of Ligamentous Injuries
J Bone Joint Surg Am. 2006;88(10):2243–2251.
About the Knee. 2nd ed. New York, NY: Churchill
Livingstone; 1994:9–26. Tegner Y, Lysholm J. Rating systems in the evaluation of
knee ligament injuries. Clin Orthop. 1985;198:43–49.
Galer BS, Bruehl S, Harden RN. IASP diagnostic criteria
for complex regional pain syndrome: a preliminary Terjesen T, Benum P, Rossvoll I, Svenningsen S, Fløystad
empirical validation study. Clin J Pain. 1998;14:48–54. Isern AE, Nordbø T. Leg-length discrepancy
measured by ultrasonography. Acta Orthop Scand.
Gerhardt JJ. Documentation of Joint Motion. 4th ed.
1991;62(2):121–124.
Portland, Ore: ISOMED Inc; 1994.
Guides6e_16_493-556.indd 556 2/19/09 2:45:31 PM

C H A P T E R 17
The Spine and Pelvis
Chapter 17
Introduction
17.3 Adjustment Grid and Grade Modifiers:

Non-Key Factors
17.4 Pelvic Impairment
17.5 Summary
Introduction
17.6 Appendix 17-A Pain Disability
Questionnaire
nent impairment due to impairments of the spine
and pelvis. For evaluation purposes, as illustrated
in Figure 17-1, the spine and pelvis are divided into
four regions:
1. Cervical spine: including occiput through T1
(motion segments occiput-C1 through C7-T1).
2. Thoracic spine: including T1-T12 (motion
segments T1-2 through T11-12).
3. Lumbar spine: including T12-S1 (motion seg-
ments T12-L1 through L5-S1).
4. Pelvis: including ilium, sacrum, and pubic rami.
Assessment of the spine requires evaluation of skel-
etal structures, soft tissues, intervertebral motion
segments, and elements of the central and peripheral
nervous system. Evaluation of the pelvis requires
assessment of skeletal structures, soft tissues, and
consideration of impairments related to other organ
systems (genitourinary, gastrointestinal) that may
occur after major trauma to the pelvis.
557
Guides6e_17_557-602.indd 557 2/19/09 2:46:25 PM

F I G U R E 17-1 standardize and simplify the rating process, to

Spine and Pelvis Regions improve content validity, and to provide a more uni-
form methodology that promotes greater interrater
reliability and agreement.
C1
2 This chapter has been updated with information
Chapter 17
3 and research provided by the state and medical

4 Cervical
5 specialty societies listed in the preface. Impairment
6 evaluations of the spine and pelvis must be per-
7
formed within the context of the directives in
T1
2 Chapters 1 and 2 and only when conditions have
3 reached Maximum Medical Improvement (MMI).
4
5
6
7 Thoracic (1) International Classification of Functioning,
8 Disability and Health (ICF) Model is used to provide
9 a common basis for the description of human func-
10 tioning and impairments; (2) principles of assess-
11 ment have been simplified and clarified; (3) specific
12 diagnosis-based rating tables (referred to as grids)
L1 for the most common injuries and diagnoses have
2 been added; (4) physical examination has been
Lumbar
3 simplified; (5) functional assessment is provided
through focused history-taking, including informa-
4 tion about Activities of Daily Living (ADLs) and
5 a functional assessment tool; and (6) a Spine and
Pelvis Impairment Evaluation Record is provided as
Sacrum (5) a template to simplify recording of the evaluation.
Coccyx (4) The authors have made every effort to provide the most
current and comprehensive information for the impair-
ment scenarios likely to be encountered. Although
In clinical situations and discussions with col-
the chapter and impairment rating method may seem
leagues regarding the potential functional severity
complex at first, information that is useful and neces-
of an injury, there are typically four considerations:
sary for impairment assessments has been presented.
(1) what is the problem, (2) what difficulties does the
The reader is encouraged to read the entire chapter and
patient report, (3) what are the examination findings,
review case examples before performing an assessment.
and (4) what are the results of clinical studies. In a
The impairment rating process has been simplified by
similar manner, these are the steps used to assess
providing a congruent rating methodology among the
most cases of musculoskeletal impairment.
three musculoskeletal chapters. Once the examiner
Impairment ratings in the spine and pelvis are based masters the methodology in one chapter, that same
on identification of a specific diagnosis or diagnoses. methodology applies to the other chapters.
In the current method, this results in assignment to
The authors of this chapter recognize that the process
an impairment class (IC), using grids designed for
described is still far from perfect with respect to defin-
this purpose. This method is, to some degree, an
ing impairment or the complexities of human function;
expansion of the diagnosis-related estimate (DRE)
however, the authors’ intent is to simplify the rating
method used in the Fifth Edition of the Guides. The
process, to improve interrater reliability, and to provide
impairment value within a class is further refined by
a solid basis for future editions of the Guides.
considering information related to functional status,
physical examination findings, and the results of
clinical testing. Range of motion is no longer used
as a basis for defining impairment, since current
evidence does not support this as a reliable indicator
of specific pathology or permanent functional status.
However, range of motion may be used to monitor
clinical progress in individuals. The rationale
for changes from previous rating methods is to
Guides6e_17_557-602.indd 558 3/3/09 7:00:28 PM

The Spine and Pelvis 559
Guides’ purpose, applications, and methods for per- • Intervertebral disk and motion segment pathology
forming and reporting impairment evaluations. The (single and multiple levels)
• Cervical and lumbar stenosis
in impairment evaluation. Other commonly used
terms are defined in the relevant sections. • Spine fractures and/or dislocations
Chapter 17
The impairment evaluation and report should • Pelvic fractures and/or dislocations
include a comprehensive, accurate medical history; a
In the event that a specific diagnosis is not included in
review and summary of all pertinent records; and a
the diagnosis-based regional grid, the examiner should
comprehensive description of the individual’s current
use a similar listed condition as a guide to determining
symptoms and their relationship to daily activities.
an impairment value. In the report, the examiner must
The examiner should perform a careful, thorough
fully explain the rationale for the analogy.
physical examination and review findings of all
relevant laboratory, radiographic (imaging), and
ancillary tests.
The medical history must describe the chief com-
Anatomic, diagnostic, and functional bases for plaint and discuss the quality, frequency, and
determining impairment are part of the ICF Model. duration of symptoms, such as pain, numbness,
Diagnosis-Based Impairment (DBI) regional grids paresthesias, weakness and functional difficul-
are provided for each of the four regions of the spine ties; exacerbating and alleviating factors; and any
and pelvis (cervical, thoracic, lumbar, and pelvis). interference with daily activities. The evaluation
These regional grids include five columns contain- report should include the individual’s description of
ing impairment classes, numbered from 0 to 4 as how the symptoms and condition developed and the
summarized in Table 17-1, Definition of Impairment assumed cause. The evaluator should ask the patient
Classes and Impairment Ranges. These classes are about any perceived relationship between the current
designed to reflect the degree of impairment related condition and any other musculoskeletal problems.
to a condition, and numerical ranges of impairment The examiner should also clarify, to the extent pos-
have been assigned to each class. sible, causation and apportionment (ie, document the
mechanism of injury for the condition being evalu-
Impairment values for the spine and pelvis are cal-
ated and any prior problems). A complete report will
culated using the DBI method. Impairment class is
include discussion of previous evaluations and thera-
determined by the diagnosis and specific criteria that
peutic interventions as described in medical records,
are considered the “key factor” and then adjusted
past medical history, review of systems, personal
by grade modifiers, or “non-key factors,” that may
and social history, and family history. Available
include Functional History (FH), Physical Findings
X rays and other imaging studies or reports should
(PE), and relevant Clinical Studies (CS). The grade
be reviewed and commented on in the report.
modifiers (non-key factors) are considered only if
they are determined by the examiner to be reliable Case history is based on information presented by
and associated with the diagnosis. The process for the patient and ascertained from medical records.
calculating impairment values is described in detail in The evaluating physician(s) should obtain objective
Section 17.3f, Impairment Calculation Methodology. data through physical examination and review of
appropriate clinical studies. If information provided
Diagnoses for the spine and pelvis are defined in
by the patient or noted in previous medical records
several major categories, based on the selected
or findings on physical examination are inconsistent,
region. Categories include:
the evaluator’s report should reference the incon-
• Non-specific chronic, or chronic recurrent spine sistencies. The diagnosis used for placement in an
pain
TA B L E 17-1
Definition of Impairment Classes and Impairment Ranges
Whole Person Impairment (%)
CLASS PROBLEM CERVICAL SPINE THORACIC SPINE LUMBAR SPINE PELVIS
0 No objective findings 0% 0% 0% 0%
1 Mild 1%–8% 1%–6% 1%–9% 1%–3%
2 Moderate 9%–14% 7%–11% 10%–14% 4%–6%
3 Severe 15%–24% 12%–16% 15%–24% 7%–11%
4 Very severe 25%–30% 17%–22% 25%–33% 12%–16%
Guides6e_17_557-602.indd 559 2/19/09 2:46:28 PM

impairment class must be based on reliable findings adequate and thorough examination. The examiner
reflective of the impairment that is being assessed, should consider the patient’s diagnosis, the reliability
and supported by the clinical history, current exami- of findings on examination, and the results of previous
nation, and clinical studies. Objective findings are examinations and observations as recorded in the medi-
always given the greater weight of evidence over cal records documenting previous treatment.
subjective complaints.
Chapter 17
Positive, negative, and nonphysiological findings

Functional History, Physical Examination, and should be documented in the evaluation report.
Clinical Studies all contribute to better understand- Whenever possible, quantitative findings should
ing of the patient’s condition. Each of these non- be reported, rather than general descriptions (ie,
key factors is described in greater detail below. document specific measurements of limb girth
Adjustment grids (Tables 17-6, 17-7 and 17-9) related as opposed to reporting extent of atrophy). More
to each of these factors, and for use in the impair- objective findings, such as atrophy, are given greater
ment calculation, are provided in Sections 17.3a relative weight over findings that require patient
Functional History, 17.3b Physical Examination, and participation, including active range of motion or
17.3c Clinical Studies. strength testing, and subjective reports of tenderness.
Inconsistencies and discrepancies between what is
Functional History observed and what has been reported previously,
A proper functional history enables the physician or what is otherwise expected, should be noted.
to determine the impact of a given spine- or pelvis- Examination findings that differ significantly from
related condition on basic function and activities previously recorded observations after the prob-
as they pertain to ADLs. Cross-validation of the able date of MMI should be reported, with com-
patient’s reported functional limitations can occur ments noting the discrepancy. Some findings may
by observing his or her activities in the examination be excluded from the impairment calculation, as
room. The patient will usually be observed per- described later in this chapter.
forming simple routine activities, including sitting,
standing, walking, and transitioning from sit to stand Clinical Studies
or supine to stand. The physician should note incon- The physician needs to review and document actual
sistencies and lack of congruence between reported studies and findings from relevant diagnostic studies,
limitations and observed activities when evident. including laboratory tests, roentgenographic (X- ray)
studies, computed tomographic (CT) scans, magnetic
A functional assessment tool may be used in addi-
resonance images (MRI), nuclear medicine scans,
tion, to further evaluate this parameter. One example
ultrasound exams, and electrodiagnostic testing (EMG/
of a functional assessment tool, the Pain Disability
NCS). In some cases, only reports may be available,
Questionnaire (PDQ), is included in this chapter’s
and that should be noted in the record. Although imag-
appendix for convenience. The PDQ has been vali-
ing and other studies may assist physicians in making a
dated as an instrument for quantifying patient reports
diagnosis, they are not the sole determinants of a diag-
of function. The physician is expected to weigh the
nosis. The examiner should comment on clinical test
patient’s subjective complaints and score on the func-
results that do not correlate with the patient’s symptoms
tional assessment tool, relative to the expected severity
or support the patient’s diagnosis.
for a given condition. The grade modifier that reflects
functional assessment may or may not be accepted as
a variable in the impairment calculation.
If multiple regions of the spine are being rated, the 17.2 Diagnosis-Based Impairment
examiner should consider the relative contribution of
each of these diagnoses to the functional complaints. Impairment ratings are calculated using the DBI
method, in which impairment class (IC) is deter-
Physical Examination mined by the diagnosis and specific criteria and then
Guided by the history, a physical examination is per- adjusted by considering non-key factors or grade
formed, documenting spine- and/or pelvis-related modifiers. As noted previously, this approach resem-
physical findings such as spinal alignment and the bles the DRE method described in the Fifth Edition,
need for assistive devices. Neurologic findings, includ- with some enhancements.
ing root tension signs and sensory and motor deficits
Figure 17-2, Spine and Pelvis Evaluation Record,
in the upper and/or lower limbs, should be described.
should be completed or all information on that
The examiner may remove a collar or lumbar sup-
record should be provided in the impairment
port or other external devices as appropriate, to permit
Guides6e_17_557-602.indd 560 2/19/09 2:46:28 PM

F I G U R E 17-2
Spine and Pelvis Impairment Evaluation Record
Name: Exam Date:

Chapter 17
Diagnosis-Based
Impairments
Grid Diagnosis / Criteria Class Diagnosis (CDX) Grade Modifier Adjustments Net Adjustment Value Whole
and Assigned Person
Grade Modifier Impairment
Cervical (C) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a Adjusted Grade Net
GMPE 0 1 2 3 4 n/a Adjustment applied to
Default Value C
GMCS 0 1 2 3 4 n/a
2 1 0 1 2
Net Adjustment (GMFH CDX) A B C D E
Thoracic (T) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a Adjusted Grade

GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 C 3 4 n/a A B C D E
Lumbar (L) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a Adjusted Grade

GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 2 3 4 n/a A B C D E
Pelvis (P) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a Adjusted Grade

GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 2 3 4 n/a
A B C D E
Signed: Date: Whole Person Impairment:
GMFH= Grade Modifier Functional History GMPE= Grade Modifier Physical Examination GMCS=Grade Modifier Clinical Studies
rating report. The terms class, default impairment, After the impairment class has been determined
adjustments, and assigned grade modifier used in based on the diagnosis, the final impairment
the evaluation record are described in detail in the grade within the class is determined using the
sections that follow. An example of a completed grade modifiers, or non-key factors, described in
Figure 17-2 is provided at the end of this chapter. the adjustment grids for the spine. Grade modi-
fiers include Functional History (FH), Physical
Diagnosis-based impairments are the method of
Examination (PE) and Clinical Studies (CS). The
impairment evaluation used for the spine and pelvis.
grade modifiers are used in the Net Adjustment
Four regional grids, listing relevant diagnoses, are
Formula as described in the box in Section 17.3 to
provided: one for each region of the spine (cervical,
calculate a net adjustment. The final impairment
thoracic, and lumbar) and one for the pelvis.
grade is determined by adjusting the grade up or
There are five classes in the DBI grid: down from the default value “C,” by the calculated
net adjustment (2 to 2). The lowest possible grade
• Class 0: no objective problem
is A, and adjustments equal to or less than 2 from
• Class 1: mild problem the default value C will automatically be considered
A; the highest possible grade is E, and adjustments
• Class 2: moderate problem
equal to or greater than 2 will automatically be
• Class 3: severe problem considered E. The regional grid is then consulted
again, to determine the appropriate impairment
• Class 4: very severe problem approaching total
value for the selected class and grade. Grade modi-
functional loss
fiers allow movement within a class but do not allow
Subjective complaints without objective physical find- movement into a different class.
ings or significant clinical abnormalities are generally
assigned class 0 and have no ratable impairment.
determine the most appropriate class for a specific
Guides6e_17_557-602.indd 561 2/19/09 2:46:29 PM

regional diagnosis and (2) to determine the final Reliability of the diagnosis is essential, and the diag-
numerical impairment rating after appropriate nosis should be consistent with the clinical history
adjustments are made using the grade modifiers. and findings at the time of impairment assessment,
whether the condition has been treated medically or
This process is repeated in each region of the spine
surgically. Treatment may alter the functional status
that is involved in the injury being rated. In most
of the condition evaluated at MMI. For example,
Chapter 17
cases only one diagnosis will be appropriate. If

treatment of a disk herniation for symptomatic
an examiner is routinely using multiple diagnoses
radiculopathy can move the impairment rating from
without objective supporting data or rating multiple
a higher class to a lower class if the radiculopa-
regions, the validity and reliability of the evaluation
thy is resolved. However, if a condition has been
may be questioned.
treated surgically, this does not result in an “add on”
value or additional distinct impairment percentage;
changes related to surgical intervention are reflected
Steps in Performing an Impairment Rating in the provided ranges for impairment values.
1. Perform history and physical examination, and It is acknowledged that an injury and surgical man-
determine if individual is at MMI. agement of that condition, including procedures that
alter motion segment integrity, may increase the
2. Establish the reliable diagnosis for each region
likelihood for additional procedures in the future.
of the spine to be rated.
Anatomic changes resulting from surgical interven-
3. Use the appropriate regional grid to determine tion are considered in the impairment ranges pro-
the impairment class. vided. Impairment ratings are based on the patient’s
condition at the time of the rating and do not other-
4. Use the adjustment grids to identify the grade
wise anticipate the need for future interventions.
modifiers for Functional History, Physical
Exam, and Clinical Studies, as applicable. Selection of the optimal diagnosis requires judgment
Then apply the Net Adjustment Calculation to and experience. If more than one diagnosis can be
determine the net adjustment and modification used, the one that provides the most clinically accu-
of the default value “C” within the class. rate impairment rating is selected; this will generally
be the more specific diagnosis. In cases where more
5. Use the regional grid to identify the appro-
than one diagnosis is applicable (eg, spinal stenosis
priate numerical impairment rating for the
and AOMSI), the causally-related diagnosis that pro-
impairment class and grade.
vides the higher impairment rating should be used.
6. Combine whole person impairments (WPIs) In the event that a specific diagnosis is not listed in
for multiple spinal regions when appropri- the DBI grid, the examiner should identify a similar
ate, using the Combined Values Chart in the listed condition to be used as a guide to the impair-
Appendix at the end of the book. ment calculation. The rationale for this decision
should be described in the report.
The regional grids have one column that includes
Diagnosis-Based Impairment Class diagnoses and 5 columns reflecting impairment
Assignment: Regional Grids classes. Identify the applicable diagnosis in the left-
As described above, the first step in determining most column. The permissible class assignments (0
an impairment rating is to choose the diagnosis to 4) are specified in the horizontal rows. Refer to
that is most applicable in the region being assessed. the specific criteria in the row for that diagnosis to
Diagnoses are divided into categories, including soft determine which class is appropriate. Above the cri-
tissues or strain/sprain, disk herniations and altera- teria in each cell are 5 numbers reflecting the range
tion of motion segment integrity (AOMSI), spinal of impairment associated with those specific diag-
stenosis, fractures, and fracture-dislocations. As nostic criteria. Each of these numbers corresponds
much as possible, impairment values from prior edi- to grades A, B, C, D, and E, with A representing the
tions of the Guides were retained unless adjustments mildest form of the condition and E the most severe.
were necessary to more appropriately reflect the The middle value is grade C and represents a default
impairment, or were required because of changes in impairment value, which typically corresponds with
the methodology. On the basis of the diagnosis and the impairment value assigned in prior editions of
other specific differentiators that may be associated the Guides. Class, grade and the corresponding final
with that diagnosis, the condition is assigned to a impairment value are modified by the use of the
specific impairment class in the regional grid. adjustment grids and the Net Adjustment Formula,
Guides6e_17_557-602.indd 562 2/19/09 2:46:30 PM

as discussed earlier. The impairment calcula- of 1% or 2% WPI would not be added to increase
tion process is described in detail in Section 17.3f, the impairment beyond maximum impairment
Impairment Calculation Methodology. assigned for grade E in that diagnostic impairment
class. Thus, a person with a grade B or 1% impair-
General Considerations ment who sustains a similar, subsequent injury that
Instructions for using the DBI grids (Tables 17-2, is rated as grade D or 3% WPI would then have a
Chapter 17
Cervical Spine; 17-3, Thoracic Spine; and 17-4, 3% WPI. In states where apportionment is appropri-
Lumbar Spine) are provided in this section and in ate, 1% impairment would have preexisted the new
Section 17.3, Adjustment Grid and Grade Modifiers: injury and 2% would be related to the new injury. A
Non-Key Factors. The evaluator should select the person who has a grade C or 2% WPI who sustains
most accurate diagnosis and identify the class a new injury, and still falls in grade A, B, or C, still
that best describes that diagnosis. As previously has a 2% WPI, meaning there is no new impairment
described, the numerical value within the range of (0%) for the new injury.
impairment associated with that diagnosis, located
The term alteration of motion segment integrity
above each diagnosis, will be determined using
was first used in earlier editions of the Guides to
Section 17.3 and the Net Adjustment Formula.
describe loss of motion segment integrity, identi-
Common conditions related to degenerative changes fied on flexion/extension X rays (following specific
in the spine, including abnormalities identified protocols) and related to either instability or fusion,
on imaging studies such as annular tears, facet regardless of the cause. In this edition, the term has
arthropathy, and disk degeneration, do not correlate been expanded to include surgical motion-preserving
well with symptoms, clinical findings, or causation technologies such as disk arthroplasty and dynamic
analysis and are not ratable according to the Guides. stabilization techniques. The current parameters for
Congenital anomalies such as spina bifida occulta, AOMSI are explained at the bottom of each regional
abnormal segmentation and conjoined nerve roots grid for the cervical, thoracic, and lumbar spine.
are not ratable as impairments. Developmental
If a diagnosis of AOMSI, pseudarthrosis, fracture or
anomalies, including spondylolysis, some forms of
spondylolisthesis is made, imaging studies should be
spondylolisthesis, kyphosis and excessive lordosis or
excluded as a grade modifier.
scoliosis are also not ratable. There may be excep-
tions to these rules in some jurisdictions, related to Many of the terms used in the grids are described in
aggravation of preexisting conditions. greater detail in the text following them.
There is a category of patients who present with per-
17.2a Cervical Spine
sistent pain and “nonverifiable” radicular complaints
The cervical spine is defined as the region from
(defined in greater detail in Section 17.3, Adjustment
occiput to T1 (motion segments occiput-C1 through
Grid: Physical Examination) that are documented
C7-T1), including all the vertebrae, intervertebral
repeatedly after an identifiable injury. These patients
disks, joints, ligamentous, and soft-tissue structures.
have no objective findings and, therefore, are often
Instructions for determining the DBI are provided in
given a diagnosis of “chronic sprain/strain” or “non-
Sections 17.1 and 17.3 and involve the use of Table 17-
specific” back or neck pain. The current methodol-
2, Cervical Spine Regional Grid: Spine Impairments.
ogy allows these patients to be rated in impairment
class 1, with a range of impairment ratings from 1 to In all cases, if there is documented myelopathy or
3% whole person impairment (WPI). The percentage spinal cord injury with findings of neurogenic bowel
impairment within that range depends on functional or bladder, or neurogenic sexual dysfunction related
assessment, since there are no reliable physical to spinal cord injury and other related findings,
examination or imaging findings in this group. an additional impairment calculation is appropri-
ate, using Chapter 13, The Central and Peripheral
The patient who is rated in this impairment class
Nervous System. The neurologic WPI should be
(IC 1) and then presents with another episode that
combined with the spine-related impairment.
results in placement in this same impairment class
(IC 1) may move up or down a grade within the class
17.2b Thoracic Spine
with each successive assessment at MMI. However,
The thoracic spine is defined as the region from T1
this patient would not be entitled to an accumulation
to T12 (motion segments T1-2 through T11-T12),
of 1% or 2% WPI ratings, or placement in a differ-
including all the soft tissues, motion segments, and
ent class, unless the diagnosis changed. That is, the
neurologic structures. Instructions for determin-
patient might, after a second injury, move from grade
ing the DBI are provided in Sections 17.1 and 17.3
B to grade C within IC 1, but successive evaluations
Guides6e_17_557-602.indd 563 3/6/09 9:42:48 AM

TA B L E 17-2 Cervical Spine Regional Grid: Spine Impairments
Cervical Spine Regional Grid

Chapter 17

IMPAIRMENT
RATING (WPI %) 0 1%–8% 9%–14% 15%–24% 25%–30%
SOFT TISSUE AND NON- SPECIFIC CONDITIONS
Non-specific 0 1 1 2 3 3
chronic, or
Documented Documented history
chronic recur-
history of of sprain/strain-type
rent neck pain
sprain/strain- injury with contin-
(also known
type injury, ued complaints of
as chronic
now resolved, axial and/or non-
sprain/strain,
or occasional verifiable radicular
symptomatic
complaints complaints; similar
degenerative
of neck pain findings docu-
disc disease,
with no mented on mul-
facet joint
objective tiple occasions (see
pain, chronic
findings on Section 17.2 General
whiplash, etc)
examination Considerations)
MOTION SEGMENT LESIONS
Intervertebral 0 4 5 6 7 8 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
disc herniation
Imaging Intervertebral Intervertebral disk Intervertebral disk Intervertebral disk
and/or AOMSIa
findings of disk herniation(s) herniation and/or herniations or herniation(s) or
Note: AOMSI intervertebral or documented AOMSI at a single AOMSI at multiple AOMSI, with medi-
includes insta- disk hernia- AOMSI at a single level with medically levels, with medically documented
bility (specifi- tion without level or multiple documented find- cally documented findings; with or
cally as defined a history levels with medi- ings; with or with- findings; with or without surgery
in the Guides), of clinically cally documented out surgery without surgery
and
arthrodesis, correlating findings; with or
and and
failed arthrod- radicular without surgery with documented
esis, dynamic symptoms with documented with documented signs of residual
and
stabilization or residual radiculopa- signs of residual bilateral or mul-
arthroplasty, for disk herniation(s) thy at the clinically radiculopathy at tiple-level radicu-
or combina- with documented appropriate level a single clinically lopathy at the
tions of those in resolved radiculopa- present at the time appropriate level clinically appropri-
multiple-level thy or nonverifiable of examination (see present at the time ate levels present
conditions radicular complaints Table 17-7 to grade of examination (see at the time of
at the clinically radiculopathy) Table 17-7 to grade examination (see
appropriate level(s) radiculopathy) Table 17-7 to grade
present at the time radiculopathy)
of examinationb
Pseudarthrosis 0 4 5 6 7 8 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
Note: Only Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis
applies after (post surgery) at (post surgery) at (post surgery) at a (post surgery) at a
spinal surgery a single level or a single level with multiple levels with multiple levels with
intended for multiple levels with medically docu- medically docu- medically docu-
fusion with medically documented findings mented findings mented findings
resultant documented findings
and and and
mented motion
and
(not necessarily with documented with documented with documented
AOMSI by defini- with documented radiculopathy at radiculopathy at signs of bilateral
tion provided in resolved radicu- the clinically appro- a single clinically or multiple-level
footnote) with lopathy or non- priate level pres- appropriate level radiculopathy at
consistent radio- verifiable radicular ent at the time of present at the time the clinically appro-
graphic findings complaints at the examination (see of examination (see priate levels pres-
or hardware clinically appropri- Table 17-7 to grade Table 17-7 to grade ent at the time of
failure; with or ate level present radiculopathy) radiculopathy) examination (see
without surgery at the time of Table 17-7 to grade
to repair examination radiculopathy)
a
See footnote a on page 571.
b
Or AOMSI in the absence of radiculopathy, or with documented resolved radiculopathy or nonverifiable radicular complaints
at the clinically appropriate levels present at the time of examination.
(continued)
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TA B L E 17-2 (C O N T I N U E D) Cervical Spine Regional Grid: Spine Impairments

IMPAIRMENT
RATING (WPI %) 0 1%–8% 9%–14% 15%–24% 25%–30%
Spinal Stenosis 0 4 5 6 7 8 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
(may include
Cervical ste- Cervical stenosis Cervical stenosis at Cervical stenosis at Cervical stenosis at
Chapter 17
AOMSI)a
nosis at 1 or at a single level or a single level with multiple levels with multiple levels with
Note: AOMSI more levels multiple levels with or without AOMSI or without AOMSI or without AOMSI
includes insta- with or with- or without AOMSI with medically doc- with medically doc- with medically doc-
bility (specifi- out AOMSI with medically documented findings; umented findings; umented findings;
cally as defined with axial umented findings; with or without with or without with or without
in the Guides), pain with or without surgery surgery surgery
arthrodesis, surgery
and and and
failed arthrod-
and
esis, dynamic with documented with documented with documented
stabilization or with documented radiculopathy at residual radicu- signs of residual
arthroplasty, resolved radicu- the clinically appro- lopathy at a single bilateral or mul-
or combina- lopathy or non- priate level pres- clinically appropri- tiple-level radicu-
tions of those in verifiable radicular ent at the time of ate level present lopathy at the
multiple-level complaints at clini- examination (see at the time of clinically appropri-
conditions cally appropriate Table 17-7 to grade examination (see ate levels present
level(s) present radiculopathy)b Table 17-7 to grade at the time of
at the time of radiculopathy)b examination (see
examination Table 17-7 to grade
radiculopathy)b
FRACTURES/DISLOCATIONS OF THE SPINE
Fractures of 1 or 0 2 2 4 6 8 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
more vertebral
Single- or Single- or multiple- Single- or multiple- Single- or multiple- Single- or multiple-
bodies
multiple-lev- level fractures with level fractures with level fractures with level fractures with
Fracture of pos- els fractures 25% compres- 25%–50% compres- 50% compression 50% compression
terior element with no or sion of any version of any ver- of 1 vertebral body; of 1 vertebral body;
(pedicle, lam- minimal com- tebral body; with tebral body; with with or without with or without
ina, articular pression of or without bony or without bony bony retropulsion; bony retropulsion;
process, trans- any vertebral retropulsion, with retropulsion; with with or without with or without
verse process) body; with or without pedicle or without pedicle pedicle and/or pedicle and/or
or without and/or posterior and/or posterior posterior element posterior element
and
pedicle and/ element fracture element fracture fracture fracture
burst fracture or posterior
Healed, with or Healed, with or Healed, with or Healed, with or
element frac-
without surgery without surgery without surgical without surgical
ture (t5-mm
(including ver- (including vertebro- intervention; with intervention; with
displacement)
tebroplasty or plasty or kypho- residual deformity residual deformity
Healed with kyphoplasty) plasty) with resid-
may have radicu- may have docu-
or without ual deformity
may have docu- lopathy at a single mented signs
surgical inter-
mented resolved may have docu- clinically appropri- of bilateral or
vention; with
radiculopathy or mented radiculopa- ate level present multiple-level
no residual
nonverifiable radic- thy at the clinically at the time of radiculopathy at
signs or
ular complaints at appropriate level examination (see the clinically appro-
symptoms
clinically appropri- present at the time Table 17-7 to grade priate levels pres-
ate level(s)b of examination (see radiculopathy)b ent at the time of
Table 17-7 to grade examination (see
radiculopathy)b Table 17-7 to grade
radiculopathy)b
a
b
With signs of spinal cord injury or myelopathy: see Chapter 13, The Central and Peripheral Nervous System, for calculating
additional impairment.
(continued)
Guides6e_17_557-602.indd 565 2/19/09 2:46:31 PM

TA B L E 17-2 (C O N T I N U E D) Cervical Spine Regional Grid: Spine Impairments

IMPAIRMENT
RATING (WPI %) 0 1%–8% 9%–14% 15%–24% 25%–30%
Dislocations/ 0 2 2 4 6 8 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
fracture-
Dislocation Single-level disloca- Single-level disloca- Multiple-level Multiple-level
Chapter 17
dislocation
or fracture- tion with or with- tion with or with- dislocation with dislocation with
dislocation out fracture out fracture or without surgi- or without surgi-
with no or cal intervention, cal intervention,
Healed, with or Healed, with or
minimal com- including fusion including fusion
without surgery without surgi-
pression of
cal intervention, may have docu- may have signs of
any vertebral and
including fusion mented radicu- bilateral or multi-
body; with with documented lopathy at a single ple-level radiculop-
or without may have docu-
resolved radicu- clinically appropri- athy at the clinically
pedicle and/ mented radiculopa-
lopathy or non- ate level present appropriate levels
or posterior thy at the clinically
verifiable radicular at the time of present at the time
element frac- appropriate level
complaints at clini- examination (see of examination (see
ture (⬍5-mm present at the time
cally appropriate Table 17-7 to grade Table 17-7 to grade
displacement) of examination (see
level(s) radiculopathy) radiculopathy)
Table 17-7 to grade
Healed, with
radiculopathy)
or without
surgical inter-
vention; with
no residual
signs or
symptoms
Postoperative 25 27 28 29 30
complications
Deep spinal
(nonneurologic)
wound infection
Note: requiring chronic
Neurologic suppressive anti-
complications biotics; or chronic
are rated in osteomyelitis
Chapter 13,
The Central
and Peripheral
Nervous System
Note: Alteration of motion segment integrity indicates AOMSI. It is defined using flexion/extension X rays (Figures 17-5 and 17-6).
In the cervical spine, a diagnosis of AOMSI by translation measurements requires greater than 20% anterior or greater than 20%
posterior relative translation of one vertebra on another, on flexion or extension radiographs, respectively; or angular motion of
more than 11° greater than each adjacent level. Alternatively, there may be complete or near-complete loss of motion of a motion
segment due to developmental fusion, or successful or unsuccessful attempts at surgical arthrodesis, including dynamic stabilization,
or preserved motion with disk arthroplasty. In the cervical spine, these specific parameters apply to motion segments from C3 to C7.
and involve the use of Table 17-3, Thoracic Spine Diagnosis-Based Impairment are provided in Sections
Regional Grid: Spine Impairments. 17.1 and 17.3 and involve the use of Table 17-4,
Lumbar Spine Regional Grid: Spine Impairments.
In all cases, if there is documented spinal cord
injury with findings of neurogenic bowel or bladder, In all cases, if there is documented cauda equina
or neurogenic sexual dysfunction related to spinal syndrome or spinal cord injury with findings of
cord injury and other related findings, an additional neurogenic bowel or bladder, or neurogenic sexual
impairment calculation is appropriate, using Chapter dysfunction related to spinal cord injury and other
13. The neurologic WPI should be combined with related findings, an additional impairment calculation
the spine-related impairment. is appropriate, using Chapter 13. The neurologic WPI
should be combined with the spine-related WPI.
17.2c Lumbar Spine
The lumbar spine is defined as the region from T12 17.3 Adjustment Grids and Grade
to S1 (motion segments T12-L1 through L5-S1) Modifiers: Non-Key Factors
including all the soft tissues, motion segments, and The adjustment grids, as described in the introduc-
neurologic structures. Instructions for determining the tion, are used to assign a grade within the class
Guides6e_17_557-602.indd 566 3/3/09 7:00:30 PM

TA B L E 17-3 Thoracic Spine Regional Grid: Spine Impairments
Thoracic Spine Regional Grid
Chapter 17
IMPAIRMENT
RATING (WPI %) 0 1%–6% 7%–11% 12%–16% 17%–22%
Non-specific 0 1 1 2 3 3
chronic, or
Documented Documented his-
chronic recur-
history of tory of sprain/
rent thoracic
sprain/strain- strain type injury
spine pain
type injury, with continued
(also known as
now resolved, complaints of
chronic sprain/
or occasional axial and/or non-
strain, etc)
complaints verifiable radicular
of mid-back complaints and sim-
pain with ilar findings docu-
no objective mented on multiple
findings on occasions (see Sec.
examination 17.2 General
Considerations)
Intervertebral 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
disk herniation
Imaging Intervertebral Intervertebral Intervertebral disk Intervertebral disk
and/or AOMSIa
findings of disk herniation(s) disk herniation or herniation(s) or herniation(s) or
Note: AOMSI intervertebral or documented AOMSI at a single AOMSI at multiple AOMSI, at multiple
includes insta- disk hernia- AOMSI, at a single level, with medi- levels with medi- levels, with medi-
bility (specifi- tion without or multiple levels, cally documented cally documented cally documented
cally as defined a history with medically doc- findings; with or findings; with or injury; with or
in the Guides), of clinically umented findings; without surgery without surgery without surgery
arthrodesis, correlating with or without
and and and
failed arthrod- radicular surgery;
esis, dynamic symptoms with documented with documented with documented
and
supral sta- residual radiculopa- signs of residual signs of residual
bilization or for disk herniation(s) thy at the clinically radiculopathy at bilateral or
arthroplasty, with documented appropriate level a single clinically multiple-level
or combina- resolved radiculopa- present at the appropriate level radiculopathy
tions of those in thy or nonverifiable time of examina- present at the time at the clinically
multiple-level radicular complaints tion (see Table of examination (see appropriate levels
conditions at clinically appro- 17-7, Examination Table 17-7 to grade present at the time
priate level(s), pres- Adjustment, radiculopathy) of examination (see
ent at the time of to grade Table 17-7 to grade
examinationb radiculopathy) radiculopathy)
Pseudarthrosis 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
applies after (post surgery) at (post surgery) at (post surgery) at (post surgery) at
may have docu- may have docu- may have docu-
mented motion
may have documented radiculopa- mented radicu- mented signs
(not necessarily
mented resolved thy at the clinically lopathy at a single of bilateral or
AOMSI by defi-
radiculopathy or appropriate level clinically appropri- multiple-level
nition provided
nonverifiable radic- present at the time ate level present radiculopathy
in footnote)
ular complaints at of examination (see at the time of at the clinically
with consistent
the clinically appro- Table 17-7 to grade examination (see appropriate levels
radiographic
priate level(s) pres- radiculopathy) Table 17-7 to grade present at the time
findings or hard-
ent at the time of radiculopathy) of examination (see
ware failure;
examination Table 17-7 to grade
with or without
radiculopathy)
surgery to repair
a
b
(continued)
Guides6e_17_557-602.indd 567 2/19/09 2:46:33 PM

TA B L E 17-3 (C O N T I N U E D) Thoracic Spine Regional Grid: Spine Impairments

IMPAIRMENT
RATING (WPI %) 0 1%–6% 7%–11% 12%–16% 17%–22%
FRACTURES/DISLOCATION OF THE SPINE
Fractures of 1 or 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
Chapter 17
more vertebral
Single- or multiple- Single- or mul- Single- or multiple- Single or multiple-
bodies includ-
level fracture(s) tiple-level fractures level fractures with level fractures with
ing compression
with 25% com- with 25%–50% 50% compres- 50% compres-
fractures,
pression of any ver- compression of any sion of any version of any ver-
fracture of pos- tebral body; with vertebral body; with tebral body; with tebral body; with
terior element or without bony or without bony or without bony or without bony
(pedicle, lam- retropulsion into retropulsion into the retropulsion into retropulsion into
ina, articular the canal, pedicle canal, pedicle and/or the canal, pedicle the canal, pedicle
process, trans- and/or posterior posterior element and/or posterior and/or posterior
verse process) element fracture fracture element fracture element fracture
and burst Healed, with or Healed, with or Healed with or Healed with or
fracture without surgery without surgery without surgery without surgery
(includes ver- (including ver- (including ver- (including ver-
tebroplasty or tebroplasty or tebroplasty or tebroplasty or
kyphoplasty) kyphoplasty) with kyphoplasty) with kyphoplasty) with
or without residual or without residual or without residual
may have docu-
deformity deformity deformity
mented resolved
radiculopathy may have docu- may have docu- may have docu-
or nonverifiable mented radiculopa- mented radicu- mented signs of
radicular com- thy at the clinically lopathy at a single bilateral or multi-
plaints at clinically appropriate level clinically appropri- ple-level radiculop-
appropriate level, present at the time ate level present athy at the clinically
present at the time of examination (see at the time of appropriate levels
of examination Table 17-7 to grade examination (see present at the time
radiculopathy) Table 17-7 to grade of examination (see
radiculopathy) Table 17-7 to grade
With signs of
radiculopathy)
spinal cord injury With signs of
or myelopathy: spinal cord injury With signs of
see Chapter 13, or myelopathy: see spinal cord injury
The Central and Chapter 13 for cal- or myelopathy:
Peripheral Nervous culating additional see Chapter 13
System, for calcu- impairment for additional
lating additional impairment
impairment
(continued)
defined by the regional grid. The grade within a default value, grade C, up or down within a given
given class is determined by considering Functional class. When determining the grade modifier, the
History, Physical Examination Findings, and the evaluator should assess each of the components of
results of relevant Clinical Studies. If any of these the adjustment as listed in the grid (eg, soft-tissue
grade modifiers were used for primary placement in findings, neural stretch test, reflexes, motor and sen-
the regional grid (eg, clinical studies for determina- sory exam). The highest grade modifier identified
tion of compression fracture), they may not be used for each category (FH, PE, CS) should be used as
again in the impairment calculation. The non-key the value for that adjustment in the Net Adjustment
factors must be consistent, reliable, and associated Formula. For example, on physical examination,
with the diagnosis. The process of determining the reflex findings may be characterized as grade 0 and
adjustments for spine-related conditions is based on neural tension signs/straight leg raise may be grade
the use of Table 17-5, Adjustment Grid: Summary. 2. The modifier for Physical Examination would
then be grade 2, because it is the higher of the two
The grade modifiers associated with Functional
grades within that grid.
History, Physical Examination, and Clinical Studies
will be used to calculate a net adjustment, accord- As stated earlier, if a grade modifier has been used
ing to Section 17.3f, that permits modification of the to determine the impairment class, it may not be
Guides6e_17_557-602.indd 568 2/19/09 2:46:34 PM

TA B L E 17-3 (C O N T I N U E D) Thoracic Spine Regional Grid: Spine Impairments

IMPAIRMENT
RATING (WPI %) 0 1%–6% 7%–11% 12%–16% 17%–22%
Dislocations/ 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
fracture-
Single- or multiple- Single-level Multiple-level Multiple-level
Chapter 17
dislocation
level dislocation dislocation with or dislocation with or dislocation with or
with or without without fracture without fracture without fracture
fracture
Healed, with or Healed with or Healed with or
Healed, with or without surgi- without surgi- without surgi-
without surgery cal intervention, cal intervention, cal intervention,
including fusion including fusion including fusion
may have docu-
mented resolved may have docu- may have docu- may have docu-
radiculopathy or mented radiculopa- mented radicu- mented signs
nonverifiable radic- thy at the clinically lopathy at a single of bilateral or
ular complaints at appropriate level clinically appropri- multiple-level
clinically appropri- present at the time ate level present radiculopathy
ate level(s) of examination (see at the time of at the clinically
Table 17-7 to grade examination (see appropriate levels
With signs of spi-
radiculopathy) Table 17-7 to grade present at the time
nal cord injury
radiculopathy) of examination (see
or myelopathy: With signs of
Table 17-7 to grade
see Chapter 13, spinal cord injury With signs of
radiculopathy)
The Central and or myelopathy: see spinal cord injury
Peripheral Nervous Chapter 13 for cal- or myelopathy: see With signs of spi-
System, for calcu- culating additional Chapter 13 for cal- nal cord injury or
lating additional impairment culating additional myelopathy: see
impairment impairment Chapter 13
Postoperative 17 18 19 20 22
complications
Deep spinal
(nonneurologic)
wound infection
Note: requiring chronic
Neurologic suppressive anti-
complications biotics; or chronic
are rated in osteomyelitis
Chapter 13,
The Central
and Peripheral
Nervous System
Note: Alteration of motion segment integrity indicates AOMSI. It is defined using flexion/extension X rays. In the thoracic
spine, a diagnosis of AOMSI by translation measurements requires at least 2.5 mm of anterior or 2.5 mm of posterior
translation of one vertebra on another, on flexion or extension radiographs respectively; or successful or unsuccessful
attempts at surgical arthrodesis, including dynamic stabilization, or preserved motion with disk arthroplasty
used again in this calculation. In the spine, radio- of activity, as summarized in Table 17-6, Functional
graphic findings will often be excluded from the History Adjustment. As explained in Section 1.8e,
Net Adjustment Formula calculation because they History of Clinical Presentation, in general, indi-
are frequently used to determine the impairment viduals with no symptoms will be assigned grade
class in the regional grid (eg, single or multiple level modifier 0, and those with constant symptoms
conditions). If any of these factors are determined by accompanied by functional deficits that persist
the examiner to be unreliable or inconsistent, they despite treatment will be assigned grade modifier 4.
should be disregarded in the grading adjustment. The
examiner should explain the basis for grade assign-
ment or discounting of a specific adjustment for lack Functional History grade modifier should
of reliability in the impairment report. be applied only to the single, highest spine-
related DBI if multiple regions are being
17.3a Adjustment Grid: Functional History rated. Specific jurisdictions may modify this
Grade assignment for Functional History is based process such that Functional History adjust-
on patient self-reports that are attributable to the ment is considered for each DBI or not consid-
impairment. Grading is based on the extent to which ered at all as a grade modifier.
functional symptoms interfere with different levels
Guides6e_17_557-602.indd 569 2/19/09 2:46:35 PM

TA B L E 17- 4 Lumbar Spine Regional Grid: Spine Impairments
Lumbar Spine Regional Grid

Chapter 17

IMPAIRMENT
RATING (WPI %) 0 1%–9% 10%–14% 15%–24% 25%–33%
SOFT TISSUE AND NON-SPECIFIC CONDITIONS
Non-specific 0 1 2 3 3
chronic, or
Documented Documented history
chronic recur-
history of sprain/strain type
rent low back
of sprain/ injury with contin-
pain (also
strain-type ued complaints of
known as:
injury, now axial and/or non-
chronic sprain/
resolved, or verifiable radicular
strain, symptom-
occasional complaints and sim-
atic degenera-
complaints ilar findings on mul-
tive disc disease,
of back pain tiple occasions (see
facet joint
with no Sec. 17.2, General
pain, SI joint
objective Considerations)
dysfunction, etc)
findings on
examination
Intervertebral 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
disk herniation
Imaging find- Intervertebral Intervertebral Intervertebral disk Intervertebral disk
and/or AOMSIa
ings of inter- disk herniation(s) disk herniation or herniations or herniations and/or
Note: AOMSI vertebral disk or documented AOMSI at a single AOMSI at multiple AOMSI, at multiple
includes herniation AOMSI, at a single level with medically levels, with medi- levels, with medi-
instability without a level or multiple documented find- cally documented cally documented
(specifically history of levels with medi- ings; with or with- findings; with or findings; with or
as defined in clinically cally documented out surgery without surgery without surgery
the Guides), correlating findings; with or
and and and
arthrodesis, radicular without surgery
failed arthrod- symptoms with documented with documented with documented
and
esis, dynamic residual radiculopa- residual radicu- signs of residual
stabilization or for disk herniation(s) thy at the clinically lopathy at a single bilateral or
arthroplasty, with documented appropriate level clinically appropri- multiple-level
or combina- resolved radiculopa- present at the ate level present radiculopathy
tions of those in thy or nonverifiable time of examina- at the time of at the clinically
multiple-level radicular complaints tion (see Physical examination (see appropriate levels
conditions at clinically appro- Examination Table 17-7 to grade present at the time
priate level(s), pres- adjustment grid in radiculopathy) of examination (see
ent at the time of Table 17-7 to grade Table 17-7 to grade
examinationa radiculopathy) radiculopathy)
Pseudarthrosis 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
applies after (post surgery) at (post surgery) at (post surgery) at a (post surgery) at a
may have docu- may have docu- may have docu-
mented motion
and mented signs of mented radicu- mented signs of
(not necessarily
radiculopathy at lopathy at a single bilateral or multiple
AOMSI by defi- with documented
the clinically appro- clinically appropri- level radiculopathy
nition provided resolved radicu-
priate level pres- ate level present at the clinically
in footnote) lopathy or non-
ent at the time of at the time of appropriate levels
with consistent verifiable radicular
examination (see examination (see present at the time
radiographic complaints at the
Table 17-7 to grade Table 17-7 to grade of examination (see
findings or hard- clinically appropri-
radiculopathy) radiculopathy) Table 17-7 to grade
ware failure; ate level(s) pres-
radiculopathy)
with or without ent at the time of
surgery to repair examination
a
(continued)
Guides6e_17_557-602.indd 570 2/19/09 2:46:35 PM

TA B L E 17- 4 (C O N T I N U E D) Lumbar Spine Regional Grid: Spine Impairments

IMPAIRMENT
RATING (WPI %) 0 1%–9% 10%–14% 15%–24% 25%–33%
Spinal stenosis a
0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
(may include
Lumbar ste- Lumbar stenosis, Lumbar stenosis, Lumbar stenosis, Lumbar stenosis,
Chapter 17
AOMSI)
nosis at 1 or at a single level at a single level at multiple levels at multiple levels
Note: AOMSI more levels or multiple levels, with or without with or without with or without
includes insta- with axial pain (with or without AOMSI with medi- AOMSI with medi- AOMSI with medi-
bility (specifi- only AOMSI) with medically documented cally documented cally documented
cally as defined cally documented findings; with or findings; with or findings; with or
in the Guides), findings; with or without surgery without surgery without surgery
arthrodesis, without surgery (decompression) (decompression) (decompression)
failed arthrod- (decompression)
and and and
esis, dynamic
or
stabilization or documented inter- documented neuro- severe neurogenic
arthroplasty, with resolved mittent neurogenic genic claudication, claudication and
or combina- previously docu- claudication (see walking limited to inability to ambu-
tions of those in mented neurogenic Table 17-7 to grade <10 minutes (see late without assis-
multiple-level claudication radiculopathy, but Table 17-7 to grade tive devices
conditions not claudication) radiculopathy, but
and may have docu-
not claudication)
may have documented signs of
may have docu-
mented signs of may have docu- bilateral or multi-
mented resolved
radiculopathy at mented signs of ple-level radiculop-
radiculopathy at
the clinically appro- radiculopathy at athy at the clinically
clinically appropri-
priate level pres- a single clinically appropriate levels
ate level(s) or non-
ent at the time of appropriate level present at the time
verifiable radicular
examination present at the time of examination
complaints at clini-
of examination
cally appropriate with signs of cauda with signs of cauda
level(s), present equina syndrome: with signs of cauda equina syndrome:
at the time of use Chapter 13 to equina syndrome: use Chapter 13 to
examination calculate additional use Chapter 13 to calculate additional
impairment calculate additional impairment
impairment
SPONDYLOLISTHESIS
Spondylolisthesis 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
Spondylolysis Spondylolisthesis Spondylolisthesis Spondylolisthesis Spondylolisthesis
or spondylolis- with medically with medically with medically with medically
thesis at one documented injury; documented injury; documented injury; documented injury;
or more levels with or without with or without with or without with or without
on imaging surgery surgery at a single surgery at multiple surgery at multiple
studies with level levels levels
and
axial pain only
and and and
with documented
resolved radicu- with documented with documented with documented
lopathy or non- signs of radiculopa- signs of radicu- signs of bilateral
verifiable radicular thy at the clinically lopathy at a single or multiple-level
complaints at clini- appropriate level clinically appropri- radiculopathy
cally appropriate present at the time ate level present at the clinically
level, present of examination (see at the time of appropriate levels
at the time of Table 17-7 to grade examination (see present at the time
examination radiculopathy) Table 17-7 to grade of examination (see
radiculopathy) Table 17-7 to grade
radiculopathy)
a
Note: The following applies to the cervical, thoracic, and lumbar spine grids: 1) Intervertebral disk herniation excludes
annular bulge, annular tear and disk herniation on imaging without consistent objective findings of radiculopathy at the
appropriate level(s) when most symptomatic. 2) When AOMSI is the diagnosis being rated, imaging is not included in the
Net Adjustment Calculation, because imaging is used to confirm the diagnosis.
(continued)
Guides6e_17_557-602.indd 571 2/19/09 2:46:36 PM


IMPAIRMENT
RATING (WPI %) 0 1%–9% 10%–14% 15%–24% 25%–33%
Degenerative 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
spondylolisthesis
Degenerative Degenerative spon- Degenerative spon- Degenerative Degenerative spon-
Chapter 17
with or without
spondylolis- dylolisthesis, at a dylolisthesis at a spondylolisthesis at dylolisthesis is at
spinal stenosis
thesis at one single or multiple single level, with multiple levels with multiple levels with
or more lev- levels, with medi- medically docu- medically docu- medically docu-
els with axial cally documented mented injury; with mented injury; with mented injury; with
pain only injury; with or or without surgery or without surgery or without surgery
without surgery
and and and
previously docu-
mented neurogenic documented inter- documented neuro- severe neurogenic
claudication mittent neurogenic genic claudication, claudication and
claudication (see walking limited to inability to ambu-
and
Table 17-7 to grade <10 minutes (see late without assis-
may have docu- radiculopathy, but Table 17-7 to grade tive devices
mented resolved not claudication) radiculopathy, but
may have docu-
radiculopathy or not claudication)
may have with doc- mented signs of
nonverifiable radic-
umented radiculop- may have docu- bilateral or multi-
ular complaints at
athy at the clinically mented radicu- ple-level radiculop-
clinically appropri-
appropriate level lopathy at a single athy at the clinically
ate level(s), pres-
present at the time clinically appropri- appropriate levels
ent at the time of
of examination ate level present present at the time
examination
at the time of of examination
examination
with signs of cauda
with signs of cauda equina syndrome:
equina syndrome: use Chapter 13 to
use Chapter 13 to calculate additional
calculate additional impairment
impairment
(continued)
As in other chapters in the Sixth Edition of the for Functional History differs by two or more grades
Guides, a functional assessment tool consisting of from that described by Physical Examination or
measurements initially designed and validated for Clinical Studies, the Functional History should be
outcome measurement has been included in this assumed to be unreliable. If the Functional History
chapter. Although many such tools have been devel- is determined to be unreliable or inconsistent with
oped and validated over the past 30 years, the PDQ other documentation or clinical findings, it is
was selected for reproduction in this chapter. (A excluded from the grading process.
description of the PDQ and instructions for admin-
istering this functional tool are provided at the end 17.3b Adjustment Grid: Physical
of this chapter in Appendix 17-A.) The Oswestry Examination
Disability Index is an alternative functional assess- When performing a physical examination, the clini-
ment that may be used for this purpose. cian needs to determine the significance of physical
findings as they relate to the impairment being evalu-
The evaluating physician may use the functional
ated. For the purposes of determining impairment,
assessment outcome questionnaire as part of the pro-
greater weight is given to those findings that are
cess of evaluating functional symptoms. However,
more objective. The highest grade modifier identified
the inventory is used only to assist the examiner in
in each adjustment grid is chosen for use in the net
defining the grade modifier for Functional History.
adjustment calculation. Some parameters described in
The inventory score does not serve as a basis for
the adjustment grid may be region-specific.
defining further impairment; nor does the score
reflect an impairment percentage. If multiple diagnoses are rated, the examiner should
determine the appropriate impairment class for each
The examiner must assess the reliability of the func-
diagnosis, and the examiner must distinguish which
tional reports, recognizing the potential influence
physical examination findings are associated with each
of behavioral and psychosocial factors. If the grade
specific ratable condition. If Physical Examination
Guides6e_17_557-602.indd 572 2/19/09 2:46:37 PM


IMPAIRMENT
RATING (WPI %) 0 1%–9% 10%–14% 15%–24% 25%–33%
FRACTURES/DISLOCATIONS OF THE SPINE
Fractures of 1 or 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
Chapter 17
more vertebral
Single- or multiple- Single- or mul- Single- or multiple- Single- or multiple-
bodies
level fractures with tiple-level fractures level fractures with level fractures with
including com- ⬍25% compression with 25%–50% ⬎50% compression ⬎50% compression
pression frac- of any vertebral compression of any of any vertebral of any vertebral
tures, fracture body; with or with- vertebral body; with body; with or with- body; with or with-
of posterior ele- out retropulsion; or without retropul- out retropulsion out retropulsion;
ment (pedicle, with or without sion; pedicle and/or into the canal; pedi- pedicle and/or
lamina, articular pedicle and/or posterior element cle and/or posterior posterior element
process, trans- posterior element fracture element fracture fracture
verse process) fracture
Healed, with or Healed, with or Healed, with or
and Healed, with or without surgery without surgery without surgery
without surgery (including ver- (including ver- (including ver-
burst fracture
(includes vertebroplasty or tebroplasty or tebroplasty or
tebroplasty or kyphoplasty) with kyphoplasty) with kyphoplasty) with
kyphoplasty) or without residual or without residual or without residual
deformity deformity deformity
and
and and and
may have docu-
mented resolved may have docu- may have signifi- may have signifi-
radiculopathy at mented radiculopa- cant radiculopathy cant radiculopathy
clinically appro- thy at the clinically at a single clinically bilaterally or at
priate level(s) or appropriate level appropriate level multiple clinically
documented non- present at the time present at the time appropriate levels
verifiable radicular of examination (see of examination (see present at the time
complaints (with- Table 17-7 to grade Table 17-7 to grade of examination (see
out radiculopathy) radiculopathy) radiculopathy) Table 17-7 to grade
at clinically appro- radiculopathy)
with signs of cauda with signs of cauda
priate level(s), pres-
equina syndrome: equina syndrome: with signs of cauda
ent at the time of
use Chapter 13 to use Chapter 13 to equina syndrome:
examination
calculate additional calculate additional use Chapter 13 to
with signs of cauda impairment impairment calculate additional
equina syndrome: impairment
use Chapter 13 to
calculate additional
impairment
(continued)
findings are determined to be unreliable or inconsis- of the spine is determined radiographically and
tent, or they are for conditions unrelated to the condi- defined according to the criteria listed in each region
tion being rated, they are excluded from the grading (Section 17.3c, Adjustment Grid: Clinical Studies).
process. In that case, the physician must explain the Table 17-7, Physical Examination Adjustment, sum-
rationale for the exclusion in his or her report. marizes the grading process.
Impairment related to radicular complaints is
Commonly Used Terms
included in the range of values for each diagnosis and
Although it is not the purpose of the Guides to dis-
accounted for by grade, using the adjustment grid.
cuss in detail how the basic physical examination
There is no separate impairment for radiculopathy,
is performed, some commonly used terminology is
unless specified in the regional grid. Findings related
defined to promote consistency.
to myelopathy, cauda equina syndrome, or spinal cord
injury are rated according to Chapter 13, The Central Nerve Tension/Compression Signs. Signs of nerve
and Peripheral Nervous System. tension or compression include the following:
Alignment and deformity are determined clinically 1. Straight leg raise.
and/or on the basis of radiographic studies. In the
2. Femoral stretch test
spine, instability is confirmed by findings on imaging
studies. For the purposes of this edition, instability 3. Spurling’s maneuver; cervical compression.
Guides6e_17_557-602.indd 573 3/3/09 7:00:31 PM


IMPAIRMENT
RATING (WPI %) 0 1%–9% 10%–14% 15%–24% 25%–33%
Dislocations/ 0 5 6 7 8 9 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
fracture-
Resolved Single- or multiple- Single-level disloca- Multiple-level dis- Multiple-level dis-
Chapter 17
dislocation
without sur- level dislocations tion with or with- location with or location with or
gery with no (with or without out fracture without fracture without fracture
residual signs fractures)
healed, with or healed, with or healed, with or
or symptoms
healed, with or without surgi- without surgi- without surgi-
without surgery cal intervention, cal intervention, cal intervention,
including fusion including fusion including fusion
may have docu-
mented resolved may have docu- may have docu- and
radiculopathy or mented radiculopa- mented radicu-
with documented
nonverifiable radic- thy at the clinically lopathy at a single
signs of bilateral
ular complaints at appropriate level clinically appropri-
or multiple level
clinically appropri- present at the time ate level present
radiculopathy
ate level(s), pres- of examination (see at the time of
at the clinically
ent at the time of Table 17-7 to grade examination (see
appropriate levels
examination radiculopathy) Table 17-7 to grade
present at the time
radiculopathy)
with signs of cauda with signs of cauda of examination (see
equina syndrome: equina syndrome: with signs of cauda Table 17-7 to grade
use Chapter 13 to use Chapter 13 to equina syndrome: radiculopathy)
calculate additional calculate additional use Chapter 13 to
with signs of cauda
impairment impairment calculate additional
equina syndrome:
impairment
use Chapter 13 to
calculate additional
impairment
Post-operative 25 27 29 31 33
complications
Deep spinal
(nonneurologic)
wound infection
Note: Neurologic requiring chronic
complications suppressive anti-
are rated in biotics; or chronic
Chapter 13, osteomyelitis
The Central
and Peripheral
Nervous System
Note: Alteration of motion segment integrity indicates AOMSI. It is defined using flexion/extension X rays (Figures 17-5 and
17-6). In the lumbar spine (L1-5), a diagnosis of AOMSI by translation measurements requires greater than 8% anterior or
greater than 9% posterior relative translation of one vertebra on another, on flexion or extension radiographs, respectively.
In the lumbosacral spine (L5-S1), it requires greater than 6% anterior or greater than 9% posterior relative translation of L5 on
S1, on flexion or extension radiographs, respectively. A diagnosis of AOMSI by angular motion measurements requires greater
than 15° at L1-2, L2-3, and L3-4; greater than 20° at L4-5, or greater than 25° at L5-S1 (compared to adjacent level angular
motion). Alternatively, may have complete or near-complete loss of motion of a motion segment due to developmental fusion
or to successful or unsuccessful attempts at surgical arthrodesis.
Sciatic nerve tension signs are important indicators performed. The L4 root moves a shorter distance.
of lumbosacral nerve root irritation. Positive tension Therefore, the SLR test has the most value in assess-
signs are most commonly seen in individuals with ing lesions of the L5 and S1 roots. The supine SLR
a herniated lumbar disk. The most commonly used test is considered positive when radicular pain is
sciatic nerve tension test is the straight leg raising reproduced at between 35° and 70° of leg elevation
(SLR) test. When performed in the supine posi- with hip flexion. Back pain that occurs with the SLR
tion, the hip is flexed as the examiner raises the leg is not a positive finding. Hamstring tightness must
with the knee extended. In the sitting position, with also be differentiated from posterior thigh pain due
the hip flexed 90°, the knee is extended. The test is to root tension.
positive when thigh and/or leg pain, often along the
Pathology at higher levels of the lumbar spine is
appropriate dermatomal distribution, is reproduced.
often associated with a negative SLR test result. A
The degree of elevation at which pain occurs is
femoral nerve stretch test stretches the femoral nerve
recorded. The L5 and S1 nerve roots are primarily
and tests the L2-4 roots. It involves prone extension
affected by a change in their length when SLR is
Guides6e_17_557-602.indd 574 2/19/09 2:46:38 PM

TA B L E 17- 5
Non-Key Specific Grade Grade Grade Grade Grade
Factor Adjustment Grid Modifier 0 Modifier 1 Modifier 2 Modifier 3 Modifier 4
Functional Table 17-6 No problem Mild problem Moderate Severe Very severe
History problem problem problem
Chapter 17
Physical Table 17-7 No problem Mild problem Moderate Severe Very severe
Examination problem problem problem
Clinical Studies Table 17-9 No problem Mild problem Moderate Severe Very severe
problem problem problem
of the hip on the affected side. Root tension signs are when pressure is applied to the top of the patient’s
most reliable when the pain is elicited in a dermato- head; alternatively, relief of symptoms occurs when
mal distribution. traction is applied under the chin and occiput.
Although the SLR test in disk herniation is relatively Reflexes. Reflexes may be normal, increased,
sensitive (72% to 97%), it is nonspecific (11% to reduced, or absent. For reflex abnormalities to be
45%). The SLR test of the asymptomatic limb that considered clinically significant, the involved and
produces sciatica in the symptomatic limb—the normal limb or limbs should show marked asym-
cross-positive SLR test—is specific (85% to 100%) metry between arms or legs on repeated testing. For
but less sensitive (23% to 42%). Supine SLR testing the purposes of impairment rating, abnormal and
can be further validated by gentle dorsiflexion and asymmetrical reflex should be a new finding, related
plantar flexion of the ankle, as well as internal and to the diagnosis being evaluated. Once lost because
external rotation of the hip with the leg raised to the of previous radiculopathy, a reflex rarely returns.
symptomatic level. A positive SLR test is validated Abnormal reflexes such as Babinski signs or clonus
by ankle dorsiflexion and hip internal rotation, in- may be signs of corticospinal tract involvement.
creasing pain while the other movements decrease
Weakness and Loss of Sensation. A careful neu-
the pain. A sitting SLR test may be useful in validat-
rologic examination should be performed to assess
ing supine SLR testing, but the examiner must inter-
dermatome-related sensory deficits and myotome-
pret the findings cautiously, since the lumbar spine
related motor deficits. Appropriate tables and figures
is generally more flexed in the sitting than in the
are provided to identify common dermatome maps,
supine position. In chronic nerve root compression
(see Figures 17-3a, 17-3b and 17-4) and the muscles
due to spinal stenosis, tension signs are often absent.
commonly affected by motor loss attributable to a
Axial compression of the spine and rotation to the specific nerve root (Table 17-8, Common Radicular
ipsilateral side of symptoms may reproduce or increase Syndromes). In order to be considered valid, the sen-
symptoms of cervical radiculopathy. Pain to the side sory findings must be in an anatomic distribution (ie,
of rotation is usually indicative of foraminal stenosis follow dermatomal patterns) although some overlap
and nerve root irritation. Spurling’s test is positive may occur. Motor findings should also be consistent
when upper extremity pain is reproduced by extend- with the affected nerves or roots. Significant, long-
ing the neck and rotating the chin toward the affected standing weakness is usually accompanied by mea-
extremity. The axial compression test reproduces pain surable atrophy.
TA B L E 17- 6
Functional History Adjustment: Spine
Functional History Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Factor 0 1 2 3 4
Activity Asymptomatic; Pain; symptoms Pain; symptoms Pain; symptoms Pain; symptoms
problem resolved; with strenuous/ with normal with less-than- at rest, limited to
inconsistent vigorous activity activity normal activity sedentary activity
symptoms (minimal activity)
PDQ or alterna- No disability Mild disability Moderate Severe disability Extreme disability
tive validated disability
PDQ 0 PDQ 0–70 PDQ 101–130 PDQ 131–150
functional assess-
PDQ 71–100
ment, scaled
appropriately
Note: PDQ indicates Pain Disability Questionnaire.
Guides6e_17_557-602.indd 575 3/3/09 7:00:31 PM

TA B L E 17-7
Physical Examination Adjustment: Spine
Physical Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Examination 0 1 2 3 4
Factor
Chapter 17
Lumbar Negative straight Positive straight

Neural leg raising test leg raising test,
Tension for radicular with reproducible
Signs pain or invalid radicular pain at
examination 35°–70°
Cervical Negative cervical Positive cervical
Compression/ compression/ compression/foram-
Foraminal foraminal inal compression
Compression compression (Spurling’s test)
with reproducible
radicular pain
Reflexes Normal and New and asym-
symmetrical metrical abnormal-
ity consistent with
other radicular
findings (ie, dif-
ferentiate between
old and new
changes)
Atrophy
UE 1 cm 1.0–1.9 cm 2.0–2.9 cm 3.0–3.5 cm 3.5 cm
LE 1 cm 1.0–1.9 cm 2.0–2.9 cm 3.0–3.5 cm 3.5 cm
Sensory No loss of sensi- Diminished light Diminished light Decreased protec- Absent superficial
Deficit bility, abnormal touch (with or touch (with some tive sensibility pain and tactile
sensation, or pain without minimal abnormal sensa (with abnormal sensibility or
abnormal sensations or slight sensations or absent protective
tions or pain) in a pain) in a clini moderate pain in a sensibility (abnor-
clinically appropri- cally appropriate clinically appropri- mal sensations, or
ate distribution, distribution, that ate distribution) severe pain) that
that is forgotten interferes with that may prevent prevents all activity
during activity some activities some activities
Motor Normal Active Active movement Active movement Active movement Slight contraction
Strength movement against against gravity and against gravity with gravity elimi- and no movement
gravity with full some resistance only, without nated (2/5) or no contraction
resistance (5/5) (4/5) resistance (3/5) (0–1/5)
Atrophy. Atrophy is measured with a tape measure identification of a condition that may be associated
at identical levels on both limbs. The difference in with radiculopathy (such as a herniated disk) on an
circumferences is described by grade modifiers for imaging study is not sufficient to make a diagnosis of
both the upper and lower extremities in Table 17-7, radiculopathy; clinical findings must correlate with
Adjustment Grid: Physical Examination. Asymmetry the radiographic findings in order to be considered.
for reasons other than atrophy does not affect the rating.
Nonverifiable Radicular Complaints. Nonveri-
Radiculopathy. For the purposes of the Guides, fiable radicular complaints are defined as chronic
radiculopathy is defined as significant alteration in persisting limb pain or numbness, which is consis-
the function of a single or multiple nerve roots and is tently and repetitively recognized in medical records,
usually caused by mechanical or chemical irritation of in the distribution of a single nerve root that the
one or several nerves. The diagnosis requires clinical examiner can name and with the following charac-
findings including specific dermatomal distribution teristics: preserved sharp vs. dull sensation and pre-
of pain, numbness, and/or paresthesias. Subjective served muscle strength in the muscles it innervates, is
reports of sensory changes are more difficult to not significantly compressed on imaging, and is not
assess; therefore, these complaints should be consis- affected on electrodiagnostic studies (if performed).
tent and supported by other findings of radiculopathy. Although there are subjective complaints of a specific
There may be associated motor weakness and loss radicular nature, there are inadequate or no objective
of reflex. A root tension sign is usually positive. The findings to support the diagnosis of radiculopathy.
Guides6e_17_557-602.indd 576 2/19/09 2:46:40 PM

F I G U R E 17-3
Skin Area Innervated by the Cervical and Thoraic Nerve Roots Showing Autonomous Zones
Chapter 17
C6
C5 C4 C7
C7
C3 C6
C5
C4 T1
C8 T2 C8
T1 T3
T4
C6
C7 C5 C4 C7
C5 C6
C4 T1 C8
C8 T2
T1 T3
T4
17.3c Adjustment Grid: Clinical Studies imaging findings. In other words, an imaging test
The patient may have undergone a variety of special is useful to confirm a diagnosis, but findings on an
tests, including imaging studies and electrodiagnostic imaging study alone are insufficient to qualify for
(EMG/ NCV) studies. The physician should review an impairment. In cases where the abnormalities
these studies, the findings, and note their interpreta- just discussed are present on imaging studies, and
tions. Whenever possible, the physician should per- are known (or assumed) to have preexisted an injury
sonally review the studies and report agreement or being rated, evaluators should acknowledge these
disagreement with previous interpretations. antecedent conditions in the report.
Although imaging and other studies may assist physi- If a diagnosis of AOMSI, pseudarthrosis, fracture or
cians in making a diagnosis, it is important to note spondylolisthesis is made, imaging studies should be
that a positive imaging study, in and of itself, does excluded as a grade modifier.
not make the diagnosis. Several reports indicate that
approximately 30% of persons who have never had Alteration of Motion Segment Integrity
back pain will have an imaging study that can be (AOMSI)
interpreted as positive for a herniated disk, and 50% There are several technical considerations in
or more will have bulging disks. The prevalence obtaining and interpreting radiographic studies to
of degenerative changes, bulges, and herniations evaluate AOMSI, including magnification, film
increases with advancing age. Developmental findings, quality and normal thresholds for translation and
such as spondylolysis, are found normally in 7% of angular motion. AOMSI as defined in the Guides is
adults, and spondylolisthesis is found in 3% of adults. assessed by plain film flexion-extension radiographs
only. Source to image distance (SID) for flexion-
For imaging studies to be of diagnostic value, clini-
extension X rays of the thoracic and lumbar spine
cal symptoms and signs must be consistent with the
Guides6e_17_557-602.indd 577 2/19/09 2:46:40 PM

F I G U R E 17- 4
Skin Areas Innervated by the Thoracic and is not defined in the literature or medical practice;
Lumbosacral Nerve Roots and Showing however, 40 SID imaging parameters are most com-
Autonomous Zones monly used in the lumbar spine. The relative transla-
tion measurements are described in this text for each
T12 spinal region, corrected for magnification.
L1
T10
Chapter 17
L2 Cervical spine AOMSI is defined using flexion/

T11 L3
L5
extension X rays (Figures 17-5 and 17-6 describe
T12 similar technique for lumbar spine). A diagnosis of
L1 S3 L4 AOMSI in the cervical spine by translation mea-
S4 S2
S5
C
surements requires greater than 20% anterior or
greater than 20% posterior relative translation of one
L2
vertebra on another, on flexion or extension radio-
L1 S1 graphs, respectively; or angular motion of more than
L3
11° greater than each adjacent level on the flexion
L3 L2
S2 radiograph. Alternatively, there may be complete or
near-complete loss of motion of a motion segment
L4 due to developmental fusion; successful or unsuc-
L4 cessful attempts at surgical arthrodesis, including
L3
dynamic stabilization; or preserved motion with disk
arthroplasty.
L5
Thoracic spine AOMSI is defined using flexion/
L5 extension X rays (Figures 17-5 and 17-6). A diagno-
sis of AOMSI in the thoracic spine by translation
L4 measurements requires at least 2.5 mm anterior
S1
or 2.5 mm posterior translation of one vertebra on
S1
another, on flexion or extension radiographs respec-
S1
tively; or successful or unsuccessful attempts at sur-
L4 L5 gical arthrodesis, including dynamic stabilization.
TA B L E 17- 8
Common Radicular Syndromes
Disk Level Nerve Root Motor Deficit Sensory Deficit Reflex Compromise
LUMBAR
L3–4 L4 Quadriceps Anterior thigh Knee
Anterior knee
Medial leg and foot
L4–5 L5 Extensor hallucis longus Lateral thigh Medial hamstrings
Anterolateral leg
Middorsal foot
L5-S1 S1 Ankle plantar flexors Posterior leg Ankle
Lateral foot
CERVICAL
C4–5 C5 Deltoid Anterolateral shoulder Biceps
Biceps and arm
C5–6 C6 Radial wrist extensor Lateral forearm and hand Brachioradialis
Biceps Thumb Pronator teres
C6–7 C7 Wrist flexors Middle finger Triceps
Triceps
Finger extensors
Ulnar wrist extensor
C7-T1 C8 Finger flexors Medial forearm and hand, None
Hand intrinsics ring and little fingers
T1-T2 T1 Hand intrinsics Medial forearm None
Guides6e_17_557-602.indd 578 2/19/09 2:46:41 PM

F I G U R E 17- 5
Loss of Motion Segment Integrity, Translation Imaging Studies
X ray and CT may be very useful in detecting bony
abnormalities. These studies can help detect fractures,
dislocations, joint narrowing, and lesions associated
with alteration of bony architecture (tumor, infection,
etc). Flexion/extension X rays may provide useful infor-
Chapter 17
mation on AOMSI (instability or loss of motion) at a
given level. MRI is more useful for detection of soft
tissue lesions, including disc and nerve root pathology.
B The identification of degenerative disk disease at one or
multiple levels, similar to the finding of arthrosis in an
A extremity joint, is not diagnostic of injury- or disease-
related pathology because such degenerative changes
can be a natural consequence of the aging process.
Electrodiagnostic Verification of Radiculopathy

tion, training, and experience in these procedures.
Typically, these studies are performed by board
certified neurologists and physical medicine special-
ists. Some jurisdictions allow others to perform such
A dot is placed at the posterior superior corner of the studies. The studies must be performed in accor-
lower vertebra, and a separate dot is placed at the pos- dance with established standards. The quality of the
terior-inferior corner of the upper vertebra. The distance test and interpretation of the results depend on the
(A) is measured as illustrated by the figure, using two
parallel lines. Measurements are obtained in flexion and skill and knowledge of the individual performing
extension. Measure the A-P sagittal plane diameter at the the study. The technique and documentation of the
midlevel of the superior vertebra (B). Distance A is then electromyographer may be considered in assess-
compared to distance B; determine % or distance in mm
ing “EMG evidence” and validity. The EMG/NCV
as specified for each region (see Section 17.3). AOMSI is
established if the regional criteria are met. is considered to be an extension of the history and
physical examination, and interpretation should cor-
relate with the clinical findings.
Lumbar spine AOMSI is defined using flexion/
Evidence of radiculopathy (axonal injury of the nerve
extension X rays (Figures 17-5 and 17-6). A diag-
root) on EMG is based on the finding of reproducible
nosis of AOMSI in the lumbar spine (L1-L5) by
positive sharp waves and/or fibrillation potentials in
translation measurements requires greater than 8%
muscles innervated by one or more nerve roots. These
anterior or greater than 9% posterior relative transla-
“spontaneous potentials” result from ongoing axonal
tion of one vertebra on another, on flexion or exten-
loss with denervation of the muscle. Abnormalities
sion radiographs respectively. In the lumbosacral
should be observed in a myotomal distribution. So-
spine (L5-S1), it requires greater than 6% anterior or
called “chronic” radiculopathy is a confusing term
greater than 9% posterior relative translation at L5-
that generally refers to findings indicative of old
S1 of L5 on S1 on flexion or extension radiographs,
nerve root injury. Interpretation of EMG findings as
respectively. A diagnosis of AOMSI in the lumbosa-
reflecting old axonal injury is more subjective and
cral spine by angular motion measurements requires
includes identifying motor unit configuration changes
greater than 15° at L1-2, L2-3, and L3-4; greater than
such as increased amplitude and duration. These are
20° at L4-5, or greater than 25° at L5-S1 (compared
not usually quantitated in routine EMG testing.
with adjacent level angular motion).
Electrodiagnostic testing does not detect all compressive
Alternatively, there may be complete or near-com-
radiculopathies, cannot detect sensory root involvement,
plete loss of motion of a motion segment due to
and cannot determine the cause of the nerve root pathol-
developmental fusion or to successful or unsuc-
ogy. However, EMG can detect noncompressive radicu-
cessful attempts at surgical arthrodesis; including
lopathies that are not identified by imaging studies when
dynamic stabilization; or preserved motion with disk
there is axonal loss. Paraspinal muscle needle EMG
arthroplasty.
findings in patients with previous spine surgery must be
Some relevant information on selected clinical tests interpreted with caution, as the paraspinal muscles may
is provided in the following subsections. exhibit abnormalities for a prolonged time after surgery.
Guides6e_17_557-602.indd 579 2/19/09 2:46:42 PM

F I G U R E 17- 6
Loss of Motion Segment Integrity, Angular Motion (Sagittal Rotation), Lumbar Spine
Chapter 17
– 18 °
+ 8°
Lines are drawn along the superior border of the vertebral body of the lower vertebrae and the superior border of the
body of the upper vertebrae and the lines extended until they join. The angles are measured and subtracted. Note that
lordosis (extension) is represented by a negative angle and kyphosis (flexion) by a positive angle. Loss of motion segment
integrity is defined as motion greater than 15° at L1–2, L2–3, and L3–4 and greater than 20° at L4 to L5. Loss of integrity of
the lumbosacral joint is defined as angular motion between L5 and S1 that is greater than 25°. The flexion angle is 8° and
the extension angle is 18°. In the illustration, the flexion angle is 8°. Therefore (8) (18) 26° and would qualify for
loss of structural integrity at any lumbar level.
At present, only the needle EMG is considered diag- In cases of myelopathy or other central nervous
nostic of radiculopathy. H reflex, F wave, nerve con- system (CNS) involvement, the rating physi-
duction studies, and evoked potentials are adjuncts cian independently assesses impairments for the
in the testing and can help evaluate for other pathol- musculoskeletal injury or illness, and for the CNS
ogy. For the purposes of Table 17-9, Clinical Studies neurologic loss. The spinal cord level of involvement
Adjustment, EMG evidence of acute radiculopathy is determined by identifying the lowest normally
requires findings of positive sharp waves and/or functioning nerve root, which determines the cord
fibrillation potentials (as described in detail in level. Identifying the level of nerve root function
Chapter 15, The Upper Extremities). A report con- helps to determine the degree of residual function.
cluding evidence of “chronic” radiculopathy should The total impairment for the spinal region results
be thoroughly scrutinized and not necessarily inter- from combining the values for the musculoskeletal
preted as evidence of an active axonal lesion. impairment and the CNS impairment.
In this chapter, when conditions that include a clini-
17.3d Corticospinal Injury
cal component best rated using CNS impairment cri-
In this edition of the Guides, rating corticospinal
teria are identified, reference is made to Chapter 13,
cord injury is deferred to Chapter 13, The Central
The Central and Peripheral Nervous System.
and Peripheral Nervous System. Only objective
impairments secondary to a corticospinal injury are
17.3e Mental and Behavioral Problems
rated. It is not appropriate to seperately rate subjec-
and Chronic Pain
tive complaints such as sexual or sleep dysfunction
In unusual cases, a musculoskeletal injury or
that are not of a neurogenic origin; these complaints
incident may be accompanied by a primary men-
are considered in the Functional History as a compo-
tal health disorder, which is rated independently
nent of activities of daily living.
using the Mental and Behavioral Disorders chapter
(Chapter 14). Under most circumstances, however,
Guides6e_17_557-602.indd 580 2/19/09 2:46:44 PM

TA B L E 17-9
Clinical Studies Adjustment: Spine
Clinical Studies Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Factor 0 1 2 3 4
Imaging studies: Imaging findings CT/MRI/other Imaging evidence
Radiographs, do not support imaging findings of major surgical
bone scan, MRI symptoms or consistent with complications,
Chapter 17
structural diagno- clinical presen- including infec-
sis within normal tation, includ- tion or major
limits ing evidence of deformity
AOMSI with seg-
or
mental instability,
normal age- fusion, or motion
related changes preservation
or device defined by
region (see row
clinically insignifi- below)
cant degenerative
changes, or find-
ings on the side
opposite clinical
presentation
Electrodiagnostic Normal EMG evidence EMG evidence
testing consistent with consistent with
single nerve root multiple nerve
radiculopathy root radiculopathy
Note: CT indicates computed tomography; MRI, magnetic resonance imaging; AOMSI, alteration of motion segment integrity; and EMG,
electromyographic.
impairment rating for mental health disorders related the impairment range. Once the impairment class
to the stressors that often accompany a chronic, dis- is determined according to diagnostic criteria, the
abling musculoskeletal disorder, is captured within impairment grade within the class is calculated using
the rating for the musculoskeletal disorder itself. the non-key factors, or grade modifiers from the
An independent mental health impairment rating is adjustment grids and the Net Adjustment Formula.
considered duplicative. In addition, Chapter 3, Pain- The first grade (A) is the lowest impairment rating
Related Impairment, provides impairment ratings that could be assigned for the class; the last grade
for chronic pain conditions that arise independent (E) is the highest.
of any organ system that is rated by usual methods.
Within the specified class, the grade should initially
Impairment ratings for those conditions are calcu-
be assigned to the default (C) rating. This initial
lated using either a musculoskeletal chapter (Chapter
default value may be modified up or down within
15, 16, or 17) or Chapter 3. Adding or combining
a class depending on the net adjustment, which is
ratings from a musculoskeletal chapter and Chapter
calculated by using the grade modifiers in the Net
3 is not permissable.
Adjustment Formula. The grade modifiers are
designed to reflect specific functional, physical, and
17.3f Impairment Calculation
clinical findings specific to the patient. Using the
Methodology
Net Adjustment Formula, the assigned value for
As described in the preceding parts of this chapter,
each grade modifier (0 to 4) is compared with the
impairment is calculated by identifying an impair-
number of the impairment class (0 to 4) using the
ment class that reflects the diagnosis, and a grade
Net Adjustment Formula, described in the box on
that considers functional, physical, and clinical
page 582, Net Adjustment Formula: Mathematical
facets of the condition. The impairment class (IC) is
Explanation. The calculated net adjustment value
determined first, using the corresponding diagnosis-
is used to move up a grade ( net adjustment value)
based regional grid. The grade within the class is
or down a grade ( net adjustment value) within a
then determined using the adjustment grids and the
class. If all the grade modifier numbers are the same
Net Adjustment Formula.
as the impairment class number, the net adjustment
The regional grids provide a range of impair- value will be 0 and the default value (C) will be the
ment values for each specific diagnosis. Each cell impairment rating value for that diagnosis. A change
within the regional grid contains a series of five in class is not permitted, regardless of the magnitude
numbers that correspond to grades A through E in of the net adjustment.
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TA B L E 17-1 0 Methodology for Determining the Grade in an Impairment Class

Chapter 17
IMPAIRMENT
CLASS 0 1 2 3 4
IMPAIRMENT
RATING (%) 0 1%–9% 10%–16% 17%–25% 26%–30%
Example Rating 3 4 5 6 7 10 11 12 13 14 17 18 19 20 21 26 27 28 29 30
METHOD
1. Using the relevant regional grid, choose the Net Adjustment Formula: Mathematical
appropriate diagnosis for the condition, located in Explanation
the left-most column. Select the appropriate class
Net adjustment may be obtained by a mathemati-
for that diagnosis, based on the criteria specified
cal formula and then use of the resultant value to
in the columns for classes 0 to 4.
define the grade. The following abbreviations are
2. Using the adjustment grids for Functional used:
History, Physical Examination, and Clinical
CDX Class of Diagnosis (Regional Grid)
Studies, identify the appropriate grade using
GMFH Grade Modifier for Functional History
grade modifiers:
GMPE Grade Modifier for Physical
a. If there are multiple components to a grade Examination
modifier, such as Physical Examination GMCS Grade Modifier for Clinical Studies
(which may include findings on palpation,
alignment, instability), choose the highest
grade modifier that is objective and is associ-
ated with the diagnosis being rated. If a grade Grade Assignments:
modifier is found to be unreliable or inconsis-
Net Adjustment Grade
tent, it should be disregarded and eliminated
(from default C)
from the calculation.
2 A
b. If a particular component, such as findings
1 B
on X ray, was used to determine impairment
0 C
1 D
the grade and is disregarded in the impair-
2 E
ment calculation.
For example, if the diagnosis is in impairment
c. The Functional History grade modifier should
class 2, then CDX 2. If net adjustment value is
be applied only to the highest DBI. Specific
2, then Grade is A.
jurisdictions may modify this process so that
Functional History adjustment is considered
for each DBI or not considered at all as a
grade modifier.
3. Apply the Net Adjustment Formula, as shown adding those values. That net adjustment value
in the box, and calculate the net adjustment value will determine how many places up or down
by subtracting the numerical value of the class from the default value “C” the rating should
(CDX) from the numerical value of the grade move. The corresponding numerical value for the
modifier for each adjustment (Functional History, impairment can then be identified in the regional
Physical Examination, and Clinical Studies) and grid and impairment class selected initially.
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Example: Lumbar Diskectomy With Residual Radiculopathy

The use of the 2-grid process can be illustrated by the rating of a lumbar laminectomy and partial diskectomy
with residual radiculopathy. According to the lumbar regional diagnosis-based grid, this results in class 2
impairment. If, on the basis of the use of the adjustment tables, it was determined that the non-key factors
were PDQ score of 80 (grade modifier 2), straight leg raising (SLR) test was positive (grade modifier 2),
Chapter 17
and MRI study confirmed the diagnosis (grade modifier 2), the net adjustment is calculated as follows:
Net Adjustment (GMFH CDX) (GMPE CDX) (GMCS CDX)
or
Net Adjustment (2 2) (2 2) (2 2) 0
A net adjustment of 0 does not move the grade up or down within the class, and therefore the grade remains at
the default rating (C) for the diagnosis; that is, it would remain at 12% whole person impairment (WPI).
To further illustrate this process, if the key fac- spine region, rather than the whole person. This is done
tor identifies class 3, and non-key factors identify by dividing the WPI estimate by the % of spine func-
grade modifier 1 and grade modifier 4 with the tion that has been assigned to that region. The conver-
third non-key factor determined to be unreliable, sion factors used in the DBI method are the same as
this would produce differences of 2 (1 3)and those used for the DRE method in the Fifth Edition.
1 (4 3), respectively. These values (2 1) add For the purposes of the DBI method, the conversion
to a net adjustment of 1, moving the rating to 1 factors are: 0.35 for the cervical spine, 0.20 for the tho-
lower grade within that class (ie, 1 position to the racic spine, and 0.75 for the lumbar spine.
left) and the corresponding impairment percent-
age. In this example, if the non-key factors both 17.3g Spine Impairment Case Examples
identified grade modifier 1, the differences would
Cervical Spine Examples
total 4 [Net Adjustment (1 3) (1 3)
4]. Since this procedure does not allow jumping
from 1 class to a lower (or higher) class, the rating
would move to the lowest grade within a class. In CLASS 0
this example, if all non-key factors identified grade 0% Whole Person Impairment
modifier 3, the impairment would remain at the
default midposition.
EXAMPLE 17-1: CERVICAL SPRAIN/STRAIN
As explained in other chapters, a modification of
this process is required for class 4 impairments.
If the key factor is class 4, and all non-key factors History: The patient was rear-ended at a stoplight in
were grade modifier 4 (the highest value), the dif- a motor vehicle accident and sustained a “whiplash-
ferences would summate to zero, and placement in type” neck injury. She was seen in an emergency room,
a grade above the default value C in class 4 would where X rays revealed straightening of the lordotic
not be possible. To correct this deficiency, if the curve without other abnormalities. She missed 2 days
key factor is class 4, automatically add 1 to the of work and then returned to the job. She saw her fam-
value of each adjustment grade modifier. For exam- ily doctor who provided anti-inflammatory analgesic
ple, if the first non-key factor was grade modifier medication and muscle relaxants, which she uses spar-
3, the second was grade modifier 4, and the class is ingly. The physical exam revealed some paravertebral
4, the differences are 1 and 0 (see Net Adjustment C3-6 tenderness, with mild mobility deficit primarily
Formula above). Adding 1 to each grade modi- affecting rotation to the right, but with no neurologic
fier raises the values to 4 and 5, and the calcula- signs. No further imaging studies were ordered. She
tion yields values of 0 and 1, which sum to a net had 3 visits with a physical therapist and, 4 weeks after
adjustment value of 1. The final grade is D, and the accident, was discharged to a home exercise pro-
the final impairment is the numerical rating associ- gram. Her doctor saw her again 6 weeks after injury
ated with class 4 grade D. and determined that the injury had resolved.
Regional Impairment Current Symptoms: Occasional pain with vigorous
In some instances, the evaluator may be asked to activity; she has returned to full function.
express an impairment rating in terms of the involved
Physical Examination: Normal examination.
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Clinical Tests: None repeated. at the clinically appropriate level present at the time
of examination,” and therefore, assigned to class 1.
Diagnosis: Resolved cervical sprain/strain.
Adjustment Grids: Functional History grade modi-
Impairment Rating: Regional Impairment: Diagnosis fier would be 4 (based on his reports and PDQ)
is consistent with “Documented history of sprain/strain however, this is 2 or more points higher than the
type injury, now resolved or continued complaints of grade modifier for clinical studies and therefore dis-
Chapter 17
neck pain with no objective findings on examination,” counted. Physical Exam: Grade modifier 0 based on
and therefore assigned to class 0. With class 0, adjust- no objective neurological deficits. Clinical Studies:
ment is not required; however, the Functional History Grade modifier 2. Net adjustment is 0, and there is
reported full function. No objective physical examina- no adjustment to the default impairment (C), result-
tion or clinical test findings at MMI also support class ing in class 1 grade C. Impairment 6% WPI.
0. Regional Impairment: 0% WPI.
CDX GMFH GMPE GMCS
1 n/a 0 2
CLASS 1 Net adjustment
1% to 8% Whole Person Impairment (GMFH CDX) n/a
(GMPE CDX) (0 1) 1
EXAMPLE 17-2: INTERVERTEBRAL DISK (GMCS CDX) (2 1) 1
HERNIATION Net adjustment 0
Subject: 36-year-old man. Result is class 1, adjustment 0, which equals class 1,

grade C impairment 6%.
History: A construction worker fell 0.9 m (3 ft) from Note: CDX indicates class of diagnosis; GMFH, grade modifier
a ladder, injuring his neck. Six months later he is for Functional History; GMPE, grade modifier for Physical
Examination; GMCS, grade modifier for Clinical Studies; and
determined to be at MMI after nonoperative care, with n/a, not applicable.
persisent neck pain radiating to his right arm. Over the
course of the 6 months he has been assessed with a
number of clinical tests. Two doctors have documented
mild hypesthesia in the C6 distribution on the right
CLASS 2
side, without motor or reflex changes. At the time of
impairment rating, the examining physician verifies
that MMI has been reached; the patient is medically
EXAMPLE 17-3: INTERVERTEBRAL DISK
stable and prepared for return to work, and no further
HERNIATION OR AOMSI AT A SINGLE LEVEL
treatment recommendations have been made.
Current Symptoms: The patient describes his pain
as constant, rating 8/10. History: The patient had an onset of neck pain and
left arm pain after repetitive lifting of boxes while
Functional Assessment: The PDQ score is 135,
stocking shelves at work. She was treated with epi-
consistent with extreme disability.
dural injections and physical therapy. Ultimately, she
Physical Examination: Severe guarding and no underwent an anterior cervical fusion.
neurological deficits.
Current Symptoms: Resolution of neck pain and
Clinical Tests: Include a normal set of cervical persistent pain in the left arm. Symptoms occur only
X rays, normal EMG, and MRI demonstrating mild with strenuous activity.
bulges and desiccation at C4, C5, and C6 with a
Functional Assessment: The PDQ is 50 consistent
right-sided disk herniation at C5-6.
with mild disability.
Diagnosis: Cervical disk herniation with resolved
Physical Exam: Slightly decreased range of motion
right-sided C6 radiculopathy.
of the cervical spine and slight weakness of wrist
Impairment Rating: Regional Impairment: extensors on the left, diminished light touch in C6
Diagnosis is consistent with “Intervertebral disk her- distribution.
niation or documented AOMSI at a single or multiple
Clinical Studies: Preoperative MRI showed a disk
levels with medically documented findings; with or
herniation at C5-6, left. Postoperative films show a
without surgery, AND with documented resolved
healed anterior interbody fusion at C5-6.
radiculopathy or non-verifiable radicular complaints
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Diagnosis: Status post herniated nucleus pulposus and Physical Exam: Decreased range of motion in the
anterior cervical diskectomy and fusion at C5-6 with neck, positive cervical compression with severe
persistent left arm pain. radiating pain to the left arm in a C8 distribution.
He has decreased finger flexion strength (3/5), and
decreased sensation in ring and little fingers.
Diagnosis is consistent with “Intervertebral disk her-
Chapter 17
niation and/or AOMSI at a single level with medically Clinical Tests: MRI: left posterolateral disk hernia-
documented findings; with or without surgery, and tion C7-T1. EMG: left C8 fibrillation potentials.
with documented resolved radiculopathy at the clini-
Diagnosis: Cervical disk herniation with C8
cally appropriate level present at the time of examina-
radiculopathy.
tion,” and therefore, assigned to class 2. Adjustment
Grids: Functional History: Grade modifier 1 based Impairment Rating: Regional Impairment:
on both functional symptoms and PDQ. Physical Diagnosis is consistent with “Intervertebral disk
Examination: Grade modifier 2 based on motor herniation and/or AOMSI at a single level with medi-
strength. Clinical Studies: Grade modifier 2 based on cally documented findings; with or without surgery
imaging studies. Net adjustment is 1 and the impair- and with documented radiculopathy at the clinically
ment is class 2 grade B. Impairment is 11% WPI. appropriate level present at the time of examination”
and therefore, assigned to class 2. Adjustment Grids:
Class 2 Example Calculation Functional History: Grade modifier 3 based on symp-
CDX GMFH GMPE GMCS toms with minimal activity and PDQ score. Physical
2 1 2 2 Examination: Grade modifier 2 based on sensory and
Net adjustment motor findings. Clinical Studies: Grade modifier 2.
Net adjustment is 1, resulting in class 2, grade D.
(GMFH CDX) (1 2) 1
Impairment is 12% WPI.
(GMPE CDX) (2 2) 0
(GMCS CDX) (2 2) 0 Class 2 Example Calculation
Net adjustment 1 CDX GMFH GMPE GMCS
Result is class 2 with an adjustment 1; therefore, 2 3 2 2
this impairment is class 2, grade B, which equals 11%
impairment Net adjustment
Note: CDX indicates class of diagnosis; GMFH, grade modifier (GMFH CDX) (3 2) 1
for Functional History; GMPE, grade modifier for Physical (GMPE CDX) (2 2) 0
Examination; and GMCS, grade modifier for Clinical Studies.
(GMCS CDX) (2 2) 0
Net adjustment 1
Result is class 2 with an adjustment 1 from the default
EXAMPLE 17- 4: INTERVERTEBRAL DISK value C, which equals class 2, grade D 12% impairment
HERNIATION OR AOMSI AT A SINGLE LEVEL
Note: CDX indicates class of diagnosis; GMFH, grade modifier
for Functional History; GMPE, grade modifier for Physical
Subject: 44-year-old man. Examination; and GMCS, grade modifier for Clinical Studies.
History: The patient sustained a blow to the posterior
aspect of his neck from a machine support that slipped. CLASS 3
Studies revealed a C7-T1 disk herniation. He was 15% to 24% Whole Person Impairment
managed conservatively, and in spite of persistent
symptoms, refused surgery. He was evaluated for
EXAMPLE 17-5: INTERVERTEBRAL DISK
impairment one year after his injury.
HERNIATIONS AND AOMSI AT MULTIPLE LEVELS
Current Symptoms: The patient reports neck
pain with radiation to the ulnar aspect of the hand
and numbness of the ring and little fingers. He History: The patient had onset of pain in the neck
is unable to use his dominant left hand for ADLs and right arm along the radial aspect and into the
without considerable pain in the neck, left upper thumb, following a medium-speed rear-end auto
back, and ulnar side of the left upper limb, with collision. Conservative treatment failed, and she
minimal activity. subsequently underwent an anterior cervical dis-
kectomy and fusion at 2 levels from C5 to C7. Her
Functional Assessment: The PDQ score is 120,
fusion healed uneventfully and she returned to work
consistent with severe disability.
6 months after the injury.
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Current Symptoms: Upper extremity pain has History: The patient fell and struck the posterior
improved; however, she reports cervical pain and part of her head and neck on a conveyor machine
right arm pain with less than normal activity. while working on an assembly line. She complained
of immediate motor and sensory deficit in the right
Functional Assessment: The PDQ score is 120
upper limb and was taken to the emergency room,
consistent with severe disability.
where compression fractures of C5 and C6 verte-
Chapter 17
Physical Exam: Slight loss of cervical spine bral body were identified. Shortly thereafter, she
motion. Neurologic examination reveals diminished underwent a fusion from C4 to C7. She participated
light touch on the right in the distribution of C6 and in appropriate rehabilitation and was evaluated one
decreased brachioradialis reflex, right. year later.
Clinical Studies: Original MRI demonstrated right- Current Symptoms: Severe neck pain and right
sided disk protrusions at C5-6 and C6-7. Post-opera- upper extremity pain with some limitation of cervi-
tive EMG demonstrated significant C6 radiculopathy cal mobility and weakness in the right arm. Pain is
on the right. Post-operative X rays showed healed constant and present at rest.
fusion from C5-7 with anterior plate in good position.
Functional Assessment: PDQ score of 140, consis-
Diagnosis: Cervical disk herniations at 2 levels, with tent with extreme disability.
unresolved radiculopathy at a single level.
Physical Exam: C6 motor deficit is graded 4/5;
Impairment Rating: Regional Impairment: Diagnosis C7 triceps weakness is graded 4/5; there is absent
is consistent with “Intervertebral disk herniations and/or and asymmetrical triceps reflex since the injury.
AOMSI, at multiple levels with medically documented The upper arm is 2 cm smaller in diameter than the
findings; with or without surgery and with documented opposite and uninvolved side.
radiculopathy at a single clinically appropriate level pres-
Clinical Tests: Initial X rays revealed compression
ent at the time of examination” and therefore, assigned
fractures at C5 and C6 both with more than 50%
to class 3. Adjustment Grids: Functional History: Grade
compression of C5 and 25% compression of C6.
modifier 3 based on pain with less than normal activity
Imaging findings at MMI of healed C4-7 arthrodesis
and PDQ score. Physical Examination: Grade modifier
with hardware in place. The EMG confirms signifi-
2 based on sensory findings. Clinical Studies: not appli-
cant motor findings in right C6 and C7 nerve roots.
cable, define class. Net adjustment is 1, resulting in
class 3, grade B. Impairment is 17% WPI. Diagnosis: Vertebral fracture with C4-7 fusion and
unresolved radiculopathy at 2 levels.
CDX GMFH GMPE GMCS
Diagnosis is consistent with “Single or multiple level
3 3 2 n/a
fractures with >50% compression of one vertebral
Net adjustment body; with or without bony retropulsion; with or
(GMFH CDX) (3 3) 0 without pedicle and/or posterior element fracture.
(GMPE CDX) (2 3) –1 Healed; with or without surgical intervention; with
Net adjustment –1 residual deformity and may have documented multiple
Result is class 3 with an adjustment 1 from the default
level radiculopathy at the clinically appropriate levels
value C, which equals class 3, grade B 17% impairment. present at the time of examination,” and is therefore
Note: CDX indicates class of diagnosis; GMFH, grade modifier assigned to class 4. Adjustment Grids: Functional
for Functional History; GMPE, grade modifier for Physical History: Grade modifier 4 based on pain/symptoms at
rest and PDQ. Physical Examination: Grade modifier
2 based on atrophy, noting the 4/5 weakness would
have resulted in grade modifier 1. Clinical Studies:
CLASS 4
not applicable, used to determine class. Since the
diagnostic class is 4, the net adjustment calculation
requires that +1 be added to each grade modifier to
EXAMPLE 17-6: VERTEBRAL FRACTURES AT calculate the net adjustment. Net adjustment compared
MULTIPLE LEVELS with diagnostic class is 0, resulting in class 4, grade C.
Impairment is 28% WPI.
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from which he had fully recovered. He experienced
CDX GMFH GMPE GMCS
severe right-sided, radiating arm pain with tingling
4 4 (1 for class 4) 5 2 (1 for class 4) 3 n/a along the chest and the underside of the right arm
Net adjustment while moving a refrigerator.
(GMFH CDX) (5 4) 1
Current Symptoms: Pain has disappeared, but
Chapter 17
(GMPE CDX) (3 4) –1
he still has some discomfort when lifting the arm
Net adjustment 0 above shoulder level or with strenous activity.
Result is class 4 with an adjustment of 0. Therefore, Reports occasional numbness along the medial
this impairment is class 4, grade C, which equals 28% right arm.
impairment.
Note: CDX indicates class of diagnosis; GMFH, grade modifier Functional Assessment: The PDQ score is 40, con-
for Functional History; GMPE, grade modifier for Physical sistent with mild disability.
Physical Exam: Normal examination, including
neurological evaluation. He describes an occasional
Thoracic Spine Examples
sensation of numbness in a T1 distribution; however, no
CLASS 0 sensory deficits are documented.
0% Whole Person Impairment
Clinical Studies: MRI: degenerative disk changees
at T1-2 with a disk herniation to the right.
EXAMPLE 17-7: THORACIC SPRAIN/STRAIN
Diagnosis: Herniated nucleus pulposus T1-2 with
Subject: 44-year-old man. thoracic radiculopathy at T2.
History: The patient works from home and spends Impairment Rating: Regional Impairment:
many hours on the phone and computer. He com- Diagnosis is consistent with “Intervertebral disk her-
plains of chronic, bilateral, upper back discomfort niation or documented AOMSI at a single or multiple
under the scapula area, which worsened 3 to 4 levels with medically documented findings; with
months ago, but improved with physical therapy. or without surgery, and with documented resolved
radiculopathy or non-verifiable radicular complaints
Physical Exam: Hunched posture. Moderate tender-
at the clinically appropriate level present at the time
ness to deep palpation over the descending trapezius
of examination,” and therefore, assigned to class 1.
muscles and the periscapular area, with right side
Adjustment Grids: Functional History: Grade modi-
more pronounced. Otherwise, normal examination.
fier 1 based on pain with strenous activity. Physical
Clinical Studies: None. Examination: Grade modifier 0, no objective sen-
sory deficits. Clinical Studies: Grade modifier 2.
Diagnosis: Postural discomfort.
Net adjustment compared with diagnostic class is 0,
Impairment Rating: Regional Impairment: Patient resulting in class 1, grade C. Impairment is 4% WPI.
has a resolved thoracic sprain/strain and class 0
impairment with 0% WPI. With class 0, adjustment Class 1 Example Calculation
is not required; however, the Functional History CDX GMFH GMPE GMCS
shows that he has full function. No objective physi- 1 1 0 2
cal examination or clinical test findings at MMI also Net adjustment
support class 0. Regional Impairment: 0% WPI.
(GMFH CDX) (1 1) 0
(GMPE CDX) (0 1) 1
(GMCS CDX) (2 1) 1
CLASS 1 Net adjustment 0
1% to 6% Whole Person Impairment Result is class 1 with an adjustment 0 The adjustment
does not move the impairment; therefore, this impair-
ment is class 1, grade C which equals 4% impairment.
EXAMPLE 17-8: INTERVERTEBRAL DISK Note: CDX indicates class of diagnosis; GMFH, grade modifier
HERNIATION OR AOMSI AT ONE OR MORE for Functional History; GMPE, grade modifier for Physical
LEVELS

History: A laborer had a prior history of multiple
musculoskeletal injuries during college football,
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CLASS 3 Class 3 Example Calculation

12% to 16% Whole Person Impairment CDX GMFH GMPE GMCS
3 1 2 n/a
EXAMPLE 17-9: VERTEBRAL FRACTURES AT Net adjustment
MULTIPLE LEVELS (GMFH CDX) (1 3) 2
Chapter 17
Subject: 35-year-old man. (GMPE CDX) (2 3) 1

Net adjustment 3
History: A window washer fell from the second
Result is class 3 with an adjustment of 3. An adjustment
floor of a building on which he was working and 2 moves the impairment to grade A; therefore, this
sustained compression fractures of T7 and T8. The impairment is class 3, grade A, which equals 12% WPI.
patient was treated with vertebroplasty and did well. Note: CDX indicates class of diagnosis; GMFH, grade modifier
After a short course of physical therapy, he was able for Functional History; GMPE, grade modifier for Physical
Examination; GMCS, grade modifier for Clinical Studies; WPI,
to perform ADLs and resume most activities. whole person impairment; and n/a, not applicable.
Current Symptoms: Moderate back pain with
heavy physical activity. Left chest wall numbness Lumbar Spine Examples
over the seventh and eighth ribs.
CLASS 0
Physical Exam: Mild hypesthesia, left posterior 0% Whole Person Impairment
chest following left eight rib; mild motion deficits
with more limitation on right rotation than left.
EXAMPLE 17-10: LUMBAR SPRAIN/STRAIN
Clinical Tests: Compression fractures of T7
(about 40%) and T8 (about 60%), treated with
vertebroplasty. History: The patient hurt his back while lifting a
large, heavy box; he described the pain as being in
Diagnosis: Compression fractures, T7 and T8,
the lumbosacral region. Examination shortly after
treated with vertebroplasty.
the injury was normal, except for a slight decrease
Impairment Rating: Regional impairment: in lumbar motion due to pain. He had no muscle
Diagnosis consistent with “single or multiple level spasm or weakness. The individual was treated with
fractures with 50% compression of one vertebral an analgesic. He was off work for 3 days and then
body; with or without retropulsion; with or without returned and has continued to work.
pedicle and/or posterior element fracture; Healed;
Current Symptoms: Occasional soreness in the low
with or without surgical intervention; with residual
back with heavy lifting; denies leg pain or numbness.
deformity and with or without documented radicu-
lopathy at a single clinically appropriate level pres- Physical Exam: No positive findings were present,
ent at the time of examination,” and therefore is including a negative SLR test, normal strength, and
assigned to Class 3 with default impairment of 14% normal sensory examination. No atrophy.
WPI. Adjustment Grids: Functional History: Grade
Clinical Studies: X rays demonstrated spina bifida
modifier 1 based on pain with strenous activity;
occulta, and otherwise normal.
Physical Examination: Grade modifier 2, for sensory
abnormalities. Clinical Studies: Clinical tests are Diagnosis: Non-specific low back pain, resolved.
not included because they are part of the class deter-
mination. Net adjustment compared with diagnostic
Diagnosis is consistent with “Documented history of
class is 3, resulting in class 3, grade A. Impairment
sprain/strain type injury, now resolved or occasional
is 12% WPI.
complaints of lumbar spine pain with no objective
findings on examination,” and therefore, assigned to
class 0. With class 0, adjustment is not required; how-
ever, the Functional History reported full function.
No objective physical examination or clinical test
findings also support class 0. Impairment is 0% WPI.
Comment: Patient has a history of a single episode
of low back pain without objective findings on exam.
Spina bifida occulta is a radiographic finding without
clinical significance. Without persistent axial pain
documented on multiple occasions, IC is 0.
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EXAMPLE 17-11: INTERVERTEBRAL DISK Physical Exam: Cautious movement in transition-

HERNATION AT A SINGLE LEVEL ing from sitting to standing. No specific neurologic
findings, except failure to perceive some light touch
stimuli of the lateral calf and foot. Straight leg raise
History: Onset of low back and left posterior thigh caused back pain only.
pain while removing and replacing windows at work.
Chapter 17
Clinical Studies: MRI was negative for any specific
He was treated with physical therapy, improved, and
findings; disk dessication reported at multiple lum-
returned to work after 6 weeks.
bar levels.
Diagnosis: Recurrent low back pain without objec-
Physical Exam: Normal examination. tive findings on examination or clinical studies.
Clinical Studies: The MRI shows a small disk her- Impairment Rating: Regional Impairment:
niation at L5-S1 on the left. Diagnosis is consistent with documented history of
sprain/strain type injury with continued complaints
Diagnosis: Herniated nucleus pulposus L5-S1, left,
of axial and/or non-verifiable radicular complaints
now asymptomatic.
and similar findings documented on multiple occasions
Impairment Rating: Regional Impairment: and present at the time of evaluation, and therefore
Diagnosis is consistent with “Intervertebral disk her- assigned to class 1. Functional History: Grade modifier
niation or AOMSI at a single level or multiple levels 1: Pain; symptoms with strenuous, vigorous activity.
with medically documented findings; with or without Physical Examination: Grade 1 based on reported
surgery; no residual signs or symptoms” and therefore, decreased sensation in S1 root distribution. Clinical
assigned to class 0. With class 0, adjustment is not Studies: Grade modifier 0. Net adjustment is 1
required; however, the Functional History reported and the impairment is class 1, grade B. Impairment
full function. No objective physical examination find- is 1%.
ings were noted at MMI. Impairment is 0% WPI.
CDX GMFH GMPE GMCS
1 1 1 0
CLASS 1 Net adjustment
(GMFH CDX) (1 1) 0
(GMPE CDX) (1 1) 0
EXAMPLE 17-12: RECURRENT LOW BACK PAIN (GMCS CDX) (0 1) 1
WITHOUT OBJECTIVE FINDINGS
Net adjustment 1
Subject: 44-year old man. Result is class 1 with an adjustment of 1; therefore,
this impairment is class 1, grade B and impairment = 1%
History: Experienced onset of low back pain and right Note: CDX indicates class of diagnosis; GMFH, grade modifier
leg pain after moving a refrigerator while working as for Functional History; GMPE, grade modifier for Physical
an appliance repairman. He saw his PCP who referred Examination; GMCS, grade modifier for Clinical Studies; and
him physical therapy, and his back pain and leg pain
improved. He continued to do his exercises and do well
CLASS 2
for about four weeks and then had a recurrent episode
10%–14% Whole Person Impairment
of low back pain, which again responded to physical
therapy. He was referred to a physiatrist who recom-
mended continued exercise, and the patient again noted EXAMPLE 17-13: INTERVERTEBRAL DISK
improvement. Six weeks later he had another episode HERNIATION OR AOMSI AT A SINGLE LEVEL
of back pain, which required regular use of NSAID
and he continued to work. He discontinued his regular
exercise program. He noted increased pain with more History: The patient had an onset of back and left
vigorous activities including heavy yard work and posterior thigh and leg pain while twisting in a flexed
improvement in his symptoms with rest. position when lifting a moderately heavy package.
Initially he presented with muscle spasm, a positive
Current Symptoms: Frequent low back pain which
SLR test on the side at 60°, a positive crossed SLR
responds to non-steroidal anti-inflammatory medica-
test at 70°, and decreased dorsiflexion strength of the
tion, occasional right leg pain in the distribution of
left ankle. Treatment with physical therapy did not
the S1 nerve root.
produce significant improvement. Three months
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after the injury, he underwent surgical diskectomy to lay cable. He was treated with physical therapy
at L4-L5. He improved and returned to work with and medications, without resolution of symptoms.
restrictions after 4 months of rehabilitation. Subsequently he underwent a laminectomy and disk
excision at L4-5 but failed to note improvement with
Current Symptoms: Persistent left leg pain with
surgery. Flexion/extension X rays after surgery docu-
normal activity, aggravated by walking and sitting,
mented instability within the parameters described
Chapter 17
for which he takes medication occasionally. He is

for AOMSI. The patient was treated with a lumbar
able to do most ADLs, but complains of back pain
fusion at L4-5 one year prior to evaluation.
with any activity.
Current Symptoms: Reported some improvement
Physical Exam: Slightly decreased dorsiflexion
in his back pain and continued to experience symp-
strength of the left ankle and normal sensory func-
toms consistent with right L5 radiculopathy.
tion. SLR test positive at 60°.
Functional History: PDQ score of 120, consistent
Clinical Studies: Original MRI showed a herniated
with severe disability.
disk at L4-5. No additional studies have been done.
Physical Exam: Decreased lumbar range of motion,
Diagnosis: Lumbar disk herniation, L4-5, left pos-
positive SLR test on the right at 30°, and decreased
terolateral, with left L5 radiculopathy.
sensation in the right L5 distribution.
Diagnosis: Status post lumbar fusion at L4-5 with
Diagnosis is consistent with “Intervertebral disk
persistent L5 radiculopathy.
herniation or AOMSI at a single level with medi-
cally documented findings; with or without sur- Impairment Rating: Regional Impairment:
gery, and with documented radiculopathy at the Diagnosis is consistent with “Intervertebral disk
clinically appropriate level present at the time of herniation or AOMSI at a single level with medi-
examination,” and therefore, assigned to class 2 with cally documented findings; with or without sur-
default impairment of12% WPI. Adjustment Grids: gery, and with documented radiculopathy at the
Functional History: Grade modifier is 2 based on clinically appropriate level present at the time of
report of pain with normal activity. Physical Exam: examination,” and therefore, assigned to class 2 with
Grade modifier 2 for positive SLR, noting that 4/5 default impairment of 12% WPI. Adjustment Grids:
strength would only be grade modifier 1. Clinical Functional History: Grade modifier 3. Note history
Testing: Grade modifier 2 as well. The net adjust- is consistent with grade modifier 2 and PDQ score is
ment is 0, and therefore this patient’s impairment is consistent with grade 3 (assuming both are reliable,
grade 2, class C, which equals 12% WPI. select highest value for net adjustment calculation).
Physical Examination: Grade modifier is 2 based on
Class 2 Example Calculation both positive SLR test and sensory loss. Clinical test-
CDX GMFH GMPE GMCS ing: Not applicable (AOMSI). The net adjustment is +1
2 2 2 2 and the impairment is class 2, grade D. Impairment is
Net adjustment 13% WPI.
(GMFH CDX) (2 2) 0
(GMPE CDX) (2 2) 0
CDX GMFH GMPE GMCS
(GMCS CDX) (2 2) 0
2 3 2 n/a
Net adjustment 0
Net adjustment
Result is class 2 with an adjustment of 0; therefore,
(GMFH CDX) (3 2) 1
this impairment is class 2 default grade C, which equals
12% impairment (GMPE CDX) (2 2) 0
Note: CDX indicates class of diagnosis; GMFH, grade modifier Net adjustment 1
Examination; and GMCS, grade modifier for Clinical Studies. Result is class 2 with a net adjustment of 1; therefore,
this impairment is class 2, grade D, which equals 13%
impairment
EXAMPLE 17-14: INTERVERTEBRAL DISK for Functional History; GMPE, grade modifier for Physical
HERNIATION OR AOMSI AT A SINGLE LEVEL Examination; and GMCS, grade modifier for Clinical Studies.

History: The patient had an onset of back pain
and right thigh and calf pain after digging trenches
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CLASS 3 Clinical Studies: do not apply, determined class. Net

15% to 23% Whole Person Impairment adjustment score is 0, and the patient’s impairment is
class 3, grade C, which is 19% WPI.
EXAMPLE 17-15: INTERVERTEBRAL DISK Class 3 Example Calculation
HERNIATION OR AOMSI AT MULTIPLE LEVELS
CDX GMFH GMPE GMCS
Chapter 17
Subject: 65-year-old man. 3 4 2 n/a
History: The patient had a new onset of back and Net adjustment
left leg pain while lifting on the job. Initially he (GMFH CDX) (4 3) 1
presented with muscle spasm and positive SLR test (GMPE CDX) (2 3) 1
on the left side at 60° with difficulty toe standing Net adjustment 0
and an absent Achilles tendon reflex. He failed to Result is class 3 with an adjustment of 0; therefore,
improve with nonoperative care and had progressive this impairment is class 3, grade C, which equals 19%
left S1 root motor loss. He underwent L5-S1 disk- impairment
ectomy 3 months after injury but failed to improve. Note: CDX indicates class of diagnosis; GMFH, grade modifier
Eight months after injury he underwent L4-S1 for Functional History; GMPE, grade modifier for Physical
arthrodesis but still complained of severe back and n/a, not applicable.
leg pain. Fusion was extended to L3 12 months after
injury. He is still off work 18 months after injury,
having dropped out of a functional rehabilitation CLASS 4
program. He is found to be at MMI. 25% to 33% Whole Person Impairment
Current Symptoms: Complaints of persistent back

and left leg pain, which is constant and present at EXAMPLE 17-16: LUMBAR SPINAL STENOSIS
rest. AT MULTIPLE LEVELS
Functional Assessment: The PDQ score is 135, Subject: 56-year-old man.

consistent with extreme disability.
History: Back and bilateral leg pain developed after
Physical Exam: Marked pain behaviors, includ- the patient repetitively lifted 22.5-kg (50-lb) sacks of
ing grimacing and moaning. Axial loading and fertilizer. Initially, he presented with muscle spasm
trunk rotation both result in increased complaints. and subsequently experienced loss of the left knee
Neurological examination reveals positive SLR test, reflex with an L5 root sensory deficit with mild foot
absent ankle reflex and numbness along the lateral drop. He reported inability to ambulate outside his
side of the foot. He had difficulty toe standing on the home without a scooter. He continued to complain of
left, 3/5. severe persistent pain despite extensive nonoperative
efforts and 7 months later underwent lumbar spinal
Clinical Tests: Postoperative imaging reveals solid
decompression without fusion for a diagnosis of
L3-S1 fusion with epidural fibrosis around left S1
spinal stenosis at L3-4 and L4-5. Postoperatively, he
nerve root without foraminal encroachment. The
remained limited in his ability to walk and reported
EMG shows no radiculopathy.
relief of his leg pain with sitting. He required a
Diagnosis: Lumbar disk herniation L5-S1 with mul- wheelchair or scooter to ambulate any significant dis-
tiple level fusion. tance. Bowel and bladder function remained intact.
Impairment Rating: Regional Impairment: Current Symptoms: Complaints of severe pain and
Diagnosis is consistent with “Intervertebral disk her- inability to walk any significant distance.
niations or AOMSI at multiple levels with medically
Functional Assessment: PDQ score of 118, consis-
documented findings; with or without surgery; AND
tent with severe disability.
with documented residual radiculopathy at a single
clinically appropriate level present at the time of Physical Exam: Persistent severe back pain and pal-
examination,” and therefore, assigned to class 3. pable spasm with persistent L5 sensory deficit and 3/5
ankle dorsiflexion weakness, absent patellar tendon
Adjustment Grids: Functional Assessment: Grade
flex. SLR test was negative, and walking in the hallway
modifier 4 based on PDQ score of 135. Physical
outside the office provoked bilateral buttock and leg
Examination: Grade modifier 2 based on positive
pain, which was relieved with rest.
SLR and absent reflex as well as motor weakness.
Findings are consistent with grade modifier 2. Clinical Tests: EMG: mild chronic L5 radiculopathy
bilaterally.
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Diagnosis: Lumbar spinal stenosis, multiple levels. must explain in writing the rationale for combining
impairments. Unless otherwise directed by a specific
jurisdiction, Functional History is used only for the
Diagnosis is consistent with “Lumbar stenosis at
single most significant ratable diagnosis.
multiple levels with or without AOMSI with medi-
cally documented findings; with or without surgery If there are multiple spine-related impairments, they
Chapter 17
and may have documented signs of bilateral or are combined at the whole person level. The com-
multiple-level radiculopathy at clinically appropri- bined value determination is based on the following
ate levels at the time of exam or severe neurogenic formula:
claudication and inability to ambulate without assis-
A% B% (100% A%) Combined Value of A%
tive devices, and therefore, assigned to class 4 with
and B%
default impairment of 29% WPI. Adjustment Grids:
Functional Assessment: Grade modifier 4, based on The Combined Values Chart (end-of-book Appendix)
limited activity. Since functional assessment is 2 or is used to determine the combined value of two
more than physical exam grade modifier, it is not impairment percentages. All percentages being com-
included. Physical Examination: Grade modifier 2 bined must be expressed using a common denomina-
based on decreased motor strength (3/5). Clinical tor or same unit relative value. Multiple impairments
studies are not included because they were used to are successively combined by first combining the
make the diagnosis. Because this is a class 4 impair- largest number with the next largest remaining num-
ment, the net adjustment calculation requires that +1 ber, and then further combining it with the next larg-
be added to each adjustment calculation. Therefore, est remaining number. This process is repeated until
the net adjustment is 1, and the impairment is class all given impairment values have been combined.
4, grade B. Impairment rating is 27%.

CDX GMFH GMPE GMCS 17.4 Pelvic Impairment
4 4(1)5 2(1)3 n/a
Net adjustment The pelvis has three bilateral components—ilium,
ischium and pubis—forming a ringlike structure
(GMFH CDX) (5 4) n/a
around the sacrum. Each ilium is attached to the
(GMPE CDX) (3 4) 1
sacrum via the sacroiliac synchondrosis. The pel-
Net adjustment 1 vis, including the symphysis pubis, assists in the
Result is class 4 with an adjustment of 1. Therefore, transfer of body weight to the lower extremities. In
the result is class 4, grade B 27% impairment. females, the pelvic structure and function are also of
Note: CDX indicates class of diagnosis; GMFH, grade modifier paramount importance in pregnancy and delivery.
Examination; GMCS, grade modifier for Clinical Studies; and Separation of the pubic symphysis is common after
n/a, not applicable. pregnancy, and should be differentiated from trau-
matic separation of the joint as the result of an injury
17.3h Combining and Converting when rating impairment.
Impairments
Traumatic pelvic fractures are frequently associ-
If there are multiple diagnoses at MMI, the examiner
ated with other injuries that may cause substantial
should determine if each should be considered or if
bleeding, sensory and motor dysfunction, and other
the impairments are duplicative. If there are multiple
injuries. Although the fractures may heal in accept-
diagnoses within a specific region, then the most
able alignment, subsequent problems including pain,
impairing diagnosis causally related to the injury is
impaired mobility, bowel and bladder impairment,
rated, because it is likely this will incorporate the
and sexual dysfunction are usually the result of dam-
functional losses of the less impairing diagnoses.
age to nerves and organs that occurred concurrently
In very rare cases, the examiner may combine mul-
with the fracture.
tiple impairments within a single region if the most
impairing diagnosis does not adequately reflect the Rating impairment of the pelvis (Table 17-11) may
losses; the examiner must fully explain the rationale require consideration of concomitant injuries, includ-
for this approach. When uncertain about whether ing injuries to the spine (Section 17.2), injuries to
diagnoses are duplicative, the evaluator should calcu- the sciatic nerve and hip (Chapter 16, The Lower
late the impairment using each diagnosis and choose Extremities), and urogenital injuries and sexual
the diagnosis that gives the most clinically accu- dysfunction according to the relevant chapters (The
rate impairment rating. The evaluating physician Digestive System, The Urinary and Reproductive
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TA B L E 17-11 Diagnosis-Based Impairment Grid: Pelvis
Diagnosis-Based Impairment Grid: Pelvis
Chapter 17
IMPAIRMENT
RATING (%) 0 1%–3% 4%–6% 7%–11% 12%–16%
FRACTURES/
DISLOCATIONS
Fractures of 0 1 2 2 3 3 4 5 5 6 6 7 8 9 10 11 12 13 14 15 16
the pubic
Nondisplaced, Nondisplaced or Displaced fractures Fractures dis- SI joint dislocations,
rami; fractures
healed fractures minimally dis- (1 cm and 2 placed 2cm or fracture-
of the ilium,
without residual placed fractures, cm) of the ilium, of the ilium, dislocations with
ischium, and/
structural defor- with or without ischium, sacrum, or ischium, sacrum, rupture of the
or sacrum
mity; no residual surgery coccyx or coccyx SI ligaments;
symptoms transverse sacral
healed and healed, with or healed, with or
fractures with
or stable, including without surgery without surgery
spinopelvic
minor separa-
*Instability is healed fracture or and dissociation
tion of the pubic
defined as a with or without
symphysis (1 traumatic separa- with deformity or
position shift surgery with no
cm and 3 cm; tion of the pubic and instabil-
that occurs residual symp- severe
unrelated to symphysis (3 cm) ity; traumatic
when compar- toms related to complications after
childbirth); with with residual signs separation of the
ing supine and fracture surgery, including
residual signs but no instability* pubic symphysis
weight-bear- pseudarthrosis,
and symptoms 3 cm with or
ing X rays. osteomyelitis,
without surgery
or documented
with residual
instability*
deformity and
instability*
Fracture of the Nondisplaced, Evaluate based

acetabulum healed fractures on restricted
without residual motion of
structural defor- the hip joint
mity; no residual (Chapter 16,
symptoms The Lower
Extremities)
or
healed fracture
with or without
surgery, with no
residual symp-
toms related to
fracture
Note: SI indicates sacroiliac.
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Systems, The Central and Peripheral Nervous Studies, the Functional History should be assumed to
System: Chapters 6, 7, and 13, respectively). be unreliable. If the Functional History is determined
to be unreliable or inconsistent with other documen-
17.4a Adjustment Grid: Functional History tation, it is excluded from the grading process.
(Pelvic Impairments)
Grade assignment for functional symptoms is based 17.4b Adjustment Grid: Physical
Chapter 17
on subjective reports that are attributable to the Examination (Pelvic Impairments)

impairment. Grading is based on the severity of func- When performing a physical examination, the cli-
tional symptoms associated with different level of nician needs to determine the significance of the
activities, as summarized in Table 17-12, Functional findings related to the impairment being evaluated.
History Adjustment: Pelvis. As explained in Section For the purposes of this evaluation, greater weight is
1.8e, History of Clinical Presentation, in general, given to those findings that are more objective. Some
individuals with no symptoms will be assigned parameters described in the adjustment grid (Table
grade modifier 0, and those with constant symp- 17-13) may be region-specific.
toms accompanied by functional deficits that persist
If multiple diagnoses are rated, the examiner
despite treatment will be assigned grade modifier 4.
should determine the appropriate impairment class
Functional History grade modifier should be applied in the relevant chapter and diagnostic grid for each
only to the single highest DBI. Jurisdictions may diagnosis. The examiner must distinguish which
modify this process such that Functional History physical examination findings are associated with
adjustment is considered for each DBI or none at all. each specific ratable condition. If x-ray or imaging
study findings of fracture displacement have been
As in other chapters in the Sixth Edition of the
used to determine impairment class placement,
Guides, a functional assessment tool consisting of
they should not be considered again as a Clinical
measurements initially designed and validated for
Studies adjustment to determine grade. If Physical
outcome measurement has been added to this chap-
Examination findings are determined to be unre-
ter; after careful consideration, the PDQ was selected.
liable or inconsistent, or they are for conditions
The evaluating physician may use the PDQ func- unrelated to the condition being rated, they are
tional assessment outcome questionnaire or another excluded from the grading process. The physician
validated functional tool as part of the process of must explain the rationale for the choice of grade in
evaluating functional symptoms. The inventory his or her report.
is used only to assist the examiner in defining the
Alignment and deformity are determined clinically
grade modifier for Functional History, and does not
and/or on the basis of radiographic studies. In the
serve as a basis for defining further impairment, nor
pelvis, stability is usually determined by findings
does the score reflect an impairment percentage. (A
on imaging studies. For the purposes of this edition,
description of the PDQ and instructions for adminis-
instability of the pelvis is determined radiographi-
tering this functional tool are provided at the end of
cally and is described in the next section.
this chapter in the appendix.)
The examiner must assess the reliability of the func- 17.4c Adjustment Grid: Clinical Studies
tional reports, recognizing the potential influence of (Pelvic Impairments)
behavioral and psychosocial factors. If the grade for The patient may have undergone a variety of special
Functional History differs by two or more grades from tests, including imaging studies and electrodiagnos-
that described by Physical Examination or Clinical tic studies. Impairment ratings for other organ sys-
TA B L E 17-12
Functional History Adjustment: Pelvis
Functional History Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Factor 0 1 2 3 4
Activity Asymptomatic; Pain; symptoms Pain; symptoms Pain; symptoms Pain; symptoms
problem resolved; with strenuous/ with normal with less than at rest, limited to
inconsistent vigorous activity activity normal activity sedentary activity
symptoms (minimal activity)
PDQ (score) No disability Mild disability Moderate Severe disability Extreme disability
PDQ (0) PDQ (0–70) disability PDQ (101–130) PDQ (131–150)
PDQ (71–100)
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TA B L E 17-13
Physical Examination Adjustment: Pelvis
Physical Examination Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Factor 0 1 2 3 4
Soft tissue No tenderness Mild localized Moderate to
tenderness severe localized
tenderness
Chapter 17
Gait No disorder of Rises to standing Rises to standing Rises and main- Cannot stand
gait or station position; walks position; walks tains standing without help,
Note: Not applica-
but has difficulty some distance position with mechanical sup-
ble in spinal stenosis
with elevations, with difficulty difficulty; can- port, and/or an
or in conditions for
grades, stairs, and without not walk without assistive device
which central ner-
deep chairs, and/ assistance but is assistance
vous system ratings
or long distances limited to level
are combined
surfaces
Deformity No deformity Mild detectable Moderate Severe deformity Posttraumatic leg
deformity or pel- deformity or or pelvic obliquity length discrep-
vic obliquity pelvic obliquity affecting gait, sit- ancy 4 cm
affecting sitting, and standing
or
ting or standing,
or
produced by instability pro-
displaced pelvic posttraumatic leg duced by pseud-
fracture and/or length discrep- arthrosis or other
dislocation ancy 2.5 cm to posttraumatic
4 cm complications
tems and the lower extremities may require the use 17.4d Pelvic Impairment Case Examples
of other appropriate chapters.The physician should
CLASS 1
identify these studies, the findings, and their inter-
pretation. Whenever possible, the physician should
personally review the studies and report agreement
or disagreement with previous interpretations. EXAMPLE 17-17: ISCHIOPUBIC STRESS
FRACTURE
Instability for the purposes of pelvis-related impair-
ment is defined as a position shift that occurs when Subject: 22-year-old man.
comparing supine and weight-bearing X rays. In
History: The patient participated in military intensive
cases when the abnormalities discussed earlier
training involving running with a backpack weighing
are present on imaging studies and are known (or
27 kg (60 lb) over an extended time and distance. He
assumed) to have preexisted an injury being rated,
fell jumping from a boulder and had difficulty stand-
evaluators should acknowledge these antecedent con-
ing up due to pain in the pelvis and right upper thigh,
ditions in the report (see Table 17-14).
which increased with walking and running.
TA B L E 17-14
Clinical Studies Adjustment: Pelvis
Clinical Studies Grade Modifier Grade Modifier Grade Modifier Grade Modifier Grade Modifier
Factor 0 1 2 3 4
Imaging No clinical test ver- CT/MRI/other Imaging findings
studies: ification of symp- imaging find- consistent with
radiographs, toms or structural ings consistent pseudarthrosis or
bone scan, diagnosis with clinical other posttrau-
MRI presentation matic complica-
tions, including
infection
Note: MRI indicates magnetic resonance imaging; CT, computed tomography.
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Current Symptoms: Pain in the right groin and Functional Assessment: Distance walking is lim-
medial upper thigh, aggravated by standing, walking, ited to flat surfaces. Patient reports pain with normal
and running and improved in the supine position. activity.
Physical Exam: Tenderness to palpation and pressure Physical Exam: Tenderness, swelling and ecchymo-
on the right pubic bone and on the right adductor and sis over symphysis pubis with a palpable defect noted
Chapter 17
hamstrings origin at the inferior ischiopubic junction. acutely. At MMI, local tenderness and antalgic gait
due to symphysis defect.
Clinical Tests: Pelvic X rays show a slightly displaced
fracture of inferior pubic ramus; there is already callus Clinical Tests: Initial X rays reveal separation of
development in the area. symphysis by approximately 3.5 cm. Follow-up X
rays 6 months later reveal persistent displacement,
Diagnosis: Ischiopubic stress fracture.
but no instability.
Diagnosis: Traumatic separation of the symphysis
Diagnosis is consistent with “Non-displaced or
pubis.
minimally displaced fractures, with or without
surgery; healed and stable; including minor separa- Impairment Rating: Regional Impairment:
tion of the pubic symphysis (unrelated to childbirth) Diagnosis is consistent with “Displaced fractures (1
with residual signs and symptoms,” and therefore, cm) of the ilium, ischium sacrum or coccyx; Healed;
assigned to class 1 with default impairment 2% WPI. with or without surgery; or traumatic separation of
Adjustment Grids: Functional History: Grade modi- the pubic symphysis ( 3 cm) with residual signs
fier 2 based on pain with normal activity. Physical but no instability,” and therefore, assigned to class 2
Exam: Grade modifier is 1. Clinical Testing is not with default impairment 5% WPI. Adjustment Grids:
included because it is used to determine class. The Functional History: Grade modifier is 3 because
net adjustment is 1, and the impairment is class 1, distance walking is limited to flat surfaces and
grade D, for a 3% impairment. patient reports pain with normal activity. Physical
Examination: Grade modifier 2. Clinical Studies are
Class 1 Example Calculation excluded because the symphysis separation is an X
CDX GMFH GMPE GMCS ray finding and the net adjustment is 1. The impair-
1 2 1 n/a ment is class 2, grade D. Impairment is 6% WPI.
Net adjustment
(GMFH CDX) (2 1) 1
CDX GMFH GMPE GMCS
(GMPE CDX) (1 1) 0
2 3 2 n/a
Net adjustment 1
Net adjustment
Result is class 1 with an adjustment 1; therefore,
this impairment is class 1, grade D, which equals 3% (GMFH CDX) (3 2) 1
impairment (GMPE CDX) (2 2) 0
Note: CDX indicates class of diagnosis; GMFH, grade modifier Net adjustment 1
Examination; GMCS, grade modifier for Clinical Studies; and Result is class 2 with an adjustment 1; therefore,
n/a, not applicable. this impairment is class 2, grade D, which equals 6%
impairment
CLASS 2
4 to 6% Whole Person Impairment
EXAMPLE 17-18: TRAUMATIC SEPARATION OF

CLASS 4
THE SYMPHYSIS PUBIS
History: The patient was involved in a crushing pel- EXAMPLE 17-19: COMPLEX PELVIC RING
vic injury, and developed immediate pelvic pain. She FRACTURE DISLOCATION
underwent catheterization, with resulting clear urine
and no evidence of ureteral injury.
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History: The patient was pinned in a car after
CDX GMFH GMPE GMCS
running into a light pole while intoxicated. After
extraction from the vehicle, he was noted to have 4 4 (1) 5 4 (1) 5 n/a
severe pelvic deformity with hypotension, and he Net adjustment
underwent surgical reduction and stabilization for (GMFH CDX) (5 4) 1
intrapelvic bleeding with a displaced fracture dislo-
Chapter 17
(GMPE CDX) (5 4) 1
cation involving the left sacroiliac joint with bilat- Net adjustment 2
eral pubic rami fractures. There was no urethral
Result is class 4 with an adjustment 2, therefore class
injury. 2 grade E. Impairment for pelvic fractures is 16% WPI.
Functional Assessment: PDQ score 135, extreme Note: CDX indicates class of diagnosis; GMFH, grade modifier
disability. Examination; and GMCS, grade modifier for Clinical Studies.
Physical Exam: The patient is able to rise from a sit-

ting position and walks with a walker. He has residual
partial loss of bladder control due to a left S3 nerve
root involvement, with sensory loss estimated at 80% 17.5 Summary
affecting the left S3 dermatome.
When evaluating an individual with spinal or pelvic
Clinical Tests: X rays identify left sacroiliac frac-
impairment, follow these suggested steps:
ture dislocation with residual displacement postop-
eratively, and moderately displaced bilateral pubic 1. Obtain detailed medical history and perform an
ramus fractures with 4-cm shortening of left leg at appropriate physical examination, as explained
MMI. in Section 17.1a.
Diagnosis: Complex pelvic ring fracture dislocation, 2. Record process and results using Spine and
surgically treated, and stabilized, with persistent defor- Pelvis Impairment Evaluation Record (Figure
mity, with residual left S3 nerve root involvement. 17-2) and using the completed record as a guide
(Figure 17-7).
Impairment Rating: Diagnosis is consistent with
“SI joint dislocations, or fracture-dislocations with 3. Review clinical studies, as explained in
rupture of the SI ligaments; transverse sacral frac- Section 17.1a.
tures with spino-pelvic dissociation or severe com-
4. Determine the diagnosis or diagnoses to be
plications after surgery including pseudoarthrosis,
rated.
osteomyelitis or documented instabililty,” and
therefore, assigned to class 4 with default impair- 5. Determine the DBI for each ratable diagnosis,
ment 14% WPI. Adjustment Grids: Functional using the regional grids, as explained in Sections
History: Grade modifier 4 based on PDQ score. 17.2 and 17.4. This includes selection of the
Physical Examination: Grade modifier is also 4. appropriate impairment class for that diagnosis.
Clinical Testing is not included because it is used
6. Use the adjustment grids for Functional History,
to determine class. Net adjustment for the pelvic
Physical Examination, and Clinical Studies, as
fracture must include the add-in of 1 for the
described in Section 17.3, to define the grade
adjustment factors and is therefore 2, for a rating
modifier for each factor. Functional History
of class 4, grade E. Impairment is 16% WPI for the
adjustment is performed only for the single most
fracture.
significant diagnosis unless otherwise specifi-
Comment: Impairment rating for the fractures must cally stated by a jurisdiction. Impairment related
be combined with impairment for neurological defi- to radiculopathy is a grade modifier, rather than
cit, using Chapter 13, The Central and Peripheral an additional value.
Nervous System and urogenital impairment, using
7. Apply the Net Adjustment Formula to calculate
Chapter 7, The Urinary and Reproductive Systems to
the net adjustment value to be applied to the
evaluate urogenital function.
default value C.
8. Use the regional grid to identify the numerical
impairment value associated with the impair-
ment class and grade.
Guides6e_17_557-602.indd 597 2/19/09 2:46:55 PM

F I G U R E 17-7
Spine and Pelvis Impairment Evaluation Record Example (Based on Example 17-2)
Name: John Smith Exam Date: 11/04/07

ID Number: 356-92-XXXX Sex: F M Side: R L Birth Date: 12/07/1971
Chapter 17
Diagnosis-Based
Impairments
Grid Diagnosis / Criteria Class Diagnosis (CDX) Grade Modifier Adjustments Net Adjustment Value Whole
and Assigned Person
Grade Modifier Impairment
Cervical (C) Adjusted Grade Net
Cervical disk herniation 0 1 2 3 4 GMFH 0 1 2 3 4 n/a
Adjustment applied to
with resolved right-sided GMPE 0 1 2 3 4 n/a Default Value C 6%
C6 radiculopathy GMCS 0 1 2 3 4 n/a
2 1 0 1 2
A B C D E
Thoracic (T) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a

Adjusted Grade
GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 2 3 4 n/a
A B C D E
Lumbar (L) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a

Adjusted Grade
GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 2 3 4 n/a
A B C D E
Pelvis (P) 0 1 2 3 4 GMFH 0 1 2 3 4 n/a

Adjusted Grade
GMPE 0 1 2 3 4 n/a
2 1 0 1 2
GMCS 0 1 2 3 4 n/a
A B C D E
Signed: Dr. Know Date: 11/04/07 Whole Person Impairment: 6%
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17.6Appendix 17-A: Pain Administering the Pain Disability

Disability Questionnaire Questionnaire
Follow these instructions for administering and scor-
ing the PDQ:
Overview
Chapter 17
1. Reproduce the PDQ (Figure 17-A) and ask the
The Pain Disability Questionnaire (PDQ) was spe- patient to complete all items on the questionnaire.
cifically developed for evaluating clinical out-comes
2. If necessary, the patient may complete the form
in a population of patients with disabling muscu-
with the assistance of a translator or reader. Be
loskeletal disorders, primarily involving the spine.
certain all 15 questions are answered. If the
It yields a total functional disability score ranging
patient is unable to complete the PDQ, no func-
from 0 (perfect function) to 150 (total disability).
tional assessment score will be given.
The focus, much like other health inventories, is
primarily on function, disability, and ADLs. Unlike 3. The evaluating doctor or an assistant will score
many other measures, this instrument is designed for the PDQ by adding together the marked integer
any musculoskeletal disorders, rather than low back in each question.
pain alone. Psychosocial variables, which have been
4. If the patient fails to mark a question, the default
shown to play an integral role in the development
score for that question is 0.
and maintenance of chronic disability, are also a
component of the PDQ. The psychometric properties 5. Apply the final score to Table 17-A and consider
of the PDQ demonstrate strong reliability, respon- this in the Net Adjustment Formula as described
siveness, and validity. The predictive validity of the in Section 17.3f.
PDQ with 1-year socioeconomic outcomes following
The PDQ scores can be divided into 5 distinct cat-
rehabilitation has been demonstrated.
egories: no disability (score of 0); mild (scores of 1 to
70); moderate (scores of 71 to 100); severe (scores of
101 to 130); and extreme (scores of 131 to 150).
TA B L E 17- A
PDQ Scoring
Questionnaire Score Pain Disability Grade Modifer
0 No disablity 0
1–70 Mild disability 1
71–100 Moderate disability 2
101–130 Severe disability 3
131–150 Extreme disability 4
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F I G U R E 17- A
Pain Disability Questionnaire (PDQ)
Patient Name: Date:

Instructions: These questions ask for your views about how your pain now affects how you function in everyday activi-
ties. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.
Chapter 17
1. Does your pain interfere with your normal work inside and outside the home?
Work normally Unable to work at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely Need help with all my personal care
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
3. Does your pain interfere with your traveling?

Travel anywhere I like Only travel to see doctors
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
4. Does your pain affect your ability to sit or stand?

No problems Cannot sit / stand at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
7. Does your pain affect your ability to walk or run?

No problems Cannot walk / run at all
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
8. Has your income declined since your pain began?

No decline Lost all income
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
9. Do you have to take pain medication every day to control your pain?
No medication needed On pain medication throughout the day
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors See doctors weekly
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?
No problem Never see them
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
12. Does your pain interfere with recreational activities and hobbies that are important to you?
No interference Total interference
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home
and housework) because of your pain?
Never need help Need help all the time
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression / tension Severe depression / tension
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
15. Are there emotional problems caused by your pain that interfere with your family, social, and / or work activities?
No problems Severe problems
0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10
Examiner
Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability Questionnaire: A New Psychometrically Sound Measure for Chronic Musculoskeletal Disorders.
Spine 2004; 29 (20): 2290-2302.
Guides6e_17_557-602.indd 600 2/19/09 2:46:57 PM

self-reported symptom severity and physical function

Bibliography in patients with degenerative lumbar conditions. Phys
Ther. 2005;85(2):120-33.
Abnormal magnetic-resonance scans of the lumbar spine Nattrass CL, Nitschke JE, Disler PB, Chou MJ, Ooi KT.
in asymptomatic subjects. A prospective investigation. Lumbar spine range of motion as a measure of physical
J Bone Joint Surg Am,1990; Mar;72(3):403-8. and functional impairment: an investigation of validity.
Clin Rehabil. 1999;13(3):211-218.
American Academy of Physical Medicine and
Chapter 17
Rehabilitation. 1999. Nitschke JE, Nattrass CL, Disler PB, Chou MJ, Ooi KT.
Reliability of the American Medical Association
Anagnostis C, Mayer TG, Gatchel RJ, Proctor TJ.
Guides’ model for measuring spinal range of motion; its
The million visual analog scale: its utility for
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predicting tertiary rehabilitation outcomes. Spine.
1999;24(3):262-268.
2003;28(10):1051-1060.
Parks KA, Crichton KS, Goldford RJ, McGill SM. A
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comparison of lumbar range of motion and functional
questionnaire: a new psychometrically sound measure
ability scores in patients with low back pain: assessment
for chronic musculoskeletal disorders. Spine.
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2004;29(20):2290-2302; discussion 2303.
Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel
Vet HC. A systematic review of the diagnostic accuracy
SW. Abnormal magnetic-resonance scans of
of provocative tests of the neck for diagnosing cervical
the lumbar spine in asymptomatic subjects. A
radiculopathy. Eur Spine J. 2007;16(3):307-319.
prospective investigation. J Bone Joint Surg Am,1990;
Mar;72(3):403-8. Sullivan MS, Dickinson CE, Troup JD. The influence of
age and gender on lumbar spine sagittal plane range
Fairbank JC, Pynsent PB. The Oswestry Disability Index.
of motion: a study of 1126 healthy subjects. Spine.
Spine. 2000;25(22):2940-52; discussion 2952.
1994;19(6):682-686.
Gatchel RJ, Mayer TG, Theodore BR. The pain disability
Valkenburg HA, Haanan HCN. The epidemiology of low
questionnaire: relationship to one-year functional and
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psychosocial rehabilitation outcomes. J Occup Rehabil.
Idiopathic Low Back Pain, St. Louis, Mo: CV Mosby
2006;16(1):75-94.
Co; 1982;9-22.
Jensen MC, Brant-Zawadski MN, Obuchwki N, et
Zuberbier OA, Hunt DG, Kozlowski AJ, et al.
al. Magnetic resonance imaging of the lumbar
Commentary on the American Medical Association
spine in people without back pain. N Engl J Med.
Guides’ lumbar impairment validity checks. Spine.
1994;331:69-73.
2001;26(24):2735-2737.
Lowery WD Jr, Horn TJ, Boden SD, Wiesel SW.
Zuberbier OA, Kozlowski AJ, Hunt DG, et al. Analysis of
Impairment evaluation based on spinal range of motion
the convergent and discriminant validity of published
in normal subjects. J Spinal Disord. 1992;5(4):398-402.
lumbar flexion, extension, and lateral flexion scores.
Lyle MA, Manes S, McGuinness M, Ziaei S, Iversen MD. Spine. 2001;26(20):472-478.
Relationship of physical examination findings and
Guides6e_17_557-602.indd 601 2/19/09 2:46:57 PM

602
Appendix
Appendix
A. Combined Values Chart
B. Burden of Treatment Compliance
603
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Guides6e_CVC_603-606.indd 604
Appendix
604
Guides to the Evaluation of Permanent Impairment
Appendix A. Combined Values Chart
1 2
2 3 4 The values are derived from the formula A ⫹ B (1–A) ⫽ combined value of A and B, where A and B are the decimal
3 4 5 6 equivalents of the impairment ratings. In the chart all values are expressed as percents. To combine any two
4 5 6 7 8 impairment values, locate the larger of the values on the side of the chart and read along that row until you come
5 6 7 8 9 10 to the column indicated by the smaller value at the bottom of the chart. At the intersection of the row and the
6 7 8 9 10 11 12 column is the combined value.
7 8 9 10 11 12 13 14
8 9 10 11 12 13 14 14 15 For example, to combine 35% and 20%, read down the side of the chart until you come to the larger value, 35%.
9 10 11 12 13 14 14 15 16 17 Then read across the 35% row until you come to the column indicated by 20% at the bottom of the chart. At the
10 11 12 13 14 15 15 16 17 18 19 intersection of the row and column is the number 48. Therefore, 35% combined with 20% is 48%. Because of the
11 12 13 14 15 15 16 17 18 19 20 21 construction of this chart, the larger impairment value must be identified at the side of the chart.
12 13 14 15 16 16 17 18 19 20 21 22 23
13 14 15 16 16 17 18 19 20 21 22 23 23 24 If three or more impairment values are to be combined, select any two and find their combined value as above.
14 15 16 17 17 18 19 20 21 22 23 23 24 25 26 Then use that value and the third value to locate the combined value of all. This process can be repeated
15 16 17 18 18 19 20 21 22 23 24 24 25 26 27 28 indefinitely, the final value in each instance being the combination of all the previous values. In each step of this
16 17 18 19 19 20 21 22 23 24 24 25 26 27 28 29 29 process the larger impairment value must be identified at the side of the chart.
17 18 19 19 20 21 22 23 24 24 25 26 27 28 29 29 30 31
18 19 20 20 21 22 23 24 25 25 26 27 28 29 29 30 31 32 33 Note: If impairments from two or more organ systems are to be combined to express a whole person impairment,
19 20 21 21 22 23 24 25 25 26 27 28 29 30 30 31 32 33 34 34 each must first be expressed as a whole person impairment percent.
20 21 22 22 23 24 25 26 26 27 28 29 30 30 31 32 33 34 34 35 36
21 22 23 23 24 25 26 27 27 28 29 30 30 31 32 33 34 34 35 36 37 38
22 23 24 24 25 26 27 27 28 29 30 31 31 32 33 34 34 35 36 37 38 38 39
23 24 25 25 26 27 28 28 29 30 31 31 32 33 34 35 35 36 37 38 38 39 40 41
24 25 26 26 27 28 29 29 30 31 32 32 33 34 35 35 36 37 38 38 39 40 41 41 42
25 26 27 27 28 29 30 30 31 32 33 33 34 35 36 36 37 38 39 39 40 41 42 42 43 44
26 27 27 28 29 30 30 31 32 33 33 34 35 36 36 37 38 39 39 40 41 42 42 43 44 45 45
27 28 28 29 30 31 31 32 33 34 34 35 36 36 37 38 39 39 40 41 42 42 43 44 45 45 46 47
28 29 29 30 31 32 32 33 34 34 35 36 37 37 38 39 40 40 41 42 42 43 44 45 45 46 47 47 48
29 30 30 31 32 33 33 34 35 35 36 37 38 38 39 40 40 41 42 42 43 44 45 45 46 47 47 48 49 50
30 31 31 32 33 34 34 35 36 36 37 38 38 39 40 41 41 42 43 43 44 45 45 46 47 48 48 49 50 50 51
31 32 32 33 34 34 35 36 37 37 38 39 39 40 41 41 42 43 43 44 45 45 46 47 48 48 49 50 50 51 52 52
32 33 33 34 35 35 36 37 37 38 39 39 40 41 42 42 43 44 44 45 46 46 47 48 48 49 50 50 51 52 52 53 54
33 34 34 35 36 36 37 38 38 39 40 40 41 42 42 43 44 44 45 46 46 47 48 48 49 50 50 51 52 52 53 54 54 55
34 35 35 36 37 37 38 39 39 40 41 41 42 43 43 44 45 45 46 47 47 48 49 49 50 51 51 52 52 53 54 54 55 56 56
35 36 36 37 38 38 39 40 40 41 42 42 43 43 44 45 45 46 47 47 48 49 49 50 51 51 52 53 53 54 55 55 56 56 57 58
36 37 37 38 39 39 40 40 41 42 42 43 44 44 45 46 46 47 48 48 49 49 50 51 51 52 53 53 54 55 55 56 56 57 58 58 59
37 38 38 39 40 40 41 41 42 43 43 44 45 45 46 46 47 48 48 49 50 50 51 51 52 53 53 54 55 55 56 57 57 58 58 59 60 60
38 39 39 40 40 41 42 42 43 44 44 45 45 46 47 47 48 49 49 50 50 51 52 52 53 54 54 55 55 56 57 57 58 58 59 60 60 61 62
39 40 40 41 41 42 43 43 44 44 45 46 46 47 48 48 49 49 50 51 51 52 52 53 54 54 55 55 56 57 57 58 59 59 60 60 61 62 62 63
40 41 41 42 42 43 44 44 45 45 46 47 47 48 48 49 50 50 51 51 52 53 53 54 54 55 56 56 57 57 58 59 59 60 60 61 62 62 63 63 64
41 42 42 43 43 44 45 45 46 46 47 47 48 49 49 50 50 51 52 52 53 53 54 55 55 56 56 57 58 58 59 59 60 60 61 62 62 63 63 64 65 65
42 43 43 44 44 45 45 46 47 47 48 48 49 50 50 51 51 52 52 53 54 54 55 55 56 57 57 58 58 59 59 60 61 61 62 62 63 63 64 65 65 66 66
43 44 44 45 45 46 46 47 48 48 49 49 50 50 51 52 52 53 53 54 54 55 56 56 57 57 58 58 59 60 60 61 61 62 62 63 64 64 65 65 66 66 67 68
44 45 45 46 46 47 47 48 48 49 50 50 51 51 52 52 53 54 54 55 55 56 56 57 57 58 59 59 60 60 61 61 62 62 63 64 64 65 65 66 66 67 68 68 69
45 46 46 47 47 48 48 49 49 50 51 51 52 52 53 53 54 54 55 55 56 57 57 58 58 59 59 60 60 61 62 62 63 63 64 64 65 65 66 66 67 68 68 69 69 70
46 47 47 48 48 49 49 50 50 51 51 52 52 53 54 54 55 55 56 56 57 57 58 58 59 60 60 61 61 62 62 63 63 64 64 65 65 66 67 67 68 68 69 69 70 70 71
47 48 48 49 49 50 50 51 51 52 52 53 53 54 54 55 55 56 57 57 58 58 59 59 60 60 61 61 62 62 63 63 64 64 65 66 66 67 67 68 68 69 69 70 70 71 71 72
48 49 49 50 50 51 51 52 52 53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 62 62 63 63 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73
49 50 50 51 51 52 52 53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 61 62 62 63 63 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 73 74
50 51 51 52 52 53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 61 62 62 63 63 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 73 74 74 75 75
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
2/17/09 3:05:44 PM
Appendix A. Combined Values Chart (continued)
51 51 52 52 53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 61 62 62 63 63 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 73 74 74 75 75 76
52 52 53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 61 62 62 63 63 64 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 73 74 74 75 75 76 76
53 53 54 54 55 55 56 56 57 57 58 58 59 59 60 60 61 61 61 62 62 63 63 64 64 65 65 66 66 67 67 68 68 69 69 69 70 70 71 71 72 72 73 73 74 74 75 75 76 76 77
54 54 55 55 56 56 57 57 58 58 59 59 59 60 60 61 61 62 62 63 63 64 64 65 65 66 66 66 67 67 68 68 69 69 70 70 71 71 71 72 72 73 73 74 74 75 75 76 76 77 77
55 55 56 56 57 57 58 58 59 59 60 60 60 61 61 62 62 63 63 64 64 64 65 65 66 66 67 67 68 68 69 69 69 70 70 71 71 72 72 73 73 73 74 74 75 75 76 76 77 77 78
56 56 57 57 58 58 59 59 60 60 60 61 61 62 62 63 63 63 64 64 65 65 66 66 67 67 67 68 68 69 69 70 70 71 71 71 72 72 73 73 74 74 74 75 75 76 76 77 77 78 78
57 57 58 58 59 59 60 60 60 61 61 62 62 63 63 63 64 64 65 65 66 66 66 67 67 68 68 69 69 69 70 70 71 71 72 72 72 73 73 74 74 75 75 75 76 76 77 77 78 78 79
58 58 59 59 60 60 61 61 61 62 62 63 63 63 64 64 65 65 66 66 66 67 67 68 68 68 69 69 70 70 71 71 71 72 72 73 73 74 74 74 75 75 76 76 76 77 77 78 78 79 79
59 59 60 60 61 61 61 62 62 63 63 64 64 64 65 65 66 66 66 67 67 68 68 68 69 69 70 70 70 71 71 72 72 73 73 73 74 74 75 75 75 76 76 77 77 77 78 78 79 79 80
60 60 61 61 62 62 62 63 63 64 64 64 65 65 66 66 66 67 67 68 68 68 69 69 70 70 70 71 71 72 72 72 73 73 74 74 74 75 75 76 76 76 77 77 78 78 78 79 79 80 80
61 61 62 62 63 63 63 64 64 65 65 65 66 66 66 67 67 68 68 68 69 69 70 70 70 71 71 72 72 72 73 73 73 74 74 75 75 75 76 76 77 77 77 78 78 79 79 79 80 80 81
62 62 63 63 64 64 64 65 65 65 66 66 67 67 67 68 68 68 69 69 70 70 70 71 71 72 72 72 73 73 73 74 74 75 75 75 76 76 76 77 77 78 78 78 79 79 79 80 80 81 81
63 63 64 64 64 65 65 66 66 66 67 67 67 68 68 69 69 69 70 70 70 71 71 72 72 72 73 73 73 74 74 74 75 75 76 76 76 77 77 77 78 78 79 79 79 80 80 80 81 81 82
64 64 65 65 65 66 66 67 67 67 68 68 68 69 69 69 70 70 70 71 71 72 72 72 73 73 73 74 74 74 75 75 76 76 76 77 77 77 78 78 78 79 79 79 80 80 81 81 81 82 82
65 65 66 66 66 67 67 67 68 68 69 69 69 70 70 70 71 71 71 72 72 72 73 73 73 74 74 74 75 75 76 76 76 77 77 77 78 78 78 79 79 79 80 80 80 81 81 81 82 82 83
66 66 67 67 67 68 68 68 69 69 69 70 70 70 71 71 71 72 72 72 73 73 73 74 74 75 75 75 76 76 76 77 77 77 78 78 78 79 79 79 80 80 80 81 81 81 82 82 82 83 83
67 67 68 68 68 69 69 69 70 70 70 71 71 71 72 72 72 73 73 73 74 74 74 75 75 75 76 76 76 77 77 77 78 78 78 79 79 79 80 80 80 81 81 81 82 82 82 83 83 83 84
68 68 69 69 69 70 70 70 71 71 71 72 72 72 72 73 73 73 74 74 74 75 75 75 76 76 76 77 77 77 78 78 78 79 79 79 80 80 80 80 81 81 81 82 82 82 83 83 83 84 84
69 69 70 70 70 71 71 71 71 72 72 72 73 73 73 74 74 74 75 75 75 76 76 76 76 77 77 77 78 78 78 79 79 79 80 80 80 80 81 81 81 82 82 82 83 83 83 84 84 84 85
70 70 71 71 71 72 72 72 72 73 73 73 74 74 74 75 75 75 75 76 76 76 77 77 77 78 78 78 78 79 79 79 80 80 80 81 81 81 81 82 82 82 83 83 83 84 84 84 84 85 85
71 71 72 72 72 72 73 73 73 74 74 74 74 75 75 75 76 76 76 77 77 77 77 78 78 78 79 79 79 79 80 80 80 81 81 81 81 82 82 82 83 83 83 83 84 84 84 85 85 85 86
72 72 73 73 73 73 74 74 74 75 75 75 75 76 76 76 76 77 77 77 78 78 78 78 79 79 79 80 80 80 80 81 81 81 82 82 82 82 83 83 83 83 84 84 84 85 85 85 85 86 86
73 73 74 74 74 74 75 75 75 75 76 76 76 77 77 77 77 78 78 78 78 79 79 79 79 80 80 80 81 81 81 81 82 82 82 82 83 83 83 84 84 84 84 85 85 85 85 86 86 86 87
74 74 75 75 75 75 76 76 76 76 77 77 77 77 78 78 78 78 79 79 79 79 80 80 80 81 81 81 81 82 82 82 82 83 83 83 83 84 84 84 84 85 85 85 85 86 86 86 86 87 87
75 75 76 76 76 76 77 77 77 77 78 78 78 78 79 79 79 79 80 80 80 80 81 81 81 81 82 82 82 82 83 83 83 83 84 84 84 84 85 85 85 85 86 86 86 86 87 87 87 87 88
76 76 76 77 77 77 77 78 78 78 78 79 79 79 79 80 80 80 80 81 81 81 81 82 82 82 82 82 83 83 83 83 84 84 84 84 85 85 85 85 86 86 86 86 87 87 87 87 88 88 88
77 77 77 78 78 78 78 79 79 79 79 80 80 80 80 80 81 81 81 81 82 82 82 82 83 83 83 83 83 84 84 84 84 85 85 85 85 86 86 86 86 86 87 87 87 87 88 88 88 88 89
78 78 78 79 79 79 79 80 80 80 80 80 81 81 81 81 82 82 82 82 82 83 83 83 83 84 84 84 84 84 85 85 85 85 85 86 86 86 86 87 87 87 87 87 88 88 88 88 89 89 89
79 79 79 80 80 80 80 80 81 81 81 81 82 82 82 82 82 83 83 83 83 83 84 84 84 84 84 85 85 85 85 86 86 86 86 86 87 87 87 87 87 88 88 88 88 88 89 89 89 89 90
80 80 80 81 81 81 81 81 82 82 82 82 82 83 83 83 83 83 84 84 84 84 84 85 85 85 85 85 86 86 86 86 86 87 87 87 87 87 88 88 88 88 88 89 89 89 89 89 90 90 90
81 81 81 82 82 82 82 82 83 83 83 83 83 83 84 84 84 84 84 85 85 85 85 85 86 86 86 86 86 87 87 87 87 87 87 88 88 88 88 88 89 89 89 89 89 90 90 90 90 90 91
82 82 82 83 83 83 83 83 83 84 84 84 84 84 85 85 85 85 85 85 86 86 86 86 86 87 87 87 87 87 87 88 88 88 88 88 88 89 89 89 89 89 90 90 90 90 90 90 91 91 91
83 83 83 84 84 84 84 84 84 85 85 85 85 85 85 86 86 86 86 86 86 87 87 87 87 87 87 88 88 88 88 88 88 89 89 89 89 89 89 90 90 90 90 90 90 91 91 91 91 91 92
84 84 84 84 85 85 85 85 85 85 86 86 86 86 86 86 87 87 87 87 87 87 88 88 88 88 88 88 88 89 89 89 89 89 89 90 90 90 90 90 90 91 91 91 91 91 91 92 92 92 92
85 85 85 85 86 86 86 86 86 86 87 87 87 87 87 87 87 88 88 88 88 88 88 88 89 89 89 89 89 89 90 90 90 90 90 90 90 91 91 91 91 91 91 91 92 92 92 92 92 92 93
86 86 86 86 87 87 87 87 87 87 87 88 88 88 88 88 88 88 89 89 89 89 89 89 89 90 90 90 90 90 90 90 90 91 91 91 91 91 91 91 92 92 92 92 92 92 92 93 93 93 93
87 87 87 87 88 88 88 88 88 88 88 88 89 89 89 89 89 89 89 89 90 90 90 90 90 90 90 91 91 91 91 91 91 91 91 92 92 92 92 92 92 92 92 93 93 93 93 93 93 93 94
88 88 88 88 88 89 89 89 89 89 89 89 89 90 90 90 90 90 90 90 90 91 91 91 91 91 91 91 91 91 92 92 92 92 92 92 92 92 93 93 93 93 93 93 93 93 94 94 94 94 94
89 89 89 89 89 90 90 90 90 90 90 90 90 90 91 91 91 91 91 91 91 91 91 92 92 92 92 92 92 92 92 92 93 93 93 93 93 93 93 93 93 94 94 94 94 94 94 94 94 94 95
90 90 90 90 90 91 91 91 91 91 91 91 91 91 91 92 92 92 92 92 92 92 92 92 92 93 93 93 93 93 93 93 93 93 93 94 94 94 94 94 94 94 94 94 94 95 95 95 95 95 95
91 91 91 91 91 91 92 92 92 92 92 92 92 92 92 92 92 93 93 93 93 93 93 93 93 93 93 93 94 94 94 94 94 94 94 94 94 94 94 95 95 95 95 95 95 95 95 95 95 95 96
92 92 92 92 92 92 92 93 93 93 93 93 93 93 93 93 93 93 93 94 94 94 94 94 94 94 94 94 94 94 94 94 95 95 95 95 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96
93 93 93 93 93 93 93 93 94 94 94 94 94 94 94 94 94 94 94 94 94 94 95 95 95 95 95 95 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 96 96 96 96 96 96 97
94 94 94 94 94 94 94 94 94 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97
95 95 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 97 97 97 96 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 98
96 96 96 96 96 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 98 98
97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 99
Appendix
98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99
99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
2/17/09 3:05:49 PM
605
Appendix
Appendix
606
Guides to the Evaluation of Permanent Impairment
Appendix A. Combined Values Chart (continued)
51 76
52 76 77
53 77 77 78
54 77 78 78 79
55 78 78 79 79 80
56 78 79 79 80 80 81
57 79 79 80 80 81 81 82
58 79 80 80 81 81 82 82 82
59 80 80 81 81 82 82 82 83 83
60 80 81 81 82 82 82 83 83 84 84
61 81 81 82 82 82 83 83 84 84 84 85
62 81 82 82 83 83 83 84 84 84 85 85 86
63 82 82 83 83 83 84 84 84 85 85 86 86 86
64 82 83 83 83 84 84 85 85 85 86 86 86 87 87
65 83 83 84 84 84 85 85 85 86 86 86 87 87 87 88
66 83 84 84 84 85 85 85 86 86 86 87 87 87 88 88 88
67 84 84 84 85 85 85 86 86 86 87 87 87 88 88 88 89 89
68 84 85 85 85 86 86 86 87 87 87 88 88 88 88 89 89 89 90
69 85 85 85 86 86 86 87 87 87 88 88 88 89 89 89 89 90 90 90
70 85 86 86 86 87 87 87 87 88 88 88 89 89 89 90 90 90 90 91 91
71 86 86 86 87 87 87 88 88 88 88 89 89 89 90 90 90 90 91 91 91 92
72 86 87 87 87 87 88 88 88 89 89 89 89 90 90 90 90 91 91 91 92 92 92
73 87 87 87 88 88 88 88 89 89 89 89 90 90 90 91 91 91 91 92 92 92 92 93
74 87 88 88 88 88 89 89 89 89 90 90 90 90 91 91 91 91 92 92 92 92 93 93 93
75 88 88 88 89 89 89 89 90 90 90 90 91 91 91 91 92 92 92 92 93 93 93 93 94 94
76 88 88 89 89 89 89 90 90 90 90 91 91 91 91 92 92 92 92 93 93 93 93 94 94 94 94
77 89 89 89 89 90 90 90 90 91 91 91 91 91 92 92 92 92 93 93 93 93 94 94 94 94 94 95
78 89 89 90 90 90 90 91 91 91 91 91 92 92 92 92 93 93 93 93 93 94 94 94 94 95 95 95 95
79 90 90 90 90 91 91 91 91 91 92 92 92 92 92 93 93 93 93 93 94 94 94 94 95 95 95 95 95 96
80 90 90 91 91 91 91 91 92 92 92 92 92 93 93 93 93 93 94 94 94 94 94 95 95 95 95 95 96 96 96
81 91 91 91 91 91 92 92 92 92 92 93 93 93 93 93 94 94 94 94 94 94 95 95 95 95 95 96 96 96 96 96
82 91 91 92 92 92 92 92 92 93 93 93 93 93 94 94 94 94 94 94 95 95 95 95 95 96 96 96 96 96 96 97 97
83 92 92 92 92 92 93 93 93 93 93 93 94 94 94 94 94 94 95 95 95 95 95 95 96 96 96 96 96 96 97 97 97 97
84 92 92 92 93 93 93 93 93 93 94 94 94 94 94 94 95 95 95 95 95 95 96 96 96 96 96 96 96 97 97 97 97 97 97
85 93 93 93 93 93 93 94 94 94 94 94 94 94 95 95 95 95 95 95 96 96 96 96 96 96 96 97 97 97 97 97 97 97 98 98
86 93 93 93 94 94 94 94 94 94 94 95 95 95 95 95 95 95 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 98 98 98 98
87 94 94 94 94 94 94 94 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 98 98 98 98 98 98 98
88 94 94 94 94 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 99
89 95 95 95 95 95 95 95 95 95 96 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 99 99 99
90 95 95 95 95 96 96 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99
91 96 96 96 96 96 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99
92 96 96 96 96 96 96 97 97 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99 99 99 99
93 97 97 97 97 97 97 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100
94 97 97 97 97 97 97 97 97 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 98 99 99 99 99 99 99 99 99 99 99 99 99 99 100 100 100
95 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100 100 100 100 100 100
96 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100 100 100 100 100 100 100 100 100
97 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100 100 100 100 100 100 100 100 100 100 100 100 100 100
98 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
99 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
2/17/09 3:05:54 PM
Appendix 607
Appendix B. Burden of Treatment Table B-2a and Table B-2b: Points for
Compliance Frequency and Route of Medications—
The burden of treatment compliance (BOTC) is Per Medication
assessed via a point system, which is then converted
to an impairment percentage. Points are assigned on TA B L E B -2 A
the basis of: Oral, Intranasal, Ocular, Skin
1. Medication usage, per medication, dependent Dosing Frequency Points
upon the route and frequency. ⬍ 1 per day 0
1 to 2 per day .5
2. Dietary modifications.
3 to 4 per day 1.0
3. Frequency of routinely performed procedures 5 to 6 per day 2.0
4. History of prior operative procedure or radiation ⬎ 6 per day 3.0
therapy.
Appendix
TA B L E B -2 B
These points are then converted into impairment
based upon Table B-1. Inhaled, Rectal
Dosing
Frequency Points - Inhaled Points - Rectal
TA B L E B -1
⬍ 1 per day 0 1.0
Burden of Treatment Compliance
1 per day 1.0 2.0
Total Total
2 per day 2.0 4.0
Points Impairment (%) Points Impairment (%)
0–1 0 26–30 6 3 per day 3.0 6.0
2–5 1 31–35 7 ⱖ 4 per day 4.0 8.0
6–10 2 36–40 8
11–15 3 41–45 9 Notes:
16–20 4 46 ⫹ 10 1. Combination medications are assessed by the
total number of medications. For example, com-
21–25 5
binations of antihypertensives and diuretics count
as two medications due to the potential side
In most situations, BOTC will not result in the addi-
effects of each.
tion of more than 2% to 3% impairment. In chap-
ters using BOTC, points are to be added onto final 2. Medications need to be taken chronically for a
impairment rating. chronic condition specific to the organ systems
under evaluation. If a medication is being used
Medication Usage for two systems it should be counted only once.
Perform the following analysis to determine the Each month is arbitrarily considered to be 28 days;
point score that will be used in calculating the the medication must be taken at least 21 days per
BOTC due to medication usage. month to count as a medication that is taken daily.
1. Assess the dosing frequency and route of admin- 3. Medications given to correct a well-documented
istration for each medication used for the condi- side effect of a medication used to treat a condi-
tion being rated, and assign points for each using tion specific to the organ system being rated are
Table B-2a for oral, inhaled, ocular, skin and rec- also counted unless:
tal medications, and Table B-2b for medications
a. The medication side effect is not well docu-
administered by an intravenous, subcutaneous,
mented by either its known pharmacologic
intramuscular, intradermal, or intracavitary route.
actions or by a review of the individual’s
2. Add these to get the total points for medications. personal medical chart.

b. The condition resulting from the side effect TA B L E B -3

is rated in conjunction with providing a rat- Points Assigned For Dietary Modification
ing for an alternative and more appropriate Modification Points
organ system.
Dietary modifications – Minimal 2.0
c. The medication (either the primary medica- Dietary modifications – Moderate 5.0
tion or the medication used to counteract a Dietary modifications – Severe 10.0
side effect) is a non-prescription or alternative
medication that is not prescribed by an allo-
pathic or osteopathic physician.
Procedure-Based Impairment
4. For “prn” – use average frequency based on use, Certain procedures are not routinely performed on all
although prn medications must be prescribed by a patients with a given disease. It is consequently unrea-
physician for a chronic condition (such as Imitrex sonable to assume a default level of impairment based
for migraines). upon the need to undergo these procedures in the rating
Appendix
assigned for these conditions. The need to have under-

TA B L E B -2C
gone procedures such as a laparotomy or radiation ther-
apy for a condition also varies from patient to patient
Points for Subcutanous, IM, Intradermal, IV, and
Intracavitary Medication and contributes slightly to impairment. A schema for
assigning procedural based impairment is as in
Route of Administration Points
Table B-4. Peritoneal dialysis, hemodialysis and
SC, IM, ID: 1 to 3 times weekly 1.0 ostomy-related impairment are sufficiently intrusive
SC, IM, ID: 4 to 7 times weekly 2.0 as to warrant the direct assignment of impairment
SC, IM, ID: 2 times a day 3.0 percentages and are covered in specific organ-system
SC, IM, ID: 3 times a day 4.0 chapters.
SC, IM, ID: 4 times a day 5.0
SC, IM, ID: 5 times a day 6.0 TA B L E B - 4
Intra-cavitary Reservoir Based on frequency Points Assigned for Procedures

that reservoir is filled Procedure Points
Intravenously 1 point per treatment Glucose monitoring: 1 times 1.0
per day up to per day
25 points/ month
Glucose monitoring: 2 times 2.0
per day
Notes: Filling the reservoir once a month or more Glucose monitoring: 3 times 3.0
frequently is assigned 4 points; for filling once every per day
2–4 months, assign 2 points; for filling the reservoir Glucose monitoring: ⱖ 4 times 4.0
less frequently, assign 1 point per day
Hemophoresis 4.0 per episode
Dietary Modification per month
Many conditions require dietary modification. The Transfusion (monthly) 2.0 per unit per month
degree to which this is necessary varies from patient Exploratory laparotomy 2.0 (assigned only once)
to patient, as does the degree to which patients com-
Radiation therapy 2.0 (per body part
ply with these restrictions. Thus, rather than build irradiated)
an allowance for this into the impairment rating, it
appears more reasonable to rate it separately. BOTC
points are given for dietary modification when the
patient is compliant, and are based upon the prem-
ise that complying with dietary restrictions restricts
ADLs in ways other than those measured by the his-
tory and medication use alone.

Glossary
Abnormal illness behavior Exaggeration or fab- factor results in an increase in symptoms, signs, and/or
rication of symptoms and/or physical findings to impairment that never returns to baseline, or what it
psychological, social, financial, or other reasons. would have been except for the aggravation (the level
Abnormal pain behavior is more specific, meaning pre-determined by the natural history of the antecedent
there are verbal and/or physical manifestations of injury or illness).
Glossary
discomfort in excess of, or unsupported by, physical
Allodynia Pain in response to a normally nonpain-
injury or illness.
ful stimulus (eg, light touch).
Accommodation Any modification of the work-
Ambulation Movement of one’s body from one
place or a specific job that allows a person with a
point in space to another (eg, walking, stair climb-
disability to perform essential functions of a job and
ing, wheelchair locomotion).
or able to be gainfully employed
Americans with Disabilities Act (ADA) A civil rights
Accuracy The quality of being correct or near
law, signed in 1990, that protects individuals with
to the truth, especially the degree to which a
disabilities against discrimination in such diverse areas
measurement, calculation, or estimate conforms
as employment (hiring, firing, advancement, compensa-
to the true value. Examples include, the patient
tion, job training, etc), government service entitlement,
presented an accurate history; when lower limb
and access to transportation, communications, public
length is measured, radiographic measurements
accommodations, and businesses.
are more accurate than measurements with a tape
measure; magnetic resonance imaging supported Ankylosis Immobilization of a joint in a specific
an accurate diagnosis. position due to disease, injury, or surgery. When
surgically created, the goal is to fuse the joint in the
Acquired Denoting an abnormality, disease,
most functional position.
or predisposition that developed after birth. Not
hereditary or congenital. Apportionment The extent to which each of 2 or
more probable causes are found responsible for an
Activity The execution of a task or action by an
effect (injury, disease, impairment, etc). Only prob-
individual. (This term along with “activity limita-
able causes (at least more probable than not) are
tions” replaces “disability” according to ICF)
included. Hence, the first step in apportionment is
Activities of Daily Living (ADLs) Basic self-care scientifically based causation analysis. Second, one
activities performed in one’s personal sphere (eg, feed- must allocate responsibility among the probable
ing, bathing, hygiene, dressing). Instrumental Activities causes and select apportionment percentages con-
of Daily Living (IADLs) are complex self-care activi- sistent with the medical literature and facts of the
ties that may be delegated to others (eg, financial man- case in question. Arbitary, merely opinion based
agement, medications, meal preparation). ADLs do not unscientific apportionment estimates which are
include highly individualized work duties. nothing more than speculations must be avoided.
When appropriate current impairment can also be
Aggravation Permanent worsening of a pre-existing
apportioned to more than one cause.
condition. A physical, chemical, biological, or other
609
Guides6e_GLO_609-616.indd 609 2/17/09 3:06:27 PM

610 Glossary
Arm That portion of the upper extremity between disorders (300.8x), factitious disorders (300.1x), and
the shoulder and elbow joints. psychological factor(s) affecting a general medical con-
dition (316), and distinct from malingering (V65.2).
Assistive device Any item made or adapted to help
a person with a functional loss perform a particular Combined Values Chart A method used to com-
task. Examples include magnifying glasses, hear- bine 2 or more impairment percentages, derived
ing aids, telephone amplifiers, reachers, shower from the formula A ⫹ B (1 ⫺ A) ⫽ Combined
chairs, walking aids (canes, crutches, walkers), and Values of A and B. Combining, as opposed to
wheelchairs. adding, ensures that the total value will not exceed
100% whole person impairment and takes into
Blindness The absence of vision; also called no
account the impact of impairment from one body
light perception (NLP).
part on impairment of another body part.
Body Mass Index (BMI) A measure comparing
Complex regional pain syndrome (CRPS) An
body weight to height used to determine if a person’s
uncommon, chronic condition characterized by
weight is too low, normal, or too high. The BMI is
burning pain that usually involves an upper or lower
calculated by dividing the individual’s weight in
extremity, and rarely other body parts. Physical
kilograms by his or her height in meters squared
findings include hypersensitivity to touch plus
(kg/m2). Using English weights and measures, the
vasomotor, sudomotor, and later trophic changes.
formula is weight in pounds multiplied by 705
Two types have been described: CRPS I, formerly
divided by height in inches squared (lb ⫻ 705/in2).
known as reflex sympathetic dystrophy, and CRPS
According to the National Institutes of Health, a
II, formerly known as causalgia. CRPS II follows an
BMI below 18.5 is underweight; 18.5 to 24.9, nor-
injury to or other lesion of a peripheral nerve, while
mal; 25 to 29.9, overweight; 30 to 39.9, obese; and 40
Glossary
CRPS I may complicate an injury or illness, or occur

or higher, morbidly obese. BMI differs from percent
spontaneously.
body fat or lean mass calculations because it consid-
ers only weight and height. Congenital Existing at birth; referring to condi-
tions, traits, defects, etc. which are hereditary or
Burden of Treatment Compliance (BOTC) The
acquired during development in utero.
impairment (impact on ADLs) that results from
adhering to a complex evaluation and treatment Continuous Referring to something, commonly an
regimen including diagnostic testing, prescription occupational activity, that occurs 67% to 100% of the
(not over-the-counter) medications, therapy, and/or time or workday.
procedures, to achieve objectively measurable clini-
Contracture Chronic and sometimes permanent
cal improvement that would not occur, or could be
shortening of soft tissues such as muscle, tendon,
reversed, without compliance.
ligament, joint capsule, and/or skin. The contracture
Causalgia See complex regional pain syndrome. often results in loss of joint motion or in deformity.
Cause In general, anything that produces an Contrast sensitivity The ability to perceive larger
effect. In medicine, cause refers to an identifiable objects with low contrast, important for tasks such as
factor (eg, genetic abnormality, toxic or infectious facial recognition.
exposure, trauma) that results in injury or illness.
Cure Complete recovery from a disease or
The cause or causes must be scientifically prob-
condition.
able following causation analysis.
Decompensation Failure of the body’s ability to
Chronic pain Pain that extends beyond the expected
compensate for a disease, causing a previously stable
healing period of the injury or illness that initiated it,
state to become unstable, with onset or worsening of
or is caused by a progressive incurable disease such
symptoms (eg, decompensated cirrhosis or heart or
as arthritis or cancer, and has outlived its usefulness
lung disease). In psychiatry, it refers to deterioration
as a warning. Chronic pain is sometimes defined as
of or inability to maintain defense mechanisms in
pain lasting more than 3 months for nociceptive pain,
response to stress, leading to pathological behavior
as most conditions affecting the musculoskeletal and
or worsening thereof.
other organ systems will heal by this time. However,
the nervous system is an exception. Desirable weight A range of weight determined to
be healthful, and depending on an individual’s sex,
Chronic pain syndrome A term for one of various
age, height, and habitus (physique or body build).
conditions more specifically defined in the DSM-
Body mass index is currently the most widely used
IV-TR, including pain disorder (307.8x), somatoform
measure of desirable weight.

Glossary 611
Diagnostic and Statistical Manual of Mental Functional limitation Restriction in or lack of abil-
Disorders, Fourth Edition, Text Revision ity to perform a task due to an impairment. In some
(DSM-IV-TR) A book published by the American instances, functional limitations may be overcome
Psychiatric Association in 2000, that lists and describes through personal or environmental accommodations.
the criteria necessary to make psychiatric diagnoses.
Guarding Any behavior that diminishes or prevents
Disability An umbrella term for activity limitations pain. Guarding may include voluntarily limiting
and/or participation restrictions in an individual with joint motion, muscle contraction to splint or protect
a health condition, disorder or disease. an injured or ill part such as abdominal guarding in
appendicitis, avoidance of contraction of an injured
Disfigurement Abnormal appearance of a body part,
muscle, flinching or withdrawal upon palpation of a
including alteration in color, shape, and/or texture,
tender area, maintaining a limb in a protected pos-
especially scarring of the skin in commonly exposed
ture such as holding the anterior forearm across the
areas such as head, face, neck, or hands. It may be
abdomen following shoulder injury, a limp (antalgic
congenital or caused by injury or disease; it is generally
gait), or applying a brace or splint to the involved
permanent. Disfigurement may cause social rejection,
body part.
diminished self-image, alteration of lifestyle, and other
adverse mental and behavioral effects. Handedness The unequal distribution of fine
motor skills between left and right hands and digits,
Dizziness A sensation of unsteadiness, imbalance,
prompting the individual to preferentially use and
lightheadedness, and/or movement, typically spin-
generally acquire greater strength and dexterity on
ning or falling.
the dominant side. Almost 90% of persons are right
Dominant extremity The limb, usually upper (more handed, and about 10% are left handed. The 1% or so
Glossary
commonly right than left) having more dexterity with of persons who are equally skilled with both hands
motor skills and hence more effective and preferentially are labeled ambidextrous. See Dominant extremity.
used for single limb activities. See Handedness.
Hernia Protrusion of an organ or tissue through the
Dysesthesia Distortion of a sense, especially touch, wall of the cavity in which it is normally contained,
such that an unpleasant sensation (eg, burning or or through a natural or surgically created opening
itching) is produced by ordinary stimuli (evoked) or where it normally would not go, due to a pressure
occurs in the absence of stimulation (spontaneous). gradient.
Exacerbation Temporary worsening of a pre-existing Human immunodeficiency virus (HIV) Any of
condition. Following a transient increase in symptoms, a group of retroviruses, and especially HIV-1, that
signs, disability, and/or impairment, the person recov- infect and destroy helper T cells of the immune sys-
ers to his or her baseline status, or what it would have tem, causing a marked reduction in their numbers. It
been had the exacerbation never occurred. Given a is one of the diagnostic criteria of AIDS and is also
condition whose natural history is one of progressive called the AIDS virus.
worsening, following a prolonged but still temporary
Hyperalgesia An exaggerated pain response to a
worsening, return to pre-exacerbation status would not
noxious stimulus.
be expected, despite the absence of permanent residuals
from the new cause. Hyperesthesia Increased sensitivity to pain, touch,
or other sensory stimuli. Allodynia, hyperalgesia,
Exposure Proximity to and/or contact with a poten-
and hyperpathia (see entries for those terms) are
tial disease-producing agent (eg, chemical, ionizing
types of hyperesthesia.
radiation, or microorganism) or mechanical forces
(eg, prolonged vibration or repetitive tensile, com- Hyperpathia An exaggerated subjective reaction to
pressive, or shear stresses). a painful stimulus.
False negative, False positive See Negative, Hypesthesia (Hypoesthesia) Decreased sensitivity
Positive, respectively. to pain, touch, or other sensory stimuli.
Forearm That portion of the upper extremity Impairment A significant deviation, loss, or loss
between the elbow and wrist joints. of use of any body structure or function in an indi-
vidual with a health condition, disorder, or disease.
Frequent Referring to something, commonly an
occupational activity, that occurs 34% to 66% of the Impairment evaluation Acquisition, recording,
time or workday. assessment, and reporting of medical evidence, using
a standard method such as described in the Guides,

612 Glossary
to determine permanent impairment associated with rehabilitation, maximum medical stability, medical
a physical or mental condition. end result, medical stability, medical stabilization,
medically stable, medically stationary, permanent and
Impairment rating Consensus-derived percentage
stationary, and stable and ratable.
estimate of loss of activity, which reflects severity
of impairment for a given health condition, and the MET See metabolic equivalent.
degrere of associated limitations in term of Activities
Metabolic equivalent (MET) The unit used to
of Daily Living (ADLs).
measure the intensity of physical activity, and
Independent medical examination (IME) A usu- express the results of stress testing. One MET equals
ally one-time evaluation performed by an indepen- 3.5 mL of oxygen consumed per kilogram of body
dent medical examiner who is not treating the patient weight per minute, the amount normally used by the
or claimant, to answer questions posed by the party body at rest (eg, sitting quietly). Activity involving
requesting the IME. less than 3 METs is considered light; 3 to 6 METs,
moderate; and over 6 METs, vigorous. Walking
Inherited Derived by genetic transmission from a
and jogging are examples of moderate and vigorous
parent or ancestor.
activity, respectively. Oxygen consumption during
Injury A sudden traumatic event producing intensive exercise may increase to 12 or more METs.
immediate or prompt symptoms and/or signs due
Mild Of low severity, force, degree, or effect
to physical and/or psychological pathology.
(eg, a mild fever, collision, burn, or analgesic,
Instrumental Activities of Daily Living See respectively).
Activities of Daily Living.
Moderate Of medium or average severity, force,
Glossary
Intermittent Marked by intervals during which the degree, or effect; not excessive or extreme.
symptoms and signs of an injury or illness, or mani-
Motivation A desire, goal, intention, and/or need
festations of another process or state, are absent;
that causes a person to act or behave in a certain
repeatedly starting and stopping; not continuous.
manner.
Leg That portion of the lower extremity between the
Negative Indicating the absence of a condition,
knee and ankle joints.
pathogen, or response (eg, a negative pregnancy test,
Malingering According to the DSM-IV-TR, streptococcal throat culture, or Trendelenberg’s sign,
malingering is the intentional production of false respectively). False negative is when the test result is
or grossly exaggerated physical or psychologi- negative but the condition is actually present. True
cal symptoms, motivated by external incentives. negative is when the test result is negative and the
Defined somewhat more broadly, it is the conscious condition is actually absent.
fabrication or exaggeration of the symptoms and/or
Neuropathic pain Pain due to abnormal function
subjective physical findings of physical or men-
of the peripheral and/or central nervous system
tal illness or injury for external gain. The motive
resulting from disease, injury, sensitization, or other
for feigning a disorder may be to obtain financial
changes. Although neuropathic pain is perceived as
compensation or drugs, avoid work or other respon-
orginating in a body part, the responsible pathology
sibilities, lessen a criminal sentence or escape
lies in the nervous system, such as pain felt in the
incarceration, or engender sympathy.
posterior thigh and leg due to compression of a lum-
Maximum Medical Improvement (MMI) The point bar nerve root (sciatica).
at which a condition has stabilized and is unlikely to
Nociception The neurophysiologic process whereby
change (improve or worsen) substantially in the next
noxious chemical, mechanical, or thermal stimuli
year, with or without treatment. While symptoms and
are transduced by sensory receptors into electrical
signs of the condition may wax and wane over time,
signals (action potentials), transmitted along afferent
further overall recovery or deterioration is not antici-
neurons through peripheral nerves to the spinal cord
pated. However, both the name given to and exact
and brain, modulated along the way, and ultimately
definition of this status vary depending on the jurisdic-
perceived as pain. Nociceptive pain resolves once the
tion. Among the numerous synonyms for MMI are
noxious stimulus is removed and tissue has healed.
(in alphabetical order): ascertainable loss, end of heal-
ing, fixed and stable, maximum cure, maximum degree Normal A range that represents healthy functioning
of medical improvement, maximum medical heal- and varies with age, sex/gender, environmental con-
ing, maximum medical recovery, maximum medical ditions, and other factors.

Glossary 613
Objective In healthcare, objective refers to some- Pain disorder A type of somatoform disorder in
thing, usually a physical finding or diagnostic test which pain is the predominant focus of clinical
result, that can be perceived by an examiner using attention; and psychological factors are judged to
one or more senses without patient input. For exam- have an important role in the onset, severity, exacer-
ple, one might see a scar, hear a heart murmur, smell bation, and maintenance of the pain.
alcohol on a patient’s breath, feel a subcutaneous
Paresthesias An abnormal sensation, most com-
mass, or read an X ray or lab report. Objective data
monly tingling or pricking (“pins and needles”),
can often be measured. In general usage as an adjec-
but sometimes burning, tickling, or creeping on the
tive, objective means based on observation or other
skin, usually associated with injury or irritation of a
data, and uninfluenced by one’s attitudes, beliefs,
sensory nerve or nerve root.
biases, emotions, and/or prejudices (eg, an objective
medical opinion or judicial decision). Compare with Participation Involvement in a life situation (This
Subjective. term along with “participation restrictions” replaces
“handicap” according to ICF)
Occasional Referring to something, commonly an
occupational activity, that occurs 10% to 33% of the Permanency Synonymous with maximum medical
time or workday. improvement.
Occupational history Acquisition, organization, Permanent impairment An impairment extant at
and assessment of information about an individ- the point of maximum medical improvement.
ual’s prior and current work, including activities
Positive Indicating the presence of a condition,
and exposures, duration thereof, and their possible
pathogen, or response (eg, a positive pregnancy test,
relationship to illness and injury. An occupational
blood culture, or Tinel’s sign, respectively). False pos-
Glossary
history can provide information important in
itive is when the test result is positive and the condi-
causation analysis and apportionment, specifi-
tion is actually absent. True positive is when the test
cally whether work caused or contributed to the
result is positive and the condition is actually present.
condition or conditions, and it that may assist in
treatment and/or prevention or minimization of Precision In general, precision refers to the quality
further illness or injury. of being sharply defined, stated, estimated, or mea-
sured. In statistics, it means the inverse of the vari-
Orthosis An externally applied device, such as a
ance of an estimate or measurement. As used in the
brace or splint, used to stabilize and/or support a
Guides, precision means the smallest unit of change
body part, most commonly a portion of the spine
a measuring instrument can distinguish, or the num-
or upper or lower limb, to facilitate healing, align it
ber of digits used to express the measurement. For
and prevent or correct deformity, assist motion of an
example, the more precise computerized inclinom-
adjacent joint or joints, unload body weight, and/or
eter showed that shoulder flexion was 91.5 degrees,
otherwise improve function.
whereas the same motion was read as 90 degrees on
Pain According to the International Association for a goniometer.
the Study of Pain, an unpleasant sensory and emo-
Prosthesis An artificial device to replace a missing
tional experience associated with actual or potential
body part.
tissue damage or described in terms of such damage.
Psychogenic pain Discomfort occurring in the
Pain behavior Verbal and/or nonverbal manifesta-
absence of organic pathology, or grossly dispropor-
tions of discomfort, and perhaps distress and suf-
tionate in distribution, severity, and/or duration to
fering. The behavior or behaviors may be audible
any physical injury or illness. The reported pain is
complaints—actions such as a grimace or other
attributed primarily or exclusively to psychological
facial expression, abnormal posture, guarding or
factors. Use of DSM-IV-TR criteria may enable a
rubbing a body part, a limp, or use of a walking aid,
specific diagnosis.
brace, or other device—or inaction such as activ-
ity avoidance, even bedrest. Pain behaviors reflect Radiculitis Inflammation of a nerve root. As com-
the way persons think, feel, and act in response to monly used, radiculitis implies symptoms such as
their discomfort, and the way they communicate the pain, numbness, tingling, and/or weakness in the
symptom to others. The behaviors may be adaptive distribution of a nerve root; but without physical
(eg, when diminished stress on an injured part is findings of radiculopathy.
necessary for healing) or pathological (when dispro-
Radiculopathy Any pathological condition of a
portionate to physical pathology).
spinal nerve root, most commonly compression

614 Glossary
with or without inflammation, or less frequently posterior thigh, then anterior, lateral, or posterior leg.
another disorder such as traction, tumor, or infection. However, the distribution may be as narrow as the
Radicular symptoms may include pain, numbness, posterior thigh.
tingling, and/or weakness in distribution of the nerve
Seldom Referring to something, commonly an
root, usually involving an upper or lower extrem-
occupational activity, that occurs less than 1% of the
ity. Physical findings are weakness of the involved
time of workday.
myotome (muscles innervated by the nerve root),
diminution in or loss of the corresponding muscle Sensitivity The state or quality of being sensitive to
stretch reflex (if any), diminished sensation in the light, sound, touch, temperature changes, chemicals,
appropriate dermatome (area of skin supplied by and/or other stimuli. In statistics, the ability of a
the nerve root), and/or positive root tension signs. diagnostic test to detect a condition when present. It
As commonly used, and for purposes of the Guides, is a proportion or percentage obtained by the number
radiculopathy requires the presence of radicular of true-positive test results divided by the sum of
physical findings, not just symptoms. true positives and false negatives. A test with 90%
sensitivity will identify 9 of 10 persons having the
Raynaud’s phenomenon A vascular disorder
condition. See Specificity and Predictive value.
marked by recurrent, temporary spasm of cutaneous
arterioles, especially those of the fingers and toes, Sensitization (pain) Increased perception of
most commonly upon exposure to cold, and gener- chemical, mechanical, and thermal stimuli, due to
ally characterized by pallor, cyanosis, and rubor nociception-induced changes in the peripheral and/or
(white, blue, and red discoloration) in succession. central nervous system, with resultant hyperalgesia
The digits often feel cold and numb during the initial and/or allodynia. It may be localized (eg, involve
ischemic phase (when blood supply is diminished), only the low back) or generalized, with most or all of
Glossary
then tingle and/or throb for a time after resolution of the body affected. In immunology, it refers to abnor-
the vasospasm and restoration of normal blood flow. mally increased response to a chemical, biological or
physical agent such as air sensitization to chemicals
Recurrence Reappearance of the symptoms and/or
leading to airway hyper-responsiveness causing an
signs of a disease after a remission (period during
asthmatic response.
which the manifestations were absent or significantly
diminished). Severe Having high severity, force, degree, or effect;
very bad, extreme.
Reflex sympathetic dystrophy (RSD) See Complex
regional pain syndrome. Social functioning An individual’s ability to inter-
act appropriately, negotiate and compromise, and
Relapse Synonymous with recurrence.
communicate effectively with other persons.
Reliability The extent to which a test or mea-
Somatization A tendency to experience and report
surement yields consistent results when repeated.
somatic complaints (physical symptoms) in response
Synonymous with reproducibility.
to psychosocial stressors and seek health care
Remission A decrease in or disappearance of the services for them.
symptoms and/or signs of a disease (partial and
Somatoform disorder A variety of conditions
complete remission, respectively).
defined in the DSM-IV-TR (300.8x), the common fea-
Replacement medication or therapy Treatment tures of which include physical symptoms that suggest
that involves the supply of something (an element, a general medical condition (hence somatoform), but
compound, or hormone) lacking in the body. are not fully explained by a general medical condition,
Although the person may be fully functional while the direct effects of a substance, or another mental
taking replacement medication, he or she may be disorder. The symptoms must cause clinically signifi-
unable to adequately respond to stresses such as cant distress or impairment in social, occupational,
trauma or infection. or other areas of functioning. An example would be
Somatoform pain disorder which requires preoccupa-
Reproducibility Synonymous with reliability.
tion with pain in the absence of physical findings that
Sciatica Pain along the course of the sciatic nerve adequately account for the pain and its intensity; plus
and its branches, usually caused by lumbar nerve psychological factors judged to have a major role in
root impingement and/or inflammation, or less the onset, severity, exacerbation, and maintenance
commonly compression of the lumbar plexus or of the pain. These disorders differ from Factitious
sciatic nerve. The pain usually radiates distally Disorders and Malingering, and Psychological Factors
from the low back through the buttock into the Affecting Medical Condition. Somatoform and

Glossary 615
factitious disorders are not work-related conditions, Transfer Movement of one’s body position while
but maladaptive coping mechanisms. remaining at the same point in space (eg, supine to
side lying, supine to sit, or sit to stand).
Specificity The ability of a diagnostic test to cor-
rectly identify those individuals without a condition True negative, True positive See Negative,
when it is not present. It is a proportion or percentage Positive, respectively.
obtained by the number of true-negative test results
Validity The extent to which an instrument or test
divided by the sum of true negatives and false posi-
actually measures what it is intended to measure.
tives. A test with 90% specificity will incorrectly
identify 1 of 10 healthy persons as having the condi- Vertigo A false sensation of motion, especially
tion. See Sensitivity and Predictive value. spinning or whirling, either the external world
revolving around the individual or the person revolv-
Spirometry Measurement by means of a spirometer
ing in space; or an exaggerated sense of motion in
of the forced vital capacity and its subdivisions, as
response to body movement.
well as measurement of the speed of airflow achieved
in performance of this maneuver. Spirometry is also Vision, low Visual acuity less than 20/63 (20/60 if
known as ventilatory studies. rounded) down to 20/1000.
Spontaneous pain Discomfort that occurs without Visual acuity The ability to recognize small objects
sensory stimulus. with high contrast, such as letters on a page, impor-
tant for reading.
Stress testing An electrocardiographic test of heart
function before, during, and after a controlled period Visual Acuity Score (VAS), Visual Field Score
of increasingly strenuous exercise (as on a treadmill). (VFS) Scales used to assign a numeric value to
Glossary
visual acuity and visual field measurements for each
Subjective In health care, refers to that which is per-
eye. Higher values indicate better vision.
ceived, reported, and/or demonstrated by a patient but
cannot be verified by an examiner on physical exami- Visual field The ability to detect objects in the
nation or via diagnostic tests. The adjective is most periphery of one’s visual environment, important for
commonly used in the context of symptoms such as orientation and mobility.
pain, but many physical findings are also subjective,
Visual impairment rating A rating calculated as
including tenderness, range of motion, and strength.
100 ⫺ FVS. Higher values indicate poorer vision.
Tenderness or the absence thereof depends on verbal
or nonverbal input from the patient,. Subjective com- Whole person impairment Percentages that esti-
plaints such as pain may be quantified, for instance, mate the impact of the impairment on the individ-
on a 0 to 10 scale, but are not measured. In general ual’s overall ability to perform Activities of Daily
usage, subjective means colored by one’s attitudes, Living, excluding work.
beliefs, biases, emotions, and/or prejudices. Subjectivity
Workers’ compensation A statutorily mandated
may influence medical, judicial, and other opinions.
insurance program in North America mainly by
Compare with Objective.
various state jurisdictions and in some cases by
Tenderness Production of pain by palpation. federal statutes to provide medical and indemnity
benefits to workers for injuries and illnesses arising
Thigh That portion of the lower extremity between
out of and in the course and scope of employment.
the hip and knee joints.
Similar statutes are also enacted by other parts of the
Tinnitus Noises (ringing, whistling, roaring, booming, industrialized world. Generally, workers’ compensa-
etc) in the ears, generally in the absence of correspond- tion statutes are “no fault,” obviating the need for
ing external sounds. Tinnitus may be audible (objective) an employee to prove negligence on the part of the
or inaudible (subjective). Audible tinnitus is usually employer or a coworker, but specify that the benefits
associated with a muscular tic or vascular bruit. The provided are usually the “sole remedy” for the injury
more common inaudible tinnitus can be heard only or illness. The exact provisions of a workers’ com-
by the person affected and may be associated with an pensation statute regarding eligibility, benefits, and
obstruction of the external auditory canal or a distur- obligations vary with each jurisdiction.
bance of the auditory nerve and/or the central nervous
system.

616
Index
A ADH, See Antidiuretic hormone American Medical Association, evidence-

Abdominal adhesions, 108 Adjustment disorder, 363–366 based literature, 9
Abdominal wall, symptoms and signs, 102 Adrenal cortex, 226–230, 227 American Thoracic Society, 10
Abnormal illness behavior, 609 corticotropin, 218 dyspnea impairment classification, 79
Academic assessment, 350 impairment evaluation summary, guidelines, 77
Accommodation, 609 244–245 Americans with Disabilities Act, 4, 609
Accuracy, definition of, 8, 609 impairment rating, 220 Amputation
Acetabulum, 493, 513 tumor causing Cushing’s syndrome, 228 lower extremities, 542–543
Achalasia, esophageal, See Esophagus Adrenal medulla, 230–232 upper extremities, 454–459, 460
Acne conglobata, 175 impairment evaluation summary, Anal anastomosis, surgically created
Acoustic neuroma, 259–260 244–245 stomas, 118
Acquired (term), 609 Adrenocortical hormones, Androgens, 226
Acquired immunodeficiency syndrome hyposecretion, 226 Anemia, 187–191
Index
(AIDS), 200 Adrenogenital syndrome, 226 aplastic, 188, 190–191
Acromegaly, 221–222 Affect, blunted, Brief Psychiatric Rating aplastic, paroxysmal nocturnal
ACTH, See Corticotropin Scale, 378 hemoglobinuria, and Budd-Chiari
Activities of daily living, See also African Americans, pulmonary function syndrome, 191
Instrumental activities of daily living predicted values, 84 autoimmune hemolytic, 190, 197
basic and advanced listed, 323 Aggravation, 25, 609 chronic, with myelodysplastic
categories of, 7 AIDS, 200 syndrome, 190–191
definition of, 6, 609 Air conduction tests, 249 congenital hemolytic, 188
digestive system impairment, 104–105 Airway hyperresponsiveness, 79, 87–91, 90 criteria for rating permanent
impairment ratings and, 5 Airway obstruction, 81, 82, 265–269, 267 impairment, 189
mental and behavioral impairment, 358 Akathisia, 379 hypoproliferative, 188
pain in impairment rating, 37 Aldosteronism, 226 megaloblastic, 188
questionnaire, 482–484 Allergic alveolitis, extrinsic, See persistent hemolytic, 188
standardized assessment Alveolitis, extrinsic allergic persistent refractory, 188
recommended, 2 Allergic rhinitis, 265, 268 rheumatoid arthritis with, 189
Activity (term), 3, 609 Allergies, contact dermatitis, 163, 167–168 sickle cell, 190
ICF terminology and definitions, 5 contact dermatitis due to chromate, 170 sickle cell trait, 188–189
limitation, ICF model of disablement, latex, and eczema, 170–171 Angina pectoris, 54
3, 5 multiple, contact dermatitis, 169–170 Angiography, magnetic resonance, 325
limitations, 3 natural rubber latex, 164 Ankle, 493
limitations, correlation with rubber accelerator, 161–162 adjustment grid and grade modifiers,
participation restrictions, 6 Allodynia, 34, 609 515–522, 516, 517, 519–520
limitations due to pain, 37 Alveolitis, extrinsic allergic, 91 amputation impairment, 542–543, 543
limitations, ICF terminology and Amblyopia, 291 arthritis, 505–507, 524
definitions, 5 Ambulation, definition of, 6, 609 arthrodesis, 507
617
Guides6e_INDX_617-634.indd 617 3/13/09 10:16:21 AM

618 Index
assessment principles, 494–496 Apportionment, description of term, work-related, 89–90

combining and converting impairments, 25–26, 609 Atherosclerosis, extremities, 68
529–530, 530–531 Arm (upper extremities), 383–491 Audibility, See Speech
complex regional pain syndrome, adjustment grids, 406–413 Audiometry, 249, 250
538–542 assessment principles, 385–386, 385 Auricular nerve, 344
diagnosis-based class assignment, clinical studies adjustment grid, 407, Australia, use of the Guides, 21
regional grids, 499–500, 501–508 409, 410–411 Automobile injuries, 21
diagnosis-based impairment, 495, description (glossary terms), 609 Autonomic nervous system, 339, 341
497–515 determining grade within impairment Awareness disturbances, 326–329, 327, 328
dorsiflexion, 546 class, 412 Axillary nerve injury, 430, 431, 434, 443
eversion, 546 diagnosis-based impairment, 387–390,
fractures, dislocations, 503 388 B
grade determination in impairment diagnosis-based impairment examples, Babylon, laws regarding compensation for
class, 520 412–418 injuries, 1
impairment calculation method, 518, forearm range of motion, 472 Back, Guides developed for injury
521–522 forearm to shoulder amputation, 457 evaluation, 2
impairment classes, lower extremities functional assessment inventories, Balance disorders, See Equilibrium
and whole person, 495 482–486 Basal cells
instability, 523 functional history, 406–407, 406 carcinoma, 164, 175
inversion, 546 impairment rating due to CNS function, disorders, 160
ligaments, 502 dysfunction, 335, 335 nevus syndrome, 175
peripheral nerve impairment, 531–533, median nerve entrapment, proximal Behavioral impairments, 332–333
534–537 forearm, 488–489 Biceps tendon rupture, 416–417
range-of-motion impairment, 543–551, neuropathies, 323 Bicycle ergometry, 49
550–551 physical examination, 407 408 Bile ducts
regions of the leg, 494 range of motion impairment, 459–478, cirrhosis secondary to bile duct
replacement, 525 460, 462–463 obstruction, example of
vascular conditions, 497 regions, 384 impairment class (whole-person
Ankylosis, 609 Arm, upper extremity and whole-person impairment), 121
Anonychia, 173 impairment classes, 385 objective tests, 103
Index
Anticoagulant therapy, burden of Arousal disorders, 329–330, 320 symptoms and signs, 102
treatment compliance, 186 Arthritis, 519 Biliary tract
thrombotic disorders, 206–208 foot and ankle, 506–507, 524 cirrhosis, example of impairment class
Antidiuretic hormone, 218, 219, 220 hip, 514 (whole-person impairment), 120–121
Antisocial personality disorder, 366–367 knee, 511, 528 cirrhosis secondary to bile duct
Anus rheumatoid, with anemia, 189 obstruction, example of
chronic fistula, example of Arthrodesis, 400, 405, 507 impairment class (whole-person
impairment class (whole-person Arthroplasty impairment), 121
impairment), 117 digital, 394 impairment evaluation summary,
healed fistula, example of shoulder, 405, 418 126–127
impairment class (whole-person wrist, 397 impairment rating criteria, 118, 120
impairment), 117 Asbestosis, 94–95, 96–97 Bimalleolar fracture, 523–524
impairment rating criteria, 116 Asian cultures, 27 Binocular visual acuity, 287
incontinence, sphincter function loss, Assistive devices, 25,610 Binocular visual field, 294, 301, 302, 303
example of impairment class Asthma, 87–91, 90 Binocularity, 305
(whole-person impairment), 117 airway obstruction in, 81 Bizarre behavior,Brief Psychiatric Rating
objective tests, 103 impairment evaluation summary, 96–97 Scale, 375–376, 381
symptoms and signs, 102 irritant–induced, 90 Bladder, 138–140, 139
Anxiety, adjustment disorder with, 364, 366 occupational, 89, 90, 94 chronic cystitis, example of impairment
Brief Psychiatric Rating Scale, 370 occupational, example of class (whole-person impairment),
Anxiety disorders, 349, 323 impairment class (whole-person 139–140
Aphasia, 331–332, 332 impairment), 94 contracted, fixed, requiring
Aphoresis, burden of treatment severity, 89 urinary diversion, example of
compliance, 186 wheezing and, 79 impairment class (whole-person
Apnea, See Obstructive sleep apnea work-aggravated, 89, 90 impairment), 140

Index 619
function, 132 Body structures, ICF model of congestive heart failure, 57, 60
neurogenic dysfunction, 336, 337 disablement, 3 coronary artery disease, 54–57, 55,
neurogenic impairment, example of Body weight, See Weight 74–75
impairment class (whole-person Bone disease, metabolic, 241–243, 242, determining grade in an impairment
impairment), 140 244–245 class, 50–51, 50,
postirradiation telangiectasia, example Bone marrow transplantation, burden of dysrhythmias, 63–65, 64, 74–75
of impairment class (whole-person treatment compliance, 186 hypertensive disease, 65–68, 67, 74–75
impairment), 138–139 BOTC (Burden of treatment compliance), impairment evaluation summary 74–75
symptoms and signs, 131–132 See Treatment compliance left ventricular function, 48, 50
Blindness Bowel, neurogenic dysfunction, 336, 337 NYHA classification of cardiac
description (glossary terms), 610 Brachial plexus, 429–443 diseases, 10, 48, 48
legal, 286 Bradydysrythmia, 63 pericardial heart disease, 60–63, 61,
near- 288, 289, 290 Brain injury, 330, 331 74–75
near- 296, 298, 307 Breast cancer, 241 peripheral vascular diseases, 68–71, 69,
statutory, 286 Brief Psychiatric Rating Scale, 355, 70, 74–75
total, 288, 289, 290 356–357, 357 pulmonary artery disease, 71–73, 72,
Blood and blood disorders, See also expanded version, symptom rating, 74–75
Hematopoietic system 369–381 valvular heart disease, 51–54, 53, 74–75
anemia, 187–191 Bronchiolitis, obliterative, 82 Carotid duplex examination, 324
bleeding, impairment evaluation Bronchitis Carpal tunnel syndrome, 449–450, 487
summary, 210–211 airway obstruction in, 81 Cataract, 292
coagulation disorders, 203–206, chronic, 79 Causalgia (glossary term), 610
204, 205 chronic, example of impairment class Causality
hematologic impairment evaluation (whole-person impairment), 93–94 apportionment, 25–26
summary, 210–211 chronic, impairment evaluation description of term, 25, 610
hemorrhagic and platelet disorders, summary, 96–97 Cellulitis, dissecting, of the scalp, 175
201–206, 202, 204, 205 Budd-Chiari syndrome, 191 Central nervous system, 34
hypercoagulable state, 207 Bullous disorders, impairment evaluation Central nervous system, 34, 323
lymphoma and metastatic disease, summary, 180–181 cerebral impairments, 326–333
209–210. 209 Burden of treatment compliance, See pituitary abnormalities causing
Index
myeloproliferative, 191–193 Treatment compliance disorders of, impairment
platelets, impairment evaluation Burns, thermal rating, 220
summary, 210–211 scarring, 168, 174 Central sleep apnea, See Sleep apneas
red cells, impairment evaluation scarring and dyspnea, 176 Cerebral function, 323
summary, 210–211 with hypertrophic scarring, 169 Cerebral impairments, 326–333
thrombotic disorders, 206–208, 208 Cervical spine, 337–338, 558, 564–566;
white cells, 193–201, 194, 196, 199, C see also Spine
210–211 Calcaneus, 503, 546 Cervical tetraplegia, 6
Blood feuds, 1 Callus, 501 Cervix, 151–154, 152
Blood pressure, 66 Canada, use of the Guides, 21 incomplete stenosis, 153
Blood transfusion Carbon dioxide, 81, 85 narrowed, 153
burden of treatment compliance, 188, Carbon monoxide diffusing capacity, 84, partial absence of, incompetence, and
190, 192, 197, 203, 205 87, 88 uterine prolapse, 153
red blood cells, 188 Carcinoma, basal cell, 164 squamous cell carcinoma, 153–154
Blood vessels, epidermal, function, Carcinoma, squamous cell, 164 Chemically induced disorders, nail
disorders, 160 Cardiac output, inadequate, 93 dystrophy and anonychia, 173
Blurred vision, 285 Cardiomyopathies, 57–60, 59, 74–75 Chemotherapy,burden of treatment
Body function (term), 5 examples of impairment classes compliance, 186, 198
Body functions, See Physiological in, 58, 60 Chest
functions impairment evaluation summary 74–75 physical examination, in pulmonary
Body mass index (glossary term), 610 Cardiopulmonary exercise testing, See disease evaluation, 81
Body structure, ICF terminology and Exercise testing roentgenograms, 81–82
definitions, 5 Cardiovascular system, 47–76 Chest wall, 96–97
Body structures, See also Organ systems anatomic loss and functional loss, 10 Chiropractic doctors, 23, 20
Body structures, 3 cardiomyopathies, 57–60, 59, 74–75 Cholangitis, 115–116

620 Index
Chromate,allergic contact dermatitis, 170 Computed tomographic myelogram, D

Chronic bronchitis, See Bronchitis, 324–325 Dark adaptation deficit, 305
chronic Computed tomographic scan, 324 DASH (Disabilities of the Arm, Shoulder
Chronic obstructive pulmonary disease Computed tomography, pulmonary and Hand), 481
physical signs and symptoms, 81 diagnosis, 82 Daubert case, 29
impairment evaluation summary, 96–97 Concentration, mental and behavioral Decompensation (glossary term), 610
Chronic pain syndrome, 32–33, 34, 610 impairment, 359 Definitions, See Terminology
Cigarette smoking, See Smoking Conceptual disorganization, Brief Deglutition, 260, 268–269, 269
Cirrhosis, 115–116 Psychiatric Rating Scale, 377 Dehydration, 219
Cirrhosis, biliary, 120–121 Concussion, headache following, 42 Delirium, 349
Clinical presentation, generic template Confidentiality, 24 Dementia, 349
for impairment classification grids, Congenital (glossary term), 610 Depigmentation, occupational
15, 13 Connective tissue, function, disorders, 160 leukoderma, 168
Clotting disorders, 203–206, 204, 205 Consciousness disturbances, 326–329, Depression
acquired, 203–204 327, 328 adjustment disorder with, 364, 366
Clubbing, digital, See Fingers; Toes Consistency, 24 Brief Psychiatric Rating Scale, 370
Coagulation disorders, 203–206, 204, 205 Continuous (glossary term), 610 Depressive disorder, major, 360–361
Cobb method, 82 Contact dermatitis, See Dermatitis Dermatitis
Coccyx, 558; See also Pelvis Contrast sensitivity, 285, 305–306 allergic contact, 167–168
Cognition, 330–331, 331 Contracture (glossary term), 610 allergic contact, due to chromate, 170
Colitis, chronic ulcerative, 115–116 Contrast sensitivity (glossary term), 610 allergic contact, multiple allergens,
Colon Contusion, 415, 522, 528 169–170
chronic recurrent enterocolitis COPD, See Chronic obstructive atopic, 161, 171, 172–173
(Crohn’s disease), example of pulmonary disease contact, 163
impairment class (whole-person Cor pulmonale, 81–82 contact, and neurodermatitis, 173–174
impairment), 115 Corneal opacity, 291 hand, 161–162
chronic ulcerative colitis, example of Coronary artery disease, 54–57, 55, hand, chronic, 169
impairment class (whole-person 74–75 impairment evaluation summary,
impairment), 115–116 examples of impairment classes in, 178–179
idiopathic ulcerative proctocolitis, 56–57 vulva, 150
Index
example of impairment class impairment evaluation summary 74–75 Dermatology Life Quality Index, 161
(whole-person impairment), 115 Corticospinal injury, 581 Dermis, function of, disorders, 160
impairment rating criteria, 113, 114 Corticosteroids, burden of treatment Desirable weight (glossary term), 610
irritable bowel syndrome, diverticulosis, compliance, 186 Devices, assistive, 25, 610
example of impairment class Corticotropin, 218 Diabetes insipidus, traumatic, 221
(whole-person impairment), 114 hypersecretion, 226 Diabetes mellitus, 232–234
objective tests, 103 impairment rating, 220 type 1, 236
symptoms and signs, 102 -releasing hormone, 219 type 2, 234–236
Color vision defects, deficits, 305, 306 Cough, clinical presentation of pulmonary Diagnosis-related estimates, introduction
Colostomy, 118 disease, 79 of, in Guides, 2
Coma, 327 Cranial nerves, 323 Diagnostic and Statistical Manual of
Combined Values Chart, 22–23, 604–606 Craniocephalic pain, 341–343, 323, 342 Mental Disorders, 348–349, 348, 610
description (glossary terms), 610 Creatinine, 131–132 Dietary modification, 217, 217
Communication Crohn’s disease, 115, 117 Dietary restrictions, 269
facial expression and, 260–261 CT, See Computed tomographic scan Diffusing capacity, See Carbon monoxide
impairments, 331–332, 332 Cubital tunnel, 488 Digestive system, 101–127
speech, 270–277 Cultural differences (examiners and examples of impairment classes in,
Compensation patients), 27 106–113
personal injuries and disabilities, 1–2 Cure (glossary term), 610 impairment determination, 104–105
relation to purpose of the Guides, 20 Cushing’s syndrome, 226 impairment evaluation summary,
Complex regional pain syndrome, 323, adrenocortical tumor causing, 228 124–126
341, 450–454, 538–542, 610 iatrogenic, 229–230 impairment impact on activities of daily
Compliance, burden of, See Treatment recurrent, 230 living, 104–105
compliance Cyanosis, 81 key factors in impairment
Compression neuropathy, 446 Cystitis, chronic, 139–140 determination, 106

Index 621
methodology for determining grade in Duodenum range of motion impairment, 459–465,

an impairment class, 105–106, 105 active ulcer, example of 472, 460, 462–463, 474–475
objective procedures, tests, 103 impairment class (whole-person regional impairment grid, 398–400
principles of assessment, 102–106 impairment), 109 ulnar neuropathy, 487–488
surgically created stomas, 118 impairment rating criteria, 107 upper extremity and whole-person
symptoms and signs, 102–103 objective tests, 103 impairment classes, 385
upper, 106–113 peptic ulcer, example of Electrical injuries, 265
upper, impairment rating criteria, 107 impairment class (whole-person Electrocochleography, 249
upper, symptoms and signs, 102 impairment), 106 Electroencephalogram, 324
weight charts, 104 symptoms and signs, 102 Electromyography, 325
Digital clubbing, See Fingers; Toes Dust inhalation, See Pneumoconiosis Electronystagmography, 255
Digital nerve impairment, See Fingers Dysarthria, 323 Emotions
Digits, See Fingers; Toes Dysesthesias, 34, 611 excitement, 380
Diplopia, 305, 306 Dysesthetic pain, See Pain impairments, 332–333
Disabilities and disablement, See also Dysphagia, 269 withdrawal, Brief Psychiatric Rating
Impairment rating Dysphasia, 331–332, 332 Scale, 378
conceptual framework for disablement, 2 Dysphonia, 323 Emphysema
description (glossary terms), 611 Dyspnea, 10, 266, 267 airway obstruction in, 81
Eastern Cooperative Oncology clinical presentation of pulmonary impairment evaluation summary, 96–97
Group Performance Status Scale, disease, 78–79 severe, example of impairment class
184, 185 impairment classification of, 79 (whole-person impairment), 95
evaluation, impairment rating and, 6 index, 11 Employability, mental and behavioral
examples of, 6 thermal burn scarring and, 176 impairment, 360
history of disablement models, 4 Dysrhythmias, 63–65, 64, 74–75 Enablement, 4
Guides operational definitions, 5 impairment evaluation summary Encephalopathy, uremic, 327
ICF model of disablement, 2–6 74–75 Endocrine system, 213–246
Institute of Medicine definition, 4 burden of treatment compliance, 216–
Karnofsky Performance Status Scale, E 218, 221
184, 185 Ear, 247–260 determination of whole-person
long–term, 6 middle, impedance measurement, 249 impairment, 218
Index
resulting from injuries, 1 principles of assessment, 248 dietary modification, 217, 217
temporary, 6 Eastern Cooperative Oncology Group hormone secretion, 214
terminology of, in ICIDH-2, 4 Performance Status Scale, 184, 185 iatrogenic impairment, 214
WHO’s international classification of Eating, 260, 264–265, 268–269, 269 impairment evaluation summary,
illness, 4 Eccrine glands, function, disorders, 160 244–245
Disablement, See Disabilities and Eczema, latex allergy and, 170–171 methodology for determining the grade
disablement EEG, See Electroencephalogram in an impairment class, 214–215, 215
Disease, ICF model of disablement, 3 Eighth nerve hearing loss, 248 principles of assessment, 214–218
Disequilibrium, See Equilibrium Ejaculatory dysfunction, See Penis Endometriosis, pelvic, 155
Disfigurement (glossary term), 611; see Elbow Energy expenditure (METs), 48, 5–9, 49,
also Face; Skin adjustment grids, 406–413 85, 86, 612
Disorders, ICF model of disablement, 3 assessment principles, 385–386, 385 Enteritis, regional, 111
Disorientation, 376–377 clinical studies adjustment grid, 407, Enterocolitis, chronic recurrent, 115
Dissociative disorders, 349 409, 410–411 Enterocutaneous fistula, See Fistula
Distractibility, 380 determining grade within impairment Entrapment neuropathy, See Peripheral
Diverticulosis, 109–110, 114 class, 412 nerves
Dizziness, 254, 255, 611 diagnosis-based impairment, 387–390, Environmental factors
Dominant extremity (glossary term), 611 388 correlation of impairment, functional
Drug therapy diagnosis-based impairment examples, limitations and disabilities, 4
burden of treatment compliance, 186 416–417 ICF model of disablement, 3, 5
enteral, intranasal and topical, in functional assessment inventories, pulmonary disease and, 80
endocrine disorders, 217 482–486 Epicondylitis, lateral, 416, 479
parenteral, in endocrine disorders, 217 functional history, 406–407, 406 Epidermis, 160
DSM-IV, See Diagnostic and Statistical lateral epicondylitis, 416, 479 Epidermolysis bullosa dystrophica, 177
Manual of Mental Disorders physical examination, 407 408 Epididymes, 146–149, 147

622 Index
Epilepsy, partial, 328–329 amputation impairment, 542–543, 543 F

Epinephrine, 231 assessment principles, 494–496 Face, 260–265
Equilibrium, 254–260 combining and converting impairments, communication and, 260–261
balance testing, 255 529–530, 530–531 crush injury, 264
computerized dynamic posturography, complex regional pain syndrome, disorders and disfigurement, 261, 262
255–256 538–542 healed fracture, scar, 263
electronystagmography, 255 diagnosis-based class assignment, loss of left side, 265
evoked vestibular responses, 256 regional grids, 499–500, 501–515 loss of structural integrity, 264–265
Ergometry, bicycle, 49 diagnosis-based impairment, 495, Factitious disorders, 349
Errors, sources of, 8 497–515 Factor VIII deficiency, 204–205, 206
Esophagojejunal anastomosis, 112 dominant (glossary term), 611 Factor XIX deficiency, 203
Esophagostomy, surgically created evaluation record example, 554 Fallopian tubes, 154–155, 154
stomas, 118 examples of peripheral vascular pelvic endometriosis, 155
Esophagus disease, 70, 71 unilateral salpingectomy, 154–155
achalasia, 110 grade determination in impairment False negative, false positive (glossary
impairment evaluation summary, class, 520 term), 611
124–125 Guides developed for injury FECA (Federal Employees Compensation
impairment rating criteria, 107 evaluation, 2 Act), 21
objective tests, 103 hierarchy in whole person concept, 22 Fecal incontinence, 116, 117
spasm, example of impairment class impairment calculation method, 518, Female reproductive system, See
(whole-person impairment), 108 521–522 Reproductive system, female
status after resection for cancer, example impairment classes, lower extremities Femoral neuropathy, 538
of impairment class (whole-person and whole person, 495 Femur, 493, 515
impairment), 112–113 peripheral nerve impairment, 531–533, FEV, See Forced expiratory volume
stricture, example of impairment 534–537 Fibrocartilage complex tear, 412, 478
class (whole-person impairment), range-of-motion impairment, 543–551, Financial compensation, See Compensation
112–113 550–551 Fingers
symptoms and signs, 102 regions of the leg, 494 adjustment grids, 406–413
Estrogens, 219, 226 vascular conditions, 497 amputation, 454–457
Eunuchoidism, 237 impairment rating criteria for peripheral assessment principles, 385–386, 385
Index
European Respiratory Society guidelines, vascular disease, 69 clinical studies adjustment grid, 407,
77 non-specific pain affecting, 41–42 409, 410–411
Evaluators, See Physicians orthopedic functional assessment determining grade within impairment
Evaluators, nonphysician, See tools, 11 class, 412
Nonphysician evaluators validity of impairment ratings, 8 diagnosis-based impairment, 387–390,
Evidence-based medicine, 8–9 Extremities, upper 383–491; See also 388
Guides inclusion of, 2 Elbow; Fingers; Hand; Shoulder; diagnosis-based impairment examples,
Evoked potentials, 249, 324 Wrist 413–415
Evoked vestibular responses, 256 dominant (glossary term), 611 digital clubbing, 81
Exacerbation,25, 611 example of peripheral vascular digital nerve impairment, 425–429, 458
Examiners, See Physicians; Nonphysician disease, 71 digital neuroma, 427–428, 457–458
evaluators Guides developed for injury examples of thumb and finger motion
Excitement, Brief Psychiatric Rating evaluation, 2 deficits, 476–477
Scale, 380 hierarchy in whole person functional assessment inventories,
Exercise testing, 48, 49,, 85–86, 85 concept, 22 482–486
Expert testimony, 27–28 impairment rating criteria for peripheral functional history, 406–407, 406
Exposure (glossary term), 611 vascular disease, 70 hierarchy in whole person concept, 21, 22
Extremities orthopedic functional assessment motor deficits, 424–425
dominant (glossary term), 611 tools, 11 peripheral nerve impairment, 419–429,
vascular diseases affecting, 68–71, 69, validity of impairment ratings, 8 420–422
70, 74–75 Extrinsic allergic alveolitis, See Alveolitis, physical examination, 407 408
Extremities, lower 493–556; See also extrinsic allergic range of motion, 468–470, 476–477
Ankle Foot; Hip; Knee; Leg; Toes Eye, See also Visual system range of motion impairment, 459–470,
adjustment grid and grade modifiers, examinations, 283–284 460, 462–463
515–522, 516, 517, 519–520 movement, electronystagmography, 255 regional impairment grid, 391–394

Index 623
sensory deficits, 423–424 Fractions, rounding, 24–25, 20 editions of, 2

thumb, hierarchy in whole person Frequent (glossary term), 611 evidence-based medicine in, 2
concept, 21, 22 FSH, See Follicle-stimulating hormone A Guide to the Evaluation of Permanent
thumb range of motion, 465–468, Functional assessment, See Impairment Impairment of the Extremities and
476–477 ratings Back, 2
upper extremity and whole-person Functional limitation (glossary term), 611 history of, 1–2
impairment classes, 385 Functional Visual Score, 282, 283, 284 ICF model applied to, 3, 5
Fistula FVC, See Forced vital capacity impairment ratings shortcomings, 2
anal, 117 internal consistency, uniform template
enterocutaneous, 118 G for impairment grids, 11–16
rectovaginal, 150–151 GAF, See Global Assessment of international use, 21
urethral, 141 Functioning key principles, 20
vesicovaginal, 150–151 Gait disorders, 336, 336 new axioms of the Sixth Edition, 2
Folic acid deficiency, 188 Gallbladder, 118, 120 not to be used for estimates of work
Follicle-stimulating hormone, 218, 219 Ganglion cyst, 415 participation restrictions, 6
Follicular occlusive triad, 175 Gas-exchange measurement, 85 objective criteria, 20, 24
Foot, 493 Gas exposure, pulmonary diseases and, 80 operational definitions, 5–6
adjustment grid and grade modifiers, Gastrectomy, 112 practical application of, 19–30
515–522, 516, 517, 519–520 Gastroesophageal reflux, example of purpose of, 20
amputation impairment, 542–543, 543 impairment class (whole-person revision of, 2
arthritis, 505–507 impairment), 109 rules for application of, 24–25
arthrodesis, 507 Gastrointestinal tract, See Digestive system simplification as a priority in, 9
assessment principles, 494–496 Gastrostomy, surgically created Sixth Edition, new directions for, 2
combining and converting impairments, stomas, 118 terminology adopted by, 2
529–530, 530–531 Gastrostomy tube, 112–113 use by workers’ compensation and other
complex regional pain syndrome, Genitofemoral nerve, 344 disability systems, 20–21
538–542 Giddiness, 254 Guilt, Brief Psychiatric Rating Scale, 371
diagnosis-based class assignment, Gigantism, 219 Guyon’s canal, 487–488
regional grids, 499–500, 501–508 Glare sensitivity, 305
diagnosis-based impairment, 495, Global Assessment of Functioning, 355, H
Index
497–515 356–357, 334, 358 Hair, function, disorders, 160
grade determination in impairment Glomerular filtration rate, 131–132 Hallucinations, Brief Psychiatric Rating
class, 520 Glomerulonephritis, 133, 136–137 Scale, 374
impairment calculation method, 518, Glossopharyngeal neuralgia, 323, 343, 343 Halstead-Reitan Neuropsychological Test
521–522 Glucagon, 232 Battery, 351
impairment classes, lower extremities Glucocorticoids, 226 Hand
and whole person, 495 Glucose monitoring, 218 adjustment grids, 406–413
ligaments, 502 Goldmann-type (visual field) testing, 294, assessment principles, 385–386, 385
midfoot, cavus, “rocker bottom,” 505 314, 315 clinical studies adjustment grid, 407,
peripheral nerve impairment, 531–533, Gonadotropins 218, 219 409, 410–411
534–537 Gonads, 219, 237–239, 239 dermatitis, 161–162
range-of-motion impairment, 543–551, hormone production, 218 dermatitis, chronic, 169
550–551 impairment evaluation summary, determining grade within impairment
regions of the leg, 494 244–245 class, 412
vascular conditions, 497 impairment rating, 220 diagnosis-based impairment, 387–390,
Forced expiratory maneuver, 83 Goniometry, See Range of motion 388
Forced expiratory volume, 83, 84 Grandiosity, Brief Psychiatric Rating diagnosis-based impairment examples,
criteria for rating permanent Scale, 373–374 413–415
impairment due to pulmonary Granulocytes, 193 functional assessment inventories,
dysfunction, 87, 88 Growth hormone, 218, 219, 220 482–486
Forced vital capacity, 83, 84 impairment rating, 220 functional history, 406–407, 406
criteria for rating permanent -releasing hormone, 219 irritant contact eczema, 170–171
impairment due to pulmonary Guarding (glossary term), 611 metacarpal amputation, 457
dysfunction, 87, 88 Guides, 1–18 peripheral nerve impairment, 419–429,
Forearm (glossary term), 611 criticisms of, 2, 9 420–422

624 Index
physical examination, 407 408 lymphoma and metastatic disease, range-of-motion impairment, 543–551,
radial nerve injury, 428 209–210, 209 550–551
range of motion impairment, 459–470, methodology for determining the grade rotation, 548
460, 462–463 in an impairment class, 186, 187 regions of the leg, 494
sensory deficits, 423–424 myeloproliferative disorders, 191–193 replacement, 515, 527, 528–529
upper extremity and whole-person principles of assessment, 184–187 Hispanic culture, 27
impairment classes, 385 thrombotic disorders, 206–208, 208 History
validity of impairment ratings, 7 white blood cell diseases, abnormalities, disablement models, 4
Handedness (glossary term), 611 193–201, 194, 196, 199 laws regarding compensation for
Handicap, WHO’s international Hemoglobin A1c, 233–234 injuries, 1–2
classification of illness, 4 Hemoglobinuria, 191 History-taking, See Patient history
Hashimoto’s thyroiditis, 222–223 Hemophilias, 204–205, 205 HIV infections, 184, 185, 198–200, 199
Headache Hemoptysis, 79 description (glossary terms), 611
migraine, 341–343, 342 Hemorrhagic disorders, 203–206, 204, Hodgkin’s disease, 209–210
post-concussive, 42 205 Home parenteral nutrition, See Nutrition,
Health condition, ICF model of Hepatitis, 118–120 parenteral
disablement, 3 Hernia, 121–123, 122 Hormones
Hearing aids, See Devices, assistive abdominal, 102 function, 219
Hearing loss, 248–260 description (glossary terms), 611 Hypothalamic-pituitary axis, 219
binaural, 251 hiatal, 106 secretion, 214
binaural, computation of impairment, impairment evaluation summary, Hostility, Brief Psychiatric Rating
252–253 126–127 Scale, 372
binaural, relationship of, to whole- impairment rating criteria, 121, 122 Human immunodeficiency virus infection,
person impairment, 254 incisional, 102–103, 122 See HIV infections
central, 248–249 inguinal, 123 Humphrey visual field plots, 316, 317
central, impairment, 248 objective tests, 103 21-hydroxylase deficiency, 229
conductive impairment, 248 recurrent bilateral inguinal, 123 Hygiene, mental and behavioral
frequency range, 249 Hidradenitis suppurativa, 175 impairment, 358
impairment evaluation, 248–249 Hip, 493 Hyperadrenocorticism, 228, 229, 230
mixed, 251 adduction and abduction, 547 Hyperalgesia, 34, 611
Index
mixed, bilateral, 251 adjustment grid and grade modifiers, Hypercarbia, 81

mixed impairment, 248 515–522, 516, 517, 519–520 Hyperesthesia (glossary term), 611
monoaural, 250–251, 250 amputation impairment, 542–543, 543 Hyperglycemia control, 235
peripheral, 248–249 arthritis, 514 Hypernatremia, 219
sensorineural, bilateral, 254 arthrodesis, 514 Hyperparathyroidism, 223, 224,
sensorineural impairment, 248 assessment principles, 494–496 225–226, 243
tests, 249 combining and converting impairments, Hyperpathia (glossary term), 611
threshold testing, 249 529–530, 530–531 Hypersensitivity pneumonitis, 91
Heart, See also Cardiovascular system complex regional pain syndrome, Hypertensive cardiovascular disease,
cardiomyopathies, 57–60, 59, 538–542 65–68, 66, 67, 74–75
74–75 diagnosis-based class assignment, Hypertensive vascular kidney
failure, congestive, 57, 60 regional grids, 499–500, 512–515 disease, 136
inadequate cardiac output, 93 diagnosis-based impairment, 495, Hyperthyroidism, 222
left ventricular function, 48, 50 497–515 Hypesthesia (glossary term), 611
pericardial disease, 60–63, 61, 74–75 dislocation, 513, 528–529 Hypoadrenalism, 227–228
valvular disease, 51–54, 53, 74–75 flexion contracture, 8 Hypoesthesia (glossary term), 611
Heel, 503, 546 fractures, 513–514 Hypoglycemia, 233, 236–237, 237
Hematopoietic system, 183–212 grade determination in impairment Hypogonadism, 218, 219
anemia, 187–191 class, 520 Hypogonadotropic hypogonadism, 219
burden of treatment compliance, 185– impairment calculation method, 518, Hyponatremia, 219,220
186, 186 521–522 Hypoparathyroidism, 223, 224, 225
hemorrhagic and platelet disorders, impairment classes, lower extremities Hypopituitarism, 219
201–206, 202, 204, 205 and whole person, 495 Hypothalamic-pituitary axis, 218–222, 220
impairment evaluation summary, peripheral nerve impairment, 531–533, impairment evaluation summary,
210–211 534–537 244–245

Index 625
suppression and adrenal calculating impairment, general subjective complaints, 20

hyporesponsiveness, 227 principles, 14, 14 use of method producing a higher
Hypothalamus, hormone production, 218 calculations explained in reports, 28 rating, 20
Hypothyroidism, 222 changes in impairment and, 26 validity of, and measurement issues, 7–8
Hypothyroidism, secondary, 219 Combined Values Chart and combining when to perform, 24
Hysterectomy, 152–153 impairments in and between organ whole-body approach, 21–23
systems, 22–23 whole-person impairment, 19–20
I conceptual and methodological Impairment rating criteria, See Specific
IADLs, See Instrumental activities of congruity, 2 organ systems and body parts
daily living conceptual foundations and Impedance measurement, 249
Iatrogenic disease, Cushing’s syndrome, philosophy, 1–18 Incontinence, fecal, 116, 117
229–230 criteria either discrete or continuous, 6–7 Incontinence, urinary, 142
ICF, See International Classification description (glossary terms), 611–612 Independent medical examination, See
of Functioning, Disability development of Guides to the also Mental and behavioral disorders
and Health Evaluation of Permanent description (glossary terms), 612
ICIDH, See International Classification Impairment, 2 Independent medical examiners, 25–27
of Impairments, Disabilities and error rates for, 2 Index finger, See Fingers
Handicaps evidence-based approach, 8–9 Infertility, 155
Idiopathic ulcerative proctocolitis, See fractional, rounding of, 24–25, 20 Inherited (glossary term), 612
Proctocolitis function assessment tools, 2 Injuries, compensation for, 1–2
Ileal pouch, surgically created stomas, 118 functional assessment applications, 9–11 Injury (glossary term), 612
Ileostomy, surgically created stomas, 118 functional assessment in generic Institute of Medicine, definition of
Iliohypogastric nerve, 344 template for impairment disability, 4
Ilioinguinal nerve, 344 classification grids, 15, 13 Instrumental activities of daily living,
ILO, See International Labor Office functional assessment tools, 10–11 definition of, 6, 612
Immunoglobulin M, 190 functional impairment classification, 11 Insulin, 232
Immunosuppressant therapy, burden of functionally based percentages, 2 Insulin-like growth factor, 220
treatment compliance, 186 Guides operational definitions, 5–6 Integrative function, 330–331, 331
Impairment ICIDH as tradition, simplistic, 4 Intellectual assessment, 350
calculating, general principles, 14, 14 internal consistency, 2 Intellectual impairment, 355
Index
changes in, from prior ratings, 26 internal consistency, uniform template Intelligibility, See Speech
class, cardiovascular system, 50–51, 50 for impairment grids in the Guides, Intercostal nerve, 344
classes of, 12–14, 13 11–16, 13 Intermittent (glossary term), 612
criteria, 12 measurement issues, 6–8 International Association for the Study of
description of term, 3, 611 measurement scales, 7 Pain, 32
examples of, 6 organ system (regional) and whole-body International Classification of
future, 20 approach, 21–23 Functioning, Disability and
grids, 12–14, 13 pain accompanying objective findings Health, 2–6
Guides operational definitions, 5 of other injury or illness, 39 application to Guides, 3, 5
ICF terminology and definitions, 5 pain as a component of, 37–40 codes and functional levels, 11
permanent, 20, 24, 26–27 pain not accompanied by objective components of, 3
regional, 20 findings, 39–40 model of disablement, 2–6, 494
WHO’s international classification of pain-related, 31–45 scale of capacity and performance
illness, 4 percentages, 12 qualifiers, 12, 11
whole-person, 19–20, 20 percentages as functionally based, 2 terminology and definitions, 5
Impairment evaluation practical application of the Guides, International Classification of
description (glossary terms), 611 19–30 Impairments, Disabilities and
by chiropractic doctors, 23, 20 pulmonary dysfunction criteria, Handicaps, 4, 4
by physicians, 23, 20 permanent impairment, 88 second (ICIDH-2), 4
law and, 27–28 purpose of the Guides, 20 International classifications, 5
Impairment rating, See also specific organ reliability, intrarater and interrater, 2 International Labor Office,
systems and body parts report preparation, 28, 30 pneumoconiosis classification, 82
activities of daily living and, 2 sample report, 30 Interpersonal relationships, impairment
air passage deficits, 267 shortcomings, 2 of, 359
apportionment, 25–26 standardized, as intent of Guides, 6 Interpolation, 24–25

626 Index
Intertrigo, 150 class (whole-person impairment), impairment calculation method, 518,

Interval scales, 7 136–137 521–522
Intervertebral discs, 564–573, 583–591 function, 131–132 impairment classes, lower extremities
Intestine, large, 124–125 proteinuria after childhood nephritis, and whole person, 495
Intestine, small example of impairment class ligaments, 509
diverticulosis, 109–110 (whole-person impairment), 133, motion deficits, 550
enteritis, 111 135 peripheral nerve impairment, 531–533,
impairment evaluation summary, pyelonephritis secondary to 534–537
124–125 vesicoureteral reflux, example of range-of-motion impairment, 543–551,
impairment rating criteria, 107 impairment class (whole-person 550–551
malabsorption due to resection, 113 impairment), 135 regions of the leg, 494
objective tests, 103 renal calculi accompanying replacement, 511, 527
obstruction, example of impairment hyperparathyroidism, 225 soft tissues, 509
class (whole-person impairment), renal calculi and bilateral chronic strain, 525
107–108 pyelonephritis, example of vascular conditions, 497
symptoms and signs, 102 impairment class (whole-person Kyphoscoliosis, 82
Iron chelation, burden of treatment impairment), 135
compliance, 186 renal calculi, example of impairment L
Irritable bowel syndrome, 114 class (whole-person impairment), Labyrinthine dysfunction, 255
Irritants 133 Langerhans cells, 160
chronic hand dermatitis, 169 renal cortical necrosis and severe Laryngectomy, 277
contact dermatitis, 163 chronic renal failure, example of Larynx, 266, 267
latex allergy, allergic and irritant impairment class (whole-person cancer, 277
contact hand eczema, 170–171 impairment), 137 voice and speech impairment, 270
Islet cells, 232 severe chronic renal failure and Latex allergy, See Allergies
Islets of Langerhans, See Pancreas refractory anemia, example of Latex paint, 167–168
Italy, Lombard laws, 1–2 impairment class (whole-person Law
impairment), 137 admissibility standards, 29
J severed urethra, hydronephrosis, expert testimony, 27–28
JAMA, See Journal of the American recurrent urinary tract infection history of, regarding compensation for
Index
Medical Association and impotence, example of injuries, 1–2

Jejunostomy, surgically created stomas, impairment class (whole-person impairment evaluation and, 27–28
118 impairment), 143 independent medical examiners,
Joint dislocation, interphalangeal, 414–415 symptoms and signs, 131–132 25–27
Joint dysfunction, hemophilia A and, transplant, example of impairment possibility and probability as concepts
204–205 class (whole-person impairment), in, 25
Joint instability, foot and ankle, 502 135–136 Left ventricular ejection fraction, 48, 50
Journal of the American Medical Knee, 493 Left ventricular function, See Heart
Association, impairment guides adjustment grid and grade modifiers, Leg (lower extremities), 493–556
published in, 2 515–522, 516, 517, 519–520 adjustment grid and grade modifiers,
amputation impairment, 542–543, 543 515–522, 516, 517, 519–520
K arthritis, 511, 528 amputation impairment, 542–543, 543
Karnofsky Performance Status Scale, 92, arthrodesis, 511 assessment principles, 494–496
184, 185 assessment principles, 494–496 combining and converting impairments,
Kidney combining and converting impairments, 529–530, 530–531
bilateral malignant hypertensive 529–530, 530–531 complex regional pain syndrome,
vascular disease, example of complex regional pain syndrome, 538–542
impairment class (whole-person 538–542 description (glossary terms), 612
impairment), 136 diagnosis-based class assignment, diagnosis-based class assignment,
bilateral polycystic renal disease, regional grids, 499–500, 509–511 regional grids, 499–500, 501–508,
advanced renal insufficiency, diagnosis-based impairment, 495, 509–511, 512–515
example of impairment class 497–515 diagnosis-based impairment, 495,
(whole-person impairment), 137 fracture, 510–511 497–515
chronic glomerulonephritis with renal grade determination in impairment grade determination in impairment
atrophy, example of impairment class, 520 class, 520

Index 627
impairment calculation method, 518, LVEF, See Left ventricular ejection Mental retardation, 349, 351
521–522 fraction Mental status, 330–331, 331
impairment classes, lower extremities Lymphatic function, disorders, 160 Mental status examination, 349
and whole person, 495 peripheral vascular disease, 68 Metabolic bone disease, See Bone disease,
neuropathies, 323 Lymphocytes, 195 metabolic
peripheral nerve impairment, 531–533, HIV infection, 198–200 Metabolic equivalents (METs), See Energy
534–537 Lymphoma, 195, 209–210, 209 expenditure (METs)
range-of-motion impairment, 543–551, Metacarpal fracture, 413
550–551 M Metatarsals, 504
regions of the leg, 494 Macroadenoma, 218 Methylene chloride exposure, 118
vascular conditions, 497 Macrophages, 201 METs, See Energy expenditure (METs)
Legal blindness, 286 Macular degeneration, 305–306 Mexican Americans, pulmonary function
Legal concepts, See Law Maculopathy predicted values, 84
Leiomyoma, uterine, asymptomatic age-related, 308–309 Microadenoma, 218
subserrous, 152 Stargardt juvenile, 292 Microadenoma, pituitary, 241
Letter chart acuity, 309, 311 Magnetic resonance angiography, 325 Middle finger, See Fingers
Leukemias, 195–198, 196 Magnetic resonance imaging, 325 Migraine headache, 341–343, 342
acute, 197–198 Male reproductive system, See Mild (glossary term), 612
acute monocytic, 201 Reproductive system, male Mineralocorticoids, 226
chronic granulocytic, 197 Malignant melanoma, See Melanoma Minnesota Multiphasic Personality
chronic lymphocytic, 197 Malingering, 353, 354 Inventory-2, 350, 351
chronic myelogenous, 197 description (glossary terms), 612 Mobility, categories of, 6
Leukoderma, 168 Mammary glands, 239–241, 240, 244–245 Moderate (glossary term), 612
Leukoplakia, 275–276 Mannerisms, Brief Psychiatric Rating Modulation, pain, 33
LH, See Luteinizing hormone Scale, 381 Monocular visual acuity, 287
Lightheadedness, 254 Masculinization, 237 Monocular visual field, 294
Lipid storage disease, 201 Mast cells, function, disorders, 160 Monocytes, 201
Little finger, See Fingers Mastication, See Eating Mood
Liver Maximum medical improvement, 6 disorders, 323, 349
hepatitis, example of impairment class description of term, uses, 26, 612 elevated, Brief Psychiatric Rating
Index
(whole-person impairment), 118 key principles of the Guides, 20 Scale, 372
hepatitis B, example of impairment when to perform impairment ratings, 24 Motivation, 352, 353
class (whole-person impairment), Measurement of impairment, See description (glossary terms), 612
118–120 Impairment ratings Motor hyperactivity, Brief Psychiatric
impairment evaluation summary, Median nerve entrapment, proximal Rating Scale, 381
126–127 forearm, 488–489 Motor nerves, 533, 534–537
impairment rating criteria, 118, 119 Medical history, See Patient history Motor retardation, Brief Psychiatric
objective tests, 103 Melanocyte function, disorders, 160 Rating Scale, 379
rating secondary disease processes, 102 Melanoma, malignant, 164 Movement disorders, 335, 336
symptoms and signs, 102 Men, See also Reproductive system, male MRI, See Magnetic resonance imaging
Lombardy, laws regarding compensation pulmonary function predicted values, 84 Muscles
for injuries, 1–2 weight chart, 104 foot and ankle, 501
Lower Extremity Impairment Evaluation Meniscus, 509, 525–526 knee, 509
Record, 494, 498 Mental and behavioral disorders, 347–382 Muscular dystrophy, 341
Lumbar diskectomy, 582 assessment principles, 348–349 Musculoskeletal system, See also Arm;
Lumbar puncture, 324 examples of impairment ratings, Leg; Pelvis; Spine
Lumbar spine, 558, 570–574, 591–592; See 360–368 functional assessment tools, 10
also Spine functional impairment scales, 352, impairment, 494
Lung cancer, 92, 92 358–360 validity of impairment ratings, 7–8
Lung impairment rating method, 356–360 Myasthenia gravis, 341
fibrotic diseases, 82 independent medical examination, Mycosis fungoides, 176–177
Interstitial diseases, 82 351–353, 352 Myelodysplasia, 194–195
hyperinflation, 81 maximum medical improvement, Myelodysplastic syndromes, 190–191, 198
total capacity, 83–84 353–355 Myelofibrosis, 191–193
Luteinizing hormone, 218, 219 vocational impairment, 354–355 Myelogram, 324–325

628 Index
Myeloproliferative disorders, 191–193 cyclic, 193–194 Ordinal scales, 7

Myocardial infarction, 54, 93 New York Heart Association, 10, 48, 48 Organ systems, See also Body structures
Myopathic disorders, 323 New Zealand, use of the Guides, 21 Oropharynx, 267
Myopathy, 341 NHANES, See National Health and Orthopedics, 11
Myositis ossificans, 509 Nutrition Examination Survey Orthosis (glossary term), 613
(NHANES) Osteochondritis, 513
N NIOSH, See US National Institute for Osteoporosis, 225
Nagi, Saad, 4 Occupational Safety and Health Osteotomy, 511, 515
Nails Nociception (glossary term), 612 Otoacoustic emission tests, 249
dystrophy and anonychia, 173 Nociceptive pain, See Pain Ovaries, 154–155, 154
foot impairment, 501 Nominal scales, 7 failure, infertility, 155
function, disorders, 160 Nonphysician evaluators, 23 hypofunction, 237
Narcolepsy, 330 Normal (glossary term), 612 irregular ovulation, 154
Nasal field loss, 302 Nose, 265–270 precocious puberty, 237
National Health and Nutrition cancers, 266 Ovulation, irregular, 154
Examination Survey (NHANES), compound bone fracture, 263 Oxygen consumption, work intensity and,
83, 84 disfigurement, 264 85, 85
Native Americans, 27 healed compound bone fracture, 263 Oxytocin, 218
Natural rubber latex allergy, See Allergies nasal field loss, 302
Near vision, See Vision olfaction and taste, 270 P
Neck, 265, 270–277 principles of assessment, 248 Pace, mental and behavioral impairment,
motion limitation, 169 rhinitis and sinus conditions, 265, 268 359
Needle electromyography, 325 rhinosinusitis, 268 Pain, 31–45
Negative (glossary term), 612 Nutrition accompanying objective findings of
Nephritis, 135 parenteral, treatment compliance, 102, other injury or illness, 39
Nephrostomy, 138, 138 105 activity limitations due to, 37
Nerve conduction, 325 post-gastrectomy problems, 112 assessment steps, process, 40
Nerve tissue function, disorders, 160 NYHA, See New York Heart Association behavior, (glossary term), 613
Nerves, peripheral, See Peripheral nerves chronic, 32–33, 610
Nervous system, 321–345; See also O complex regional pain syndrome, 323,
Index
Peripheral nerves Obesity-hypoventilation syndrome, 92–93 341, 450–454

assessment principles, 322–326 Objective (glossary term), 612–613 controversies in rating, 31–32, 35–37
episodic impairments, 327–329, 328 Objective test results, See Test results craniocephalic, 323, 341–343, 342
impairment evaluation summary, Obliterative bronchiolitis, See credibility and consistency in
344, 344 Bronchiolitis, obliterative impairment rating, 37–38
Nervousness, Brief Psychiatric Rating Obstructive sleep apnea, See Sleep apneas definition and classification, 32–34
Scale, 379 Occasional (glossary term), 613 description (glossary terms), 613
Neural tube defects, 188 Occipital nerves, 344 disorder, (glossary term), 613
Neuralgia, 323, 343, 343 Occupational exposure, 256 dysesthetic, 339
Neurodermatitis, 173–174 allergic rhinitis, 265, 268 future directions and establishing
Neurogenic dysfunction, See Bladder; asthma, 89–90, 94 validity of impairment rating,
Bowel; Respiratory system; Sexual chromate allergic contact dermatitis, 40–41
dysfunction 170 Guides developed for evaluation of, 2
Neuroma contact dermatitis, 163 inappropriate illness behavior, 39
acoustic, 259–260 leukoderma, 168 isolated vs as a component of a medical
digital, 427–428, 457–458 neurodermatitis and contact dermatitis, condition, 35–36
Neuromuscular junction, 323, 341 173–174 lower back, and adjustment disorder,
Neuropathic pain (glossary term), 612 pneumoconiosis, 82 363–364
Neuropathies, 34, 323, 339–341; see also pneumoconiosis, 91–92, 94–95 modulation, 33, 33
Peripheral nerve impairment pulmonary disease and, 80 neuropathic, 34, 612
Neuropathy, entrapment, See Peripheral Occupational history (glossary term), 613 nociceptive, 33, 33, 612
nerves Olfaction, 270 non-specific, affecting right lower
Neuropsychologic assessment, evaluation, Oligospermia, 147 extremity, 41–42
324, 350, 351 Optic neuritis, 292–293 objective findings lacking, 39–40
Neutropenia, 193–194, 194 Orchiectomy, traumatic, 148 perception, 33, 33

Index 629
peripheral neuropathy, 339–341 pain and inappropriate illness Peripheral vascular diseases, 68–71, 69,
persistent, 34 behavior, 39 70, 74–75
post-concussive headache, 42 subjective complaints, 20 Peritonitis, 108
psychiatric reaction, 349 Pelvis, 592–597 Permanency, description of term,
psychogenic, 613 adjustment grid and grade modifiers, 26–27, 613
rules of applying the Guides, 25 566, 569–583, 573, 574 Permanent impairment (glossary term), 613
sensitization, 614 assessment principles, 558–560, 559 Persistence, mental and behavioral
spontaneous, 34, 615 diagnosis-based impairment, 560–566 impairment, 359
subjectivity of, 35 endometriosis, 155 Persistent vegetative state, 327
transduction, 33, 33 impairment evaluation record, 561 Personal factors
transmission, 33, 33 pain disability questionnaire, 599, 600 domains of personal function, 6
whole-person evaluation, 35, 40, 40 regions, 558 ICF model of disablement, 3, 5
Pain behavior (glossary term), 613 relaxation, 142 Personal injury claims, 21
Pain disorder (glossary term), 613 summary of impairment evaluation, Personality assessment, 350
Pain Disability Questionnaire, 39–40, 597–598 Personality disorders, 349, 355, 366–367
43–44, 40, 599, 600 Pemphigus vulgaris, 176 Pheochromocytoma, 231–232
Pancreas, 232–237 Penis, 143–146, 144 Phlebotomy, burden of treatment
example of impairment class (whole- postirradiation lymphedema of skin, compliance, 186, 192
person impairment), 110 example of impairment class Physical examination
impairment evaluation summary, 124– (whole-person impairment), 145 findings, in generic template for
125, 244–245 posttraumatic ejaculatory dysfunction impairment classification grids,
impairment rating criteria, 107 and penile anesthesia, example of 15, 13
insufficiency, example of impairment class (whole-person lower extremities, 496, 517
impairment class (whole-person impairment), 144 pulmonary disease evaluation, 81
impairment), 113 posttraumatic fibrosis of left mid- report preparation, 28, 30
objective tests, 103 corpus cavernosum, example of upper extremity adjustment grid, 407,
symptoms and signs, 102 impairment class (whole-person 408
Pancreatectomy, 113 impairment), 143–144 Physicians
example of impairment class (whole- posttraumatic vascular and neurologic cultural differences between examiner
person impairment), 111–112 insufficiency, example of and patient, 27
Index
example of impairment class (whole- impairment class (whole-person examiner’s roles and responsibilities,
person impairment), 108 impairment), 144–145 23–24
Paraplegia, 338–339 Peptic ulcer, See Ulcer impairment evaluation, 23, 20
Parathyroid glands, 223–226, 224, Perception, pain, 33 independent medical examination and
244–245 Pericardial heart disease, 60–63, 61 examiners, 25–27, 351–353, 352
Parathyroid hormone, 223 examples of impairment classes in, Physiological functions, 3
Parenteral nutrition, See Nutrition, 62–63 ICF model of disablement, 3
parenteral impairment evaluation summary ICF terminology and definitions, 5
Paresthesias, 34, 613 74–75 pulmonary, 83–86
Participation (glossary term), 613 Perimetry,294, 301 Pigmentation, See Skin pigmentation
Participation restrictions, 3 Peripheral nerves and peripheral nervous Pituitary gland, See also Hypothalamic-
ICF terminology and definitions, 5 system, 34, 323, 339–341, 339 pituitary axis
with activity limitations, 6 brachial plexus, 429–443 microadenoma, 241
Patch testing, 161–162 entrapment neuropathy, 432–433, Plantar flexion, 546
Patella, 510, 526–527 445–450 Plantar fasciitis, 522–523
Pathology (WHO’s international entrapment syndromes, Platelet disorders, 201–203, 202
classification of illness), 4 electrodiagnostic evaluation, Pleura, 82
Patients 487–490 Plexus injuries, 323
compliance, neurological impairment, impairment, lower extremities, 531–533, Pneumoconioses, 82, 91–92
325–326 534–537 impairment evaluation summary, 96–97
confidentiality and disclosure, 24 impairment, upper extremities, 419–450 occupational, 94–95
history, clinical presentation, physical miscellaneous, 344 Pneumonia, 79
findings, test results, 13 multiple simultaneous neuropathies, Pneumonitis, hypersensitivity, 91
malingering, 353, 354 448, 450 Polycystic renal disease, See Kidney
motivation, 352, 353 neuropathy, 323, 339–341, 339 Polycythemia, 191–193

630 Index
Polysomnography, 93 clinical presentation of disease, 78–79 goniometer, 547

Positive (glossary term), 613 diagnostic imaging, 81–82 ICF classification, 550
Positron emission tomography, 325 examples of impairment classes, 93–95 measurement, 20
Possibility (legal and medical concepts), fibrotic lung diseases, 82 precision and accuracy, 8
25 goals of and steps in impairment Ratio scales, 7
Postthrombosis syndrome, 207–208 assessment, 78 Raynaud’s phenomenon, 69
Posttraumatic stress disorder, 362–363 hypersensitivity pneumonitis, 91 description (glossary terms), 614
Posture, 254, 255–256 impairment criteria, 88 Reading acuity, 290, 309–312, 310
Posturing, Brief Psychiatric Rating impairment evaluation summary, Recreational activities, mental and
Scale, 381 96–97 behavioral impairment, 359
Precision, description of, 8, 613 lung cancer, 92, 92 Rectovaginal fistula, 150–151
Pregnancy, folic acid deficiency, 188 lung cancer, impairment evaluation Rectum
Pre-hypertension, 65, 66 summary, 96–97 impairment rating criteria, 113, 114
Proctocolitis, 115 methodology for determining grade in objective tests, 103
Prolactin, 218, 219, 220 an impairment class, 86–87, symptoms and signs, 102
Prosthesis (glossary term), 613 86, 88 Recurrence (glossary term), 614
Prostate, 148–149, 149 neurogenic dysfunction, 337–339, 338 Red blood cells, 187–189
Prostatectomy, 142, 149 obstructive disorders, impairment Reeve, Christopher, 6
Prostatitis, 146–147 evaluation summary, 96–97 Reflex sympathetic dystrophy, 341
acute, 149 physiologic tests, 83–86 description (glossary terms), 614
chronic, 148–149 pneumoconiosis, 91–92 Refractive error, 287
Prostheses, See Devices, assistive restrictive disorders, impairment Regional impairment, See specific organ
Protein C deficiency, 207–208 evaluation summary, 96–97 systems
Proteinuria, 133, 135 sleep disorders and, 92–93 Rehabilitation, visual, 285
Pruritis, 161 spinal and other musculoskeletal Relapse (glossary term), 614
Psoriasis abnormalities affecting, 82–83 Reliability
impairment evaluation summary, Pulmonary vascular abnormalities, 81 description of term, 9, 614
180–181 Purpura intrarater and interrater, 2
pustular flares and, 174–175 amegakaryocytic thrombocytopenic, Remission, 353–354
Psychiatric evaluation, 349–351 with absent radii syndrome, 203 description (glossary terms), 614
Index
Psychiatric Impairment Rating Scale, 355, chronic idiopathic autoimmune Renal calculi, See Kidney
356–357, 360 thrombocytopenic, 203 Renal function, See Kidney
Psychiatric impairments, See Mental and Pustular flares, 174–175 Replacement medication, replacement
behavioral disorders; Nervous system Pyelonephritis, 135, 138, 142 therapy (glossary term), 614
Psychological evaluation, 349–351, 350 Pyeloureteral disease, 138 Reproducibility (glossary term), 614
Psychological factors, 5 Reproductive system, female, 149–155,
Psychosexual disorders, 349 Q 156–157,
Psychotic disorders, 323, 349 QuickDASH, 482–486 assessment principles, 130–131, 130
Psychogenic pain (glossary term), 613 cervical and uterine disease,
Puberty, precocious, 237 R 151–154, 152
Pudendal nerve, 344 Radial nerve fallopian tube and ovarian disease,
Pulmonary artery disease, 71–73, 72, entrapment, 489–490 154–155, 154
74–75 injury, 430, 439–442 methodology for determining the
impairment evaluation summary 74–75 Radiculitis (glossary term), 613 grade in an impairment class,
Pulmonary disease, 80 Radiculopathy, 323, 577–580, 582 130–131, 130
Pulmonary disease, chronic obstructive, description (glossary terms), 613–614 vulval and vaginal disease, 149–151, 151,
See Chronic obstructive pulmonary Radiography, chest, 81–82 Reproductive system, male, 129–131,
disease Radiotherapy 143–149, 156–157
Pulmonary fibrosis, 82, 91 burden of treatment compliance, 186 assessment principles, 130–131, 130
impairment evaluation summary, 96–97 postirradiation lymphedema of scrotal impairment evaluation summary,
Pulmonary function tests, 83–86 and penile skin, 145 156–157
Pulmonary hypertension, 71–73, 74–75, postirradiation telangiectasia of bladder, methodology for determining the
81–82 138–139 grade in an impairment class,
Pulmonary system, 77–99 Range of motion, 459–478, 543–551 130–131, 130
asthma, 87–91, 90 charts introduced in Guides, 2 penile disease, 143–145, 144

Index 631
scrotal disease, 145–146, 146 Scrotum SIADH, See Syndrome of inappropriate

severed urethra, hydronephrosis, burn ablation, example of antidiuretic hormone
recurrent urinary tract infection impairment class (whole-person Sickle cell anemia, 190
and impotence, example of impairment), 145 Sickle cell trait, 188–189
impairment class (whole-person postirradiation lymphedema of skin, Single-photon emission computed
impairment), 143 example of impairment class tomography, 325
testicular, epididymal and spermatic (whole-person impairment), 145 Sinusitis, 268
cord disease, 146–149, 147 Sebaceous glands, 160 Skin, 159–182
Research skin ablation, example of assessment principles, 160–162
AHCPR hierarchy of study types, 8 impairment class (whole-person burden of treatment compliance, 160
design, 8–9 impairment), 145 cancer, 164
pain impairment rating validation, Seldom (glossary term), 614 cancer, basal cell nevus syndrome, 175
40–41 Self-care criteria for rating permanent
Resilience, mental and behavioral categories of, 6 impairment due to, 164–165,
impairment, 360 mental and behavioral impairment, 358 166–167
Respiration, 265–269, 267 Self-neglect, Brief Psychiatric Rating depigmentation (occupational
Respiratory impairment, See Pulmonary Scale, 376 leukoderma), 168
system Self-reports, functional assessment, 10 disfigurement, 162
Retinoblastoma, 291, 308 Seminal vesicles, 148–149, 149 examples of impairment class (whole-
Rheumatoid arthritis, See Arthritis Sensitivity (glossary term), 614 person impairment), 167–177
Rhinosinusitis, 268 Sensitization (glossary term), 614 grafts, 162–163
Ring finger, See Fingers Sensory deficits, 340 impairment evaluation summary,
Roentgenography, pulmonary disease Sensory nerves, 532, 534–537 178–181
imaging, 81–82 Serum creatinine, 131–132 maximum impairment rating, 161
Role functioning, mental and behavioral Sesamoids, 504 penile, 145
impairment, 359 Severe (glossary term), 614 pigmentation, impairment evaluation
Roman Empire, laws regarding Severity grade, cardiovascular summary, 178–181
compensation for injuries, 1 impairment, 50, 50 pigmentation, xeroderma
Rotator cuff, 402, 403, 417–418 Sex hormones, 237 pigmentosum, 177
Rubber accelerator, 161–162 Sexual dysfunction, neurogenic, scrotal, 145
Index
Rubber latex allergy, 164 336, 338 structure, function, disorders, 160
Shoulder symptoms and signs, 161
S adjustment grids, 406–413 tests, procedures, 161–162
Sacrum, 558; See also Pelvis arthroplasty, 418 Skindex–16, 161
Salpingectomy, unilateral, 154–155 assessment principles, 385–386, 385 Skindex–29, 161
Scalp, dissecting cellulitis, 175 clinical studies adjustment grid, 407, Sleep apneas, 92–93
Scarring, 169, 174 409, 410–411 obstructive, 266, 333
Scars, 162–163 determining grade within impairment Sleep disorders, 329–330, 349, 320
follicular occlusive triad (acne class, 412 apneas, 92–93, 266, 333
conglobata, hidradenitis diagnosis-based impairment, 387–390, pulmonary impairment and, 92–93
suppurativa, dissecting cellulitis of 388 Small intestine, See Intestine, small
scalp), 175 diagnosis-based impairment examples, Smell, sense of, See Olfaction
hypertrophic, 169 417–418 Smoking, 80
impairment evaluation summary, forearm to, amputation, 457 Snellen values, 289, 311
180–181 functional assessment inventories, Social activities, mental and behavioral
thermal burns, 168, 169, 174, 176 482–486 impairment, 359
vocal fold, 275–276 functional history, 406–407, 406 Social functioning (glossary term), 614
Schizophrenia, 361–362, 367–368 pain, 417 Somatic concern, Brief Psychiatric Rating
Sciatica (glossary term), 614 physical examination, 407 408 Scale, 369
SCORAD, See SCORing Atopic range of motion impairment, 459–465, Somatization (glossary term), 614
Dermatitis 472–476, 477–478, 460, Somatoform disorders, 349
SCORing Atopic Dermatitis, 161 462–463, 475 description (glossary terms), 614
Scotoma, juxtafoveal, 300 regional impairment grid, 401–405 Somatomedin-C, 220
Scotoma, midperipheral, 300 upper extremity and whole-person Sources of error, See Errors
Scotomata, central, 304, 304 impairment classes, 385 Specificity (glossary term), 615

632 Index
SPECT, See Single-photon emission Stratum corneum, function, disorders, 160 Thomas test, 8
computed tomography Stress testing (glossary term), 615 Thoracic spine, 338–339, 558, 567–569;
Speech, 270–277 Strength, measurement, 20 See also Spine
evaluation, 271–274, 274 Structure, See Body structure Thought content, unusual, Brief
laryngeal cancer, 277 Studies, See Research Psychiatric Rating Scale, 374–375
loss of normal function, 264–265 Subjective (glossary term), 615 Throat, 248, 265, 270–277
Spermatic cords, 146–149, 147 Substance abuse and substance use Thrombocytopenic purpura, 203
Spinal cord, 323, 333–335, 334 disorders, 349, 366–367 Thrombocytosis, essential, 191–193
Christopher Reeve, 6 Suffering, See Pain Thrombosis, venous, 207–208
injury, diagnosis-related estimates, 2 Suicidality, 371 Thrombotic disorders, 206–207
injury, dysesthetic pain, 339 Suppression (vision), 305 Thumb, See Fingers
Spinal roots, 323 Surgery, stomas created by, 118 Thyroid gland, 222–223, 223
Spinal tap, 324 Swallowing, 260, 269 impairment evaluation summary,
Spine, 557–592 Sweat glands, See Eccrine glands 244–245
adjustment grid and grade modifiers, Syndrome of inappropriate antidiuretic impairment rating, 220
566, 569–583, 573, 574 hormone, 219, 220 secondary hypothyroidism, 219
assessment principles, 558–560, 559 Thyroiditis, Hashimoto’s, 222–223
C4 tetraplegia, 337–338 T Thyrotropin, 218
combining and converting Tachydysrythmia, 63 impairment rating, 220
impairments, 592 Talus, 503 Tibia, 493, 502–503, 510–511
diagnosis-based impairment, 560–566 Tangent screen (visual field) testing, 294 Tinnitus, 248–260
impairment evaluation by chiropractic Taste, sense of, 270 description (glossary terms), 615
doctors, 20 Temporal field loss, 303 Tobacco, See Smoking
impairment evaluation record, 561 Temporomandibular joint, 268–269 Toes 493; See also Foot
kyphoscoliosis, 82 Tenderness (glossary term), 615 amputation, 6, 542–543, 543
orthopedic functional assessment tools, 11 Tendonitis, 501 arthrodesis, 508
pain disability questionnaire, 599, 600 Tenosynovitis, stenosing, 413, 414 digital clubbing, 81
regions, 558 Tension, Brief Psychiatric Rating great, 6
summary of impairment evaluation, Scale, 379 range of motion, 545
597–598 Terminology Tomography, See Computed tomography
Index
T10 paraplegia, 338–339 concepts important to independent Trachea, 267

Spirometry, 83–84 medical examiners, 25–27 Transduction, pain, 33
description (glossary terms), 615 domains of personal function, 6 Transfer, definition of, 6, 615
Spleen, 201 glossary of terms, 609–615 Travel, mental and behavioral
Splenectomy, 201 Guides operational definitions, 5–6 impairment, 359
Spondylolisthesis, 571 ICF conceptual framework, 3 Treadmill testing, 48, 49
Spontaneous pain (glossary term), 615 ICF definitions listed, 5 Treatment compliance
Sputum, 79 ICIDH-2, 4 burden of, 102, 105
Squamous cells Institute of Medicine definition of burden of acromegaly, 222
carcinoma 164 disability, 4 burden of, description, 607, 607, 610
function, disorders, 160 International Classification of burden of, generic template for
Stargardt juvenile maculopathy, 292 Functioning, Disability and impairment classification grids,
Station disorders, 336, 336 Health, 2 15–16, 13
Statistics, normative, 7 WHO’s international classification of burden of hematopoietic disorders,
Statutory blindness, 286 illness, 4 185–186, 186
Stereopsis, 305 Test results, generic template for burden of, impairment percentages, 607
Stomach impairment classification grids, 15, 13 burden of pulmonary impairment, 78
impairment evaluation summary, Testicles, 146–149, 147 burden of skin disorders, 160
124–125 hypofunction, 237 failure, 24
impairment rating criteria, 107 Testosterone, 219 home parenteral nutrition, 102, 105
objective tests, 103 Tetraplegia, 337–338 Triangular fibrocartilage complex tear,
post-gastrectomy nutritional problems, cervical, 6 412, 478
example of impairment class (whole- Thermal burn scarring, See Scars Trigeminal neuralgia, 323, 343, 343
person impairment), 112–113 Thigh (glossary term), 615 True negative, true positive (glossary
symptoms and signs, 102 Thirst, 219 term), 615

Index 633
TSH, See Thyrotropin methodology for determining the Vision, See also Visual acuity; Visual
Tunnel vision, 285 grade in an impairment class, field; Visual system
Turner syndrome, 238 130–131, 130 blurred, 285
renal calculi, example of contrast, glare, color and other
U impairment class (whole-person impairments, 305
Ulcer, active duodenal, 109 impairment), 133 contrast sensitivity, 285
Ulcer, peptic, 106 severed urethra, hydronephrosis, low, 286–287, 288, 289, 296, 298,
Ulcerative colitis, See Colitis recurrent urinary tract infection 307, 310
Ulcerative proctocolitis, See and impotence, example of low (glossary term), 615
Proctocolitis impairment class (whole-person near, 282
Ulnar neuropathy, 487–488 impairment), 143 rehabilitation, 285
Uncooperativeness, Brief Psychiatric symptoms and signs, 131–132 tunnel, 285, 301
Rating Scale, 379 upper tract, 131, 132–138, 134 Visual acuity, 285–293
Upper extremities, See Elbow; Fingers; Urticaria, 178–179 description of, 285, 615
Hand; Shoulder; Wrist US National Institute for Occupational examples of impairment calculation,
Uremic encephalopathy, 327 Safety and Health, 82 291–293
Ureter, pyelonephritis secondary to Uterus, 151–154, 152 functional acuity score, 289, 290
vesicoureteral reflux, 135 asymptomatic subserrous leiomyoma, 152 Functional Visual Score, 282
Ureteroileostomy, 138 prolapse, and partial cervical absence impairment rating steps, 287–290, 288,
Ureterointestinal urinary diversion, 138 and incompetence, 153 289, 290
Ureterolithiasis, 225 monocular vs binocular, 287
Ureterostomy, cutaneous, 138 V near vs distance, 309–312, 310
Urethra, 140–143, 141 Vagina, 149–151, 151 reading, 290
female stress urinary incontinence due vault prolapse, posthysterectomy, score, 283, 284, 288–289, 288
to pelvic relaxation, example of 152–153 score, combining for visual system
impairment class (whole-person Vaginal stenosis, 150 impairment score, 303–309
impairment), 142 Validity, description of term, 9, 615 score (glossary term), 615
fistula, example of impairment class Valvular heart disease, 51–54, 53 testing, 286–287
(whole-person impairment), 141 examples of impairment classes in, Visual field, 293–302
narrowing, example of impairment class 52, 54 binocular, 294, 301, 302, 303
Index
(whole-person impairment), 140 impairment evaluation summary 74–75 confrontation, 293
severed, with hydronephrosis, Vascular diseases, See also Cardiovascular description of, 285, 615
recurrent urinary tract infection system examples of impairment calculation,
and impotence, example of extremities affected by, 68–71, 69, 70, 297, 299, 301–302
impairment class (whole-person 74–75 Functional Visual Score, 282
impairment), 143 kidney disease, hypertensive, 136 impairment rating calculation, 295–297,
stress urinary incontinence after Vasopressin, 218 296, 297, 298, 299
radical prostatectomy, example of Vegetative state, See Persistent vegetative impairment rating (glossary term), 615
impairment class (whole-person state monocular, 294
impairment), 142 Venous disorders, 68 normal, 299
symptoms and signs, 131–132 Venous thrombosis, 207–208 overlays for conversion of Goldmann
traumatic stricture with chronic Ventricular function, See Heart plots, 314, 315
pyelonephritis, example of Vertebrae, See also Intervertebral discs; overlays for conversion of Humphrey
impairment class (whole-person Spine plots, 316, 317
impairment), 142 fracture, 586, 587 score, 294, 295
Urinary diversion disorders, 138, 140, 138 Vertigo, 254–255, 256, 259 score, combining for visual system
Urinary incontinence, 142 description (glossary terms), 615 impairment score, 303–309
Urinary system, 129–143, 156–157, Vesicoureteral reflux, 135 scores, 283, 284
assessment principles, 130–131, 130 Vesicovaginal fistula, 150–151 testing, 293–294
diversion disorders, 138, 138 Vestibular disorders, 254–255, 323 Visual system, 281–319
glomerulonephritis, example of acoustic neuroma, 259–260 assessment principles, 282–285
impairment class (whole-person evoked vestibular responses, 256 impairment calculation, 303–309
impairment), 133 impairment rating, 256–260, 258 impairment rating reporting forms, 313
impairment evaluation summary, neuronitis, 259 whole person impairment, 284, 306–
156–157 unilateral injury, 260 309, 307

634 Index
Vitamin B12 deficiency, 188 White blood cells, 193–201, 194, 196, 199 International Classification of
VO2, 85, 87, 88 WHO, See World Health Organization Impairments, Disabilities and
Vocal cord dysfunction, 266, 267, 268 Whole person impairment, See also Handicaps, 4
Vocal cord paralysis, 268, 276–277 Impairment; Impairment rating; Wrist
Vocal fold scars, 275–276 specific organ systems and body parts adjustment grids, 406–413
Vocational impairments, See Work; description (glossary terms), 615 assessment principles, 385–386, 385
Workers’ compensation Women, See also Reproductive system, clinical studies adjustment grid, 407,
Voice disorders, 270–277 female 409, 410–411
evaluation, 271–274, 274 hypogonadism, 218 determining grade within impairment
vocal fold paralysis, 276–277 pulmonary function predicted values, 84 class, 412
vocal fold scars, 275–276 weight chart, 104 diagnosis-based impairment, 387–390,
von Willebrand’s disease, 204–205, 206 Work, See also Occupational exposure 388
Vulva, 149–151, 151 intensity and oxygen consumption, diagnosis-based impairment examples,
85, 85 415–416
W mental and behavioral disorders, functional assessment inventories,
Waddell’s sign, 27 354–355 482–486
Wechsler Adult Intelligence Scale, participation, Guides not to be used for functional history, 406–407, 406
350z, 351 estimates of restrictions on, 6 fusion, 416
Weight physical impairments in vocational physical examination, 407 408
charts for men and women, 104 context, 6 range of motion impairment, 459–465,
desirable (glossary term), 610 -related injury, 356 470–472, 460, 462–463, 473
desirable, in digestive system Workers’ compensation, 6 regional impairment grid, 395–397
evaluation, 103–104 description (glossary terms), 615 triangular fibrocartilage complex tear,
Weight loss Guides use, 20 412, 478
intestinal malabsorption after World Health Assembly, adoption of ICF ulnar neuropathy, 487–488
surgery, 113 model, 5 upper extremity and whole-person
post-gastrectomy, 112 World Health Organization impairment classes, 385
post-pancreatectomy, 113 Family of International Classifications, 5
Western medicine, 27 International Classification of X
Wheezing, clinical presentation of Functioning, Disability and Xeroderma pigmentosum, 177
Index
pulmonary disease, 79 Health, 2–6

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SIXTH EDITION

Guides to the Evaluation of

Senior Contributing Editor

Guides_07_FM_i-xxiv.indd i 2/17/09 3:03:52 PM

© 2008 by the American Medical Association

Internet address: www.ama-assn.org

Limited portions of the information in this publication may be

Additional copies of this book may be ordered by calling 800 621-8335

Library of Congress Cataloging-in-Publication Data

Guides_07_FM_i-xxiv.indd ii 3/6/09 9:39:21 AM

Guides_07_FM_i-xxiv.indd iii 2/17/09 3:03:53 PM

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• Assist in the review and further development of

As recommendations are received, they will be

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Editorial Panel August Colenbrander, MD

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Guides_07_FM_i-xxiv.indd vii 2/17/09 3:03:55 PM

James P. Robinson, MD, PhD Naomi N. Shields, MD Paulette S. Wehner, MD

Guides_07_FM_i-xxiv.indd viii 2/17/09 3:03:55 PM

Guides_07_FM_i-xxiv.indd ix 2/17/09 3:03:56 PM

Larry Herron, MD James Luck, Jr, MD David C. Randolph, MD, MPH,

Morton Kasdan, MD Annyce Mayer, MD, MSPH David Schenkar, MD

Kenneth B. Kauvar, MD Todd McFarren, BA, MA, JD Andrew Sew Hoy, MD

Kenneth Kingdon, JD, LLM Roy T. McKay, PhD Stanley L. Schrier, MD

David M. Klein, MD Thomas Blair Megowan, BA Raymond J. Schumacher, MD, MPH

Randall D. Lea, MD Ali Reza Moattari, MD Lisa M. Shulman, MD

Norma J. Leclair, PhD, RN Peter A. Moskovitz, MD Mitchel U. Silverman, MD

Steven W. Leclair, PhD William E. Narrow, MD, MPH Roy L. Silverstein, MD

Guides_07_FM_i-xxiv.indd x 2/17/09 3:03:56 PM

Daniel Y. Sumner, JD Jon B. Tucker, MD Pamela A. Warren, PhD

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P R E FAC E iii CHAPTER 3

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The Pulmonary System 77 The Urinary and Reproductive

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The Endocrine System 213 The Central and Peripheral

12.1 Principles of Assessment . . . . . . . . . . . . . . . . 282 C H A P T E R 14

Guides_07_FM_i-xxiv.indd xv 2/17/09 3:03:58 PM

The Upper Extremities 383 The Spine and Pelvis 557

15.1 Principles of Assessment . . . . . . . . . . . . . . . . 385 17.1 Principles of Assessment . . . . . . . . . . . . . . . . 558

The Lower Extremities 493 INDEX 617

16.1 Principles of Assessment . . . . . . . . . . . . . . . . 494

Guides_07_FM_i-xxiv.indd xvi 3/3/09 4:45:05 PM

CHAPTER 1 Table 4-3 Energy Expenditure in METs During

The Cardiovascular System 47 The Pulmonary System 77

Table 4-1 NYHA Functional Classification of Table 5-1 Impairment Classification of

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Table 9-1 Karnofsky Performance Status Scale

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* Indicates Impairment Rating Table

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CHAPTER 1 Figure 12-6 Effect of Nasal Field Loss on the

Practical Application of the Guides 19

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Figure 15-9 Impairment Estimates for Upper C H A P T E R 16

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1.1 History of the Guides

1.2 New Directions for the Sixth Edition

1.3 The International Classification of

1.4 Measurement Issues