{"id":"F2023L00223","name":"Seafarers Rehabilitation and Compensation Act 1992 – Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0","slug":"f2023l00223","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":441758,"registerId":"F2023L00223-fast-fetch-1775956978312","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"2","sectionType":"section","heading":"Commencement","content":"2  Commencement\n\n  This instrument commences on 1 April 2023 (the commencement date).\n\n","sortOrder":0},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"3  Authority\n\n  This instrument is made under section 42 of the Seafarers Rehabilitation and Compensation Act 1992.\n\n","sortOrder":1},{"sectionNumber":"4","sectionType":"section","heading":"Definitions","content":"4  Definitions\n\nNote: A number of expressions used in this instrument are defined in the Seafarers Act, including the following:\n\n(a)     aggravation (subsection 3(1));\n\n(b)     ailment (subsection 6(1));\n\n(c)     Authority (subsection 3(1));\n\n(d)     determination (subsection 76(1));\n\n(e)     employee (section 4);\n\n(f)      impairment (subsection 3(1));\n\n(g)     non-economic loss (subsection 3(1));\n\n(h)     permanent (subsection 3(1));\n\n(i)       reviewable decision (subsection 76(1)).\n\n  In this instrument:\n\n  Activities of daily living has the meaning given in the approved Guide.\n\n  AMA4 has the meaning given in the approved Guide.\n\n  AMA5 has the meaning given in the approved Guide.\n\n  approved Guide means the Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0 set out in Schedule 1 to this instrument.\n\n  assessor has the meaning given in the approved Guide.\n\n  binaural hearing loss has the meaning given in the approved Guide.\n\n  commencement date has the meaning given in section 2 of this instrument.\n\n  disease has the meaning given in the approved Guide.\n\n  employer, in relation to an employee, has the same meaning as in the Seafarers Act (see also subsection 4(3) of that Act).\n\n  injury has the same meaning as in the Seafarers Act (see subsection 3(1) and sections 6 and 7 of that Act) and the TPCA Act (see sections 6 and 7 of that Act).\n\n  loss of amenities has the meaning given in the approved Guide.\n\n  medical treatment has the meaning given in the approved Guide.\n\n  pain has the meaning given in the approved Guide.\n\n  repealed Guide has the meaning given in section 7 of this instrument.\n\n  Seafarers Act means the Seafarers Rehabilitation and Compensation Act 1992.\n\n  suffering has the meaning given in the approved Guide.\n\n  TPCA Act means the Seafarers Rehabilitation and Compensation (Transitional Provisions and Consequential Amendments) Act 1992.\n\n","sortOrder":2},{"sectionNumber":"5","sectionType":"section","heading":"Approved Guide","content":"5  Approved Guide\n\n  The Guide prepared by the Authority, which is set out in Schedule 1 to this instrument, is approved for the purposes of the Seafarers Act.\n\nNote: If an employer or the Administrative Appeals Tribunal is required to assess or reassess, or review the assessment or reassessment of, the degree of permanent impairment of an employee resulting from an injury, or the degree of non-economic loss suffered by an employee, the assessment, reassessment or review must be made in accordance with the approved Guide (Seafarers Act, subsection 42(4)).\n\n","sortOrder":3},{"sectionNumber":"6","sectionType":"section","heading":"Application of the approved Guide","content":"6  Application of the approved Guide\n\n (1) The approved Guide applies to the assessment or reassessment of the degree of permanent impairment of an employee resulting from an injury, or the degree of non-economic loss suffered by an employee as a result of an injury or impairment, relating to a claim for compensation under sections 39, 40 or 41 of the Seafarers Act received by the employer on or after the commencement date.\n\n (2) The approved Guide applies to the reassessment of the degree of permanent impairment of an employee resulting from an injury, or the degree of non-economic loss suffered by an employee as a result of an injury or impairment, relating to a claim for compensation under sections 39, 40 or 41 of the Seafarers Act received by the employer before the commencement date where the request for reassessment was received on or after the commencement date.\n\n (3) For the purposes of subsection (2), a request for reassessment does not include the following in relation to a determination made under sections 39, 40 or 41 of the Seafarers Act, whether the determination was made before, on or after the commencement date:\n\n (a) a request for reconsideration of that determination under section 78 of the Seafarers Act;\n\n (b) an application to the Administrative Appeals Tribunal for review of a reviewable decision made in relation to that determination under section 88 of the Seafarers Act.\n\n (4) The approved Guide applies to the assessment or reassessment of the degree of permanent impairment of an employee resulting from an injury relating to a request under section 40 of the Seafarers Act received by the employer on or after the commencement date.\n\n (5) The approved Guide applies to all reviews by the Administrative Appeals Tribunal of an assessment or reassessment to which subsection (1), (2) or (4) applies.\n\n","sortOrder":4},{"sectionNumber":"7","sectionType":"section","heading":"Repeal","content":"7  Repeal\n\n  The Seafarers Rehabilitation and Compensation Act 1992 – Guide to the Assessment of the Degree of Permanent Impairment Edition 2.1 [F2012C00534] (the repealed Guide) is repealed.\n\nNote 1: The Acts Interpretations Act 1901 (subsection 7(2)) relevantly provides, in effect, that:\n\n(a)     the repeal does not: revive anything not in force or existing at the time at which the repeal takes effect; or affect the previous operation of the repealed Guide, or anything duly done under the repealed Guide; or affect any right, privilege, obligation or liability acquired, accrued or incurred under the repealed Guide; or affect any investigation, legal proceeding or remedy in respect of any such right, privilege, obligation or liability; and\n\n(b)     any such investigation, legal proceeding or remedy may be instituted, continued or enforced, as if the repealed Guide had not been repealed.\n\nNote 2: The Acts Interpretations Act 1901 applies to the approved Guide and repealed Guide as if it were an Act by operation of the Legislation Act 2003 (subsection 13(1)).\n\n","sortOrder":5},{"sectionNumber":"Sch 1","sectionType":"schedule","heading":"Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0","content":"Schedule 1—Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0\n\n![Australia Coat of Arms logo under which appears the words Australian Government then Seafarers Safety, Rehabilitation and Compensation Authority](image.002.png)\n\nGUIDE TO THE ASSESSMENT OF THE DEGREE OF PERMANENT IMPAIRMENT EDITION 3.0\n\n# CONTENTS\n\n[List of Tables and Figures](#_Toc123241209)\n\n[List of Tables](#_Toc123241210)\n\n[List of Figures](#_Toc123241211)\n\n[Introduction to Edition 3.0 of the Guide](#_Toc123241212)\n\n[Structure of this Guide](#_Toc123241213)\n\n[Application of this Guide](#_Toc123241214)\n\n[Whole person impairment](#_Toc123241215)\n\n[Entitlements under the Seafarers Act](#_Toc123241216)\n\n[Non-economic loss](#_Toc123241217)\n\n[Compensation payable](#_Toc123241218)\n\n[Interim and final assessments](#_Toc123241219)\n\n[Increase in degree of whole person impairment](#_Toc123241220)\n\n[Survival of claims](#_Toc123241221)\n\n[Principles of Assessment](#_Toc123241222)\n\n[Impairment and non-economic loss](#_Toc123241223)\n\n[Employability and incapacity](#_Toc123241224)\n\n[Permanent impairment](#_Toc123241225)\n\n[Pre-existing conditions and aggravation](#_Toc123241226)\n\n[Pre-existing conditions and injury other than aggravation, to same body part, system or function](#_Toc123241227)\n\n[The impairment tables](#_Toc123241228)\n\n[Malignancies and conditions resulting in major systemic failure](#_Toc123241229)\n\n[Percentages of impairment](#_Toc123241230)\n\n[Comparing assessments under alternative tables](#_Toc123241231)\n\n[Combined values](#_Toc123241232)\n\n[Calculating the assessment](#_Toc123241233)\n\n[Ordering of additional investigations](#_Toc123241234)\n\n[Exceptions to use of this Guide](#_Toc123241235)\n\n[List of References](#_Toc123241236)\n\n[Glossary](#_Toc123241237)\n\n[Division 1 – Assessment of the degree of the permanent impairment of an employee resulting from an injury](#_Toc123241238)\n\n[Chapter 1 – The cardiovascular system](#_Toc123241239)\n\n[1.0 Introduction](#_Toc123241240)\n\n[1.1 Coronary artery disease](#_Toc123241241)\n\n[1.2 Hypertension](#_Toc123241242)\n\n[1.2.1 Diastolic hypertension](#_Toc123241243)\n\n[1.2.2 Systolic hypertension](#_Toc123241244)\n\n[1.3 Arrhythmias](#_Toc123241245)\n\n[1.4 Peripheral vascular disease of the lower extremities](#_Toc123241246)\n\n[1.5 Peripheral vascular disease of the upper extremities](#_Toc123241247)\n\n[1.6 Raynaud’s disease](#_Toc123241248)\n\n[Chapter 2 – The respiratory system](#_Toc123241249)\n\n[2.0 Introduction](#_Toc123241250)\n\n[2.1 Assessing impairment of respiratory function](#_Toc123241251)\n\n[2.1.1 Measurements](#_Toc123241252)\n\n[2.1.2 Methods of measurement](#_Toc123241253)\n\n[2.1.3 Impairment rating](#_Toc123241254)\n\n[2.2 Asthma and other hyper-reactive airways diseases](#_Toc123241255)\n\n[2.3 Lung cancer and mesothelioma](#_Toc123241256)\n\n[2.4 Breathing disorders associated with sleep](#_Toc123241257)\n\n[Chapter 3 – The endocrine system](#_Toc123241258)\n\n[3.0 Introduction](#_Toc123241259)\n\n[3.1 Thyroid and parathyroid glands](#_Toc123241260)\n\n[3.2 Adrenal cortex and medulla](#_Toc123241261)\n\n[3.3 Pancreas (diabetes mellitus)](#_Toc123241262)\n\n[3.4 Gonads and mammary glands](#_Toc123241263)\n\n[Chapter 4 – Disfigurement and skin disorders](#_Toc123241264)\n\n[4.0 Introduction](#_Toc123241265)\n\n[4.1 Skin disorders](#_Toc123241266)\n\n[4.2 Facial disfigurement](#_Toc123241267)\n\n[4.3 Bodily disfigurement](#_Toc123241268)\n\n[Chapter 5 – Psychiatric conditions](#_Toc123241269)\n\n[5.0 Introduction](#_Toc123241270)\n\n[5.1 Psychiatric conditions](#_Toc123241271)\n\n[Chapter 6 – The visual system](#_Toc123241272)\n\n[6.0 Introduction](#_Toc123241273)\n\n[6.1 Central visual acuity](#_Toc123241275)\n\n[6.1.1 Determining the loss of central vision in one eye](#_Toc123241276)\n\n[6.2 Determining loss of monocular visual fields](#_Toc123241277)\n\n[6.3 Abnormal ocular motility and binocular diplopia](#_Toc123241278)\n\n[6.4 Other ocular abnormalities](#_Toc123241279)\n\n[6.5 Other conditions causing permanent deformities causing up to 10% impairment of the whole person](#_Toc123241280)\n\n[6.6 Calculation of visual system impairment for both eyes](#_Toc123241281)\n\n[Chapter 7 – Ear, nose and throat disorders](#_Toc123241282)\n\n[7.0 Introduction](#_Toc123241283)\n\n[7.1 Hearing loss](#_Toc123241284)\n\n[7.2 Tinnitus](#_Toc123241285)\n\n[7.3 Olfaction and taste](#_Toc123241286)\n\n[7.4 Speech](#_Toc123241287)\n\n[7.5 Air passage defects](#_Toc123241288)\n\n[7.6 Nasal passage defects](#_Toc123241289)\n\n[7.7 Chewing and swallowing](#_Toc123241290)\n\n[Chapter 8 – The digestive system](#_Toc123241291)\n\n[8.0 Introduction](#_Toc123241292)\n\n[8.0.1 Calculation of Body Mass Index (BMI)](#_Toc123241293)\n\n[8.1 Upper digestive tract – oesophagus, stomach, duodenum, small intestine and pancreas](#_Toc123241294)\n\n[8.2 Lower gastrointestinal tract – colon and rectum](#_Toc123241295)\n\n[8.3 Lower gastrointestinal tract – anus](#_Toc123241296)\n\n[8.4 Surgically created stomas](#_Toc123241297)\n\n[8.5 Liver – chronic hepatitis and parenchymal liver disease](#_Toc123241298)\n\n[8.6 Biliary tract](#_Toc123241299)\n\n[8.7 Hernias of the abdominal wall](#_Toc123241300)\n\n[Chapter 9 – The musculoskeletal system](#_Toc123241301)\n\n[9.0 Introduction](#_Toc123241302)\n\n[PART I – THE LOWER EXTREMITIES – FEET AND TOES, ANKLES, KNEES AND HIPS](#_Toc123241303)\n\n[PART I – INTRODUCTION](#_Toc123241304)\n\n[9.1 Feet and toes](#_Toc123241305)\n\n[9.2 Ankles](#_Toc123241306)\n\n[9.3 Knees](#_Toc123241307)\n\n[9.4 Hips](#_Toc123241308)\n\n[9.5 Lower extremity amputations](#_Toc123241309)\n\n[9.6 Spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities](#_Toc123241310)\n\n[9.6.1 Spinal nerve root impairment affecting the lower extremity](#_Toc123241311)\n\n[9.6.2 Peripheral nerve injuries affecting the lower extremities](#_Toc123241312)\n\n[9.7 Lower extremity function](#_Toc123241313)\n\n[PART II – THE UPPER EXTREMITIES – HANDS AND FINGERS, WRISTS, ELBOWS AND SHOULDERS](#_Toc123241314)\n\n[PART II – INTRODUCTION](#_Toc123241315)\n\n[9.8 Hands and fingers](#_Toc123241317)\n\n[9.8.1 Abnormal motion of digits](#_Toc123241318)\n\n[9.8.2 Sensory losses in the thumb and fingers](#_Toc123241319)\n\n[9.9 Wrists](#_Toc123241320)\n\n[9.10 Elbows](#_Toc123241321)\n\n[9.11 Shoulders](#_Toc123241322)\n\n[9.12 Upper extremity amputations](#_Toc123241323)\n\n[9.13 Neurological impairments affecting the upper extremities](#_Toc123241324)\n\n[9.13.1 Cervical nerve root impairment](#_Toc123241325)\n\n[9.13.2 Specific nerve lesions affecting the upper extremities](#_Toc123241326)\n\n[9.13.3 Chronic pain conditions](#_Toc123241327)\n\n[9.14 Upper extremity function](#_Toc123241328)\n\n[PART III – THE SPINE](#_Toc123241329)\n\n[PART III – INTRODUCTION](#_Toc123241330)\n\n[PART III – DEFINITIONS OF CLINICAL FINDINGS FOR DIAGNOSIS-RELATED ESTIMATES IN ASSESSING SPINAL IMPAIRMENT](#_Toc123241331)\n\n[PART III – MULTI-LEVEL FRACTURES INVOLVING THE SPINAL CANAL](#_Toc123241332)\n\n[9.15 Cervical spine – diagnosis-related estimates](#_Toc123241333)\n\n[9.16 Thoracic spine – diagnosis-related estimates](#_Toc123241334)\n\n[9.17 Lumbar spine – diagnosis-related estimates](#_Toc123241335)\n\n[9.18 Fractures of the pelvis](#_Toc123241336)\n\n[Chapter 10 – The urinary system](#_Toc123241337)\n\n[10.0 Introduction](#_Toc123241338)\n\n[10.1 The upper urinary tract](#_Toc123241339)\n\n[10.2 Urinary diversion](#_Toc123241340)\n\n[10.3 Lower urinary tract](#_Toc123241341)\n\n[Chapter 11 – The reproductive system](#_Toc123241342)\n\n[11.0 Introduction](#_Toc123241343)\n\n[11.1 Male reproductive system](#_Toc123241344)\n\n[11.1.1 Male reproductive organs – penis](#_Toc123241345)\n\n[11.1.2 Male reproductive organs – scrotum](#_Toc123241346)\n\n[11.1.3 Male reproductive organs – testes, epididymes and spermatic cords](#_Toc123241347)\n\n[11.1.4 Male reproductive organs – prostate and seminal vesicles](#_Toc123241348)\n\n[11.2 Female reproductive system](#_Toc123241349)\n\n[11.2.1 Female reproductive organs – vulva and vagina](#_Toc123241350)\n\n[11.2.2 Female reproductive organs – cervix and uterus](#_Toc123241351)\n\n[11.2.3 Female reproductive organs – fallopian tubes and ovaries](#_Toc123241352)\n\n[Chapter 12 – The neurological system](#_Toc123241353)\n\n[12.0 Introduction](#_Toc123241354)\n\n[12.1 Disturbances of levels of consciousness and awareness](#_Toc123241355)\n\n[12.1.1 Permanent disturbances of levels of consciousness and awareness](#_Toc123241356)\n\n[12.1.2 Epilepsy, seizures and convulsive disorders](#_Toc123241357)\n\n[12.1.3 Sleep and arousal disorders](#_Toc123241358)\n\n[12.2 Impairment of memory, learning, abstract reasoning and problem solving ability](#_Toc123241359)\n\n[12.3 Communication impairments – dysphasia and aphasia](#_Toc123241360)\n\n[12.4 Emotional or behavioural impairments](#_Toc123241361)\n\n[12.5 Cranial nerves](#_Toc123241362)\n\n[12.5.1 The olfactory nerve (I)](#_Toc123241363)\n\n[12.5.2 The optic nerve, the oculomotor and trochlear nerves and the abducens (II, III, IV and VI)](#_Toc123241364)\n\n[12.5.3 The trigeminal nerve (V)](#_Toc123241365)\n\n[12.5.4 The facial nerve (VII)](#_Toc123241366)\n\n[12.5.5 The auditory nerve (VIII)](#_Toc123241367)\n\n[12.5.6 The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#_Toc123241368)\n\n[12.6 Neurological impairment of the respiratory system](#_Toc123241369)\n\n[12.7 Neurological impairment of the urinary system](#_Toc123241370)\n\n[12.8 Neurological impairment of the anorectal system](#_Toc123241371)\n\n[12.9 Neurological impairment affecting sexual function](#_Toc123241372)\n\n[Chapter 13 – The haematopoietic system](#_Toc123241373)\n\n[13.0 Introduction](#_Toc123241374)\n\n[13.1 Anaemia](#_Toc123241375)\n\n[13.2 Leukocyte abnormalities or disease](#_Toc123241376)\n\n[13.3 Haemorrhagic disorders and platelet disorders](#_Toc123241377)\n\n[13.4 Thrombotic disorders](#_Toc123241378)\n\n[Division 2 – Assessment of the degree of non-economic loss suffered by an employee as a result of an injury or impairment](#_Toc123241379)\n\n[Introduction](#_Toc123241380)\n\n[B1 Pain](#_Toc123241381)\n\n[B2 Suffering](#_Toc123241382)\n\n[B3 Loss of amenities](#_Toc123241383)\n\n[B4 Other loss](#_Toc123241384)\n\n[B5 Loss of expectation of life](#_Toc123241385)\n\n[B6 Calculation of non-economic loss](#_Toc123241386)\n\n[Division 3 – Calculation of the total entitlement to compensation for permanent impairment and non-economic loss](#_Toc123241387)\n\n[Appendix 1 – Combined values chart](#_Toc123241388)\n\n# LIST OF TABLES AND FIGURES\n\n## LIST OF TABLES\n\n[Table 1.1: Coronary artery disease](#_Toc123132403)\n\n[Table 1.2.1: Diastolic hypertension](#_Toc123132404)\n\n[Table 1.2.2: Systolic hypertension](#_Toc123132405)\n\n[Table 1.3: Arrhythmias](#_Toc123132406)\n\n[Table 1.4: Peripheral vascular disease of the lower extremities](#_Toc123132407)\n\n[Table 1.5: Peripheral vascular disease of the upper extremities](#_Toc123132408)\n\n[Table 1.6: Raynaud’s disease](#_Toc123132409)\n\n[Table 2.1: Conversion of respiratory function values to impairment](#_Toc123132410)\n\n[Table 2.2: WPI derived from asthma impairment score](#_Toc123132411)\n\n[Table 2.4: WPI derived from obstructive sleep apnoea score](#_Toc123132412)\n\n[Table 3.1: Thyroid and parathyroid glands](#_Toc123132413)\n\n[Table 3.2: Adrenal cortex and medulla](#_Toc123132414)\n\n[Table 3.3: Pancreas (diabetes mellitus)](#_Toc123132415)\n\n[Table 3.4: Gonads and mammary glands](#_Toc123132416)\n\n[Table 4.1: Skin disorders](#_Toc123132417)\n\n[Table 4.2: Facial disfigurement](#_Toc123132418)\n\n[Table 4.3: Bodily disfigurement](#_Toc123132419)\n\n[Table 5.1: Psychiatric conditions](#_Toc123132420)\n\n[Table 6.1: Conversion of the visual system to WPI rating](#_Toc123132421)\n\n[Table 7.2: Tinnitus](#_Toc123132422)\n\n[Table 7.3: Olfaction and taste](#_Toc123132423)\n\n[Table 7.4: Speech](#_Toc123132424)\n\n[Table 7.5: Air passage defects](#_Toc123132425)\n\n[Table 7.6: Nasal passage defects](#_Toc123132426)\n\n[Table 7.7: Chewing and swallowing](#_Toc123132427)\n\n[Table 8.1: Upper digestive tract – oesophagus, stomach, duodenum, small intestine and pancreas](#_Toc123132428)\n\n[Table 8.2: Lower gastrointestinal tract – colon and rectum](#_Toc123132429)\n\n[Table 8.3: Lower gastrointestinal tract – anus](#_Toc123132430)\n\n[Table 8.4: Surgically created stomas](#_Toc123132431)\n\n[Table 8.5: Chronic hepatitis and parenchymal liver disease](#_Toc123132432)\n\n[Table 8.6: Biliary tract](#_Toc123132433)\n\n[Table 8.7: Hernias of the abdominal wall](#_Toc123132434)\n\n[Table 9.1: Feet and toes](#_Toc123132435)\n\n[Table 9.2: Ankles](#_Toc123132436)\n\n[Table 9.3: Knees](#_Toc123132437)\n\n[Table 9.4: Hips](#_Toc123132438)\n\n[Table 9.5: Lower extremity amputations](#_Toc123132439)\n\n[Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#_Toc123132440)\n\n[Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities](#_Toc123132441)\n\n[Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities](#_Toc123132442)\n\n[Table 9.7: Lower extremity function](#_Toc123132443)\n\n[Table 9.8.1a: Abnormal motion/ankylosis of the thumb – IP and MP joints](#_Toc123132444)\n\n[Table 9.8.1b: Radial abduction/adduction/opposition of the thumb – abnormal motion/ankylosis](#_Toc123132445)\n\n[Table 9.8.1c: Abnormal motion/ankylosis of the fingers – index and middle fingers](#_Toc123132446)\n\n[Table 9.8.1d: Abnormal motion/ankylosis of the fingers – ring and little fingers](#_Toc123132447)\n\n[Table 9.8.2a: Sensory losses in the thumb](#_Toc123132448)\n\n[Table 9.8.2b: Sensory losses in the index and middle fingers](#_Toc123132449)\n\n[Table 9.8.2c: Sensory losses in the little finger](#_Toc123132450)\n\n[Table 9.8.2d: Sensory losses in the ring finger](#_Toc123132451)\n\n[Table 9.9.1a: Wrist flexion/extension](#_Toc123132452)\n\n[Table 9.9.1b: Radial and ulnar deviation of wrist joint](#_Toc123132453)\n\n[Table 9.10.1a: Elbow – flexion/extension](#_Toc123132454)\n\n[Table 9.10.1b: Pronation and supination of forearm](#_Toc123132455)\n\n[Table 9.11.1a: Shoulder – flexion/extension](#_Toc123132456)\n\n[Table 9.11.1b: Shoulder – internal/external rotation](#_Toc123132457)\n\n[Table 9.11.1c: Shoulder – abduction/adduction](#_Toc123132458)\n\n[Table 9.12.1: Upper extremity amputations](#_Toc123132459)\n\n[Table 9.12.2: Amputation of digits](#_Toc123132460)\n\n[Table 9.13.1: Cervical nerve root impairment](#_Toc123132461)\n\n[Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#_Toc123132462)\n\n[Table 9.13.2b: Specific nerve lesions affecting the upper extremities – motor impairment](#_Toc123132463)\n\n[Table 9.13.3: Chronic pain conditions](#_Toc123132464)\n\n[Table 9.14: Upper extremity function](#_Toc123132465)\n\n[Table 9.15: Cervical spine – diagnosis-related estimates](#_Toc123132466)\n\n[Table 9.16: Thoracic spine – diagnosis-related estimates](#_Toc123132467)\n\n[Table 9.17: Lumbar spine – diagnosis-related estimates](#_Toc123132468)\n\n[Table 9.18: Fractures of the pelvis](#_Toc123132469)\n\n[Table 10.1: The upper urinary tract](#_Toc123132470)\n\n[Table 10.2: Urinary diversion](#_Toc123132471)\n\n[Table 10.3: Lower urinary tract](#_Toc123132472)\n\n[Table 11.1.1: Male reproductive organs – penis](#_Toc123132473)\n\n[Table 11.1.2: Male reproductive organs – scrotum](#_Toc123132474)\n\n[Table 11.1.3: Male reproductive organs – testes, epididymes and spermatic cords](#_Toc123132475)\n\n[Table 11.1.4: Male reproductive organs – prostate and seminal vesicles](#_Toc123132476)\n\n[Table 11.2.1: Female reproductive organs – vulva and vagina](#_Toc123132477)\n\n[Table 11.2.2: Female reproductive organs – cervix and uterus](#_Toc123132478)\n\n[Table 11.2.3: Female reproductive organs – fallopian tubes and ovaries](#_Toc123132479)\n\n[Table 12.1.1: Permanent disturbances of levels of consciousness and awareness](#_Toc123132480)\n\n[Table 12.1.2: Epilepsy, seizures and convulsive disorders](#_Toc123132481)\n\n[Table 12.1.3: Sleep and arousal disorders](#_Toc123132482)\n\n[Table 12.2: Impairment of memory, learning, abstract reasoning and problem solving ability](#_Toc123132483)\n\n[Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#_Toc123132484)\n\n[Table 12.4: Emotional or behavioural impairments](#_Toc123132485)\n\n[Table 12.5.1: The olfactory nerve (I)](#_Toc123132486)\n\n[Table 12.5.3: The trigeminal nerve (V)](#_Toc123132487)\n\n[Table 12.5.4: The facial nerve (VII)](#_Toc123132488)\n\n[Table 12.5.5: The auditory nerve (VIII)](#_Toc123132489)\n\n[Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#_Toc123132490)\n\n[Table 12.6: Neurological impairment of the respiratory system](#_Toc123132491)\n\n[Table 12.7: Neurological impairment of the urinary system](#_Toc123132492)\n\n[Table 12.8: Neurological impairment of the anorectal system](#_Toc123132493)\n\n[Table 12.9: Neurological impairment affecting sexual function](#_Toc123132494)\n\n[Table 13.1: Anaemia](#_Toc123132495)\n\n[Table 13.2: Leukocyte abnormalities or disease](#_Toc123132496)\n\n[Table 13.3: Haemorrhagic disorders and platelet disorders](#_Toc123132497)\n\n[Table 13.4: Thrombotic disorders](#_Toc123132498)\n\n[Table B1: Pain](#_Toc123132499)\n\n[Table B2: Suffering](#_Toc123132500)\n\n[Table B3.1: Mobility](#_Toc123132501)\n\n[Table B3.2: Social relationships](#_Toc123132502)\n\n[Table B3.3: Recreation and leisure activities](#_Toc123132503)\n\n[Table B4: Other loss](#_Toc123132504)\n\n[Table B5: Loss of expectation of life](#_Toc123132505)\n\n[Table B6: Worksheet – calculation of non-economic loss](#_Toc123132506)\n\n## LIST OF FIGURES\n\n[Figure 1-A: Activities of daily living](#_Toc123132311)\n\n[Figure 1-B: Symptomatic level of activity in METS according to age and gender](#_Toc123132312)\n\n[Figure 1-C: Definitions of functional class](#_Toc123132313)\n\n[Figure 1-C: Definitions of functional class](#_Toc123132314)\n\n[Figure 2-A: Calculating asthma impairment score](#_Toc123132315)\n\n[Figure 2-B: Calculating obstructive sleep apnoea score](#_Toc123132316)\n\n[Figure 4-A: Activities of daily living](#_Toc123132317)\n\n[Figure 5-A: Activities of daily living](#_Toc123132318)\n\n[Figure 6-A: Steps for calculating impairment of the visual system](#_Toc123132319)\n\n[Figure 6-B: Revised LogMar equivalent for different reading cards](#_Toc123132320)\n\n[Figure 6-C: Percentage loss of central vision in one eye](#_Toc123132321)\n\n[Figure 6-D: Normal extent of the visual field](#_Toc123132322)\n\n[Figure 6-E: Percentage loss of ocular motility of one eye in diplopia fields](#_Toc123132323)\n\n[Figure 6-F: Calculation of visual system impairment for both eyes](#_Toc123132324)\n\n[Figure 8-A: Activities of daily living](#_Toc123132325)\n\n[Figure 8-B: Body Mass Index criteria](#_Toc123132326)\n\n[Figure 9-A: Activities of daily living](#_Toc123132327)\n\n[Figure 9-B: Tables of normal ranges of motion of joints](#_Toc123132328)\n\n[Figure 9-C: Grading system](#_Toc123132329)\n\n[Figure 9-D: Grading system](#_Toc123132330)\n\n[Figure 12-A: Activities of daily living](#_Toc123132331)\n\n[Figure 12-B: Clinical dementia rating (CDR)](#_Toc123132332)\n\n[Figure 12-C: %WPI modifiers for episodic conditions](#_Toc123132333)\n\n[Figure 13-A: Activities of daily living](#_Toc123132334)\n\n# INTRODUCTION TO EDITION 3.0 OF THE GUIDE\n\n## STRUCTURE OF THIS GUIDE\n\n1            [Division 1](#_DIVISION_1__) is used to assess the degree of the permanent impairment of an employee resulting from an injury.\n\n2            [Division 2](#_DIVISION_2__) is used to assess the degree of non-economic loss suffered by an employee as a result of an injury or impairment.\n\n3            [Division 3](#_DIVISION_3__) is used to calculate the total entitlement to compensation for permanent impairment and non-economic loss based on the assessments completed in Divisions 1 and 2.\n\n4            [Appendix 1](#_APPENDIX_1__) is used to obtain the combined value of multiple impairments resulting from a single injury where combination is required.\n\n5            The [Principles of Assessment](#_PRINCIPLES_OF_ASSESSMENT) and [Glossary](#_GLOSSARY) contain information relevant to the interpretation and application of Divisions 1 and 2.\n\n## APPLICATION OF THIS GUIDE\n\n6            This Guide (including the [Principles of Assessment](#_bookmark9) and [Glossary](#_bookmark16)) applies to the assessment or re-assessment of the degree of permanent impairment or non-economic loss of an employee relating to all claims and requests under sections 39, 40 and 41 of the Seafarers Act received by the employer on or after the commencement date and to the review by the Administrative Appeals Tribunal of any such assessment or re-assessment. See sections 2 and 6 of the instrument titled Seafarers Rehabilitation and Compensation Act 1992 – Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0 for when this Guide applies to a particular assessment, reassessment or review.\n\n7            See Edition 2.1 of the Guide (now repealed) for the criteria, methods and application provisions relevant to the assessment or reassessment of the degree of permanent impairment or non-economic loss of an employee relating to claims and requests under sections 39, 40 and 41 of the Seafarers Act that were received by the employer prior to the commencement date. Edition 2.1 of the Guide can be accessed via the Federal Register of Legislation here: <https://www.legislation.gov.au/Details/F2012C00534>.\n\n## WHOLE PERSON IMPAIRMENT\n\n8            Prior to 1993, the Seamen’s Compensation Act 1911 (repealed by the Seafarers Rehabilitation and Compensation (Transitional Provisions and Consequential Amendments) Act 1992) provided for the payment of lump sum compensation where a seaman suffered the loss of, or loss of efficient use of, a part of the body or faculty, as specified in a table of maims. The range of conditions compensated was exclusive and did not reflect the broad range of work- related conditions.\n\n9            This Guide, like the previous editions, is, for the purposes of expressing the degree of impairment as a percentage, based on the concept of ‘whole person impairment’. Subsection 39(5) of the Seafarers Act provides for the determination of the degree of permanent impairment of the employee resulting from an injury, that is, the employee as a whole person. The whole person impairment concept, therefore, provides for compensation for the permanent impairment of any body part, system or function to the extent to which it permanently impairs the employee as a whole person.\n\n10         Paragraph 42(1)(a) of the Seafarers Act provides that the Guide may set out criteria by reference to which the degree of the permanent impairment of an employee resulting from an injury shall be determined. Paragraph 42(1)(c) of the Act relevantly provides that methods by which the degree of permanent impairment, as determined under those criteria, shall be expressed as a percentage. Subsection 42(5) of the Act relevantly provides that the percentage of permanent impairment suffered by an employee as a result of an injury ascertained under the methods referred to in paragraph 42(1)(c) may be 0%.\n\n11         Whole person impairment is the methodology used in this Guide in accordance with section 42 of the Seafarers Act and is therefore the methodology by which the degree of permanent impairment of an employee resulting from an injury is expressed as a percentage. While the employee’s impairment resulting from a particular injury is to be assessed against criteria in this Guide by reference to the functional capacities of a normal healthy person, the degree of permanent impairment of that employee resulting from that particular injury may be assessed as:\n\na)      0% if there is no increase in the employee’s whole person impairment when assessed in accordance with this Guide; or\n\nb)      less than the threshold for compensation under section 39 of the Act even if there is an increase in the employee’s whole person impairment when assessed in accordance with this Guide.\n\n","sortOrder":6},{"sectionNumber":"12","sectionType":"section","heading":"Whole person impairment is assessed under [Division 1](#_DIVISION_1__) of this Guide.","content":"12         Whole person impairment is assessed under [Division 1](#_DIVISION_1__) of this Guide.\n\n## ENTITLEMENTS UNDER THE SEAFARERS ACT\n\n13         Where the degree of permanent impairment of the employee is determined by the employer under subsection 39(5) of the Seafarers Act to be less than 10%, subsection 39(7) of the Seafarers Act provides that compensation is not payable to the employee under section 39 of that Act.\n\n14         Subsection 39(8) of the Seafarers Act excludes the operation of subsection 39(7) in relation to impairment constituted by the loss, or the loss of the use, of a finger or toe, or the loss of the sense of taste or smell. The threshold for compensation under section 39 of the Act for an injury resulting in a permanent impairment constituted by such a loss is 1% to 5% WPI under this Guide depending on the nature of the impairment.\n\n## NON-ECONOMIC LOSS\n\n15         Subsection 41(1) of the Seafarers Act provides that where there is liability to pay compensation in respect of a permanent impairment, additional compensation for non-economic loss is payable in accordance with section 41.\n\n","sortOrder":7},{"sectionNumber":"16","sectionType":"section","heading":"Non-economic loss is assessed under [Division 2](#_bookmark282) of this Guide.","content":"16         Non-economic loss is assessed under [Division 2](#_bookmark282) of this Guide.\n\n## COMPENSATION PAYABLE\n\n17         The maximum level of payment is prescribed in the legislation and indexed annually on 1 July in accordance with the Consumer Price Index. Compensation is calculated at the rate applicable at the time of the assessment. See [Division 3](#_DIVISION_3__) of this Guide for calculation of total entitlement to compensation for permanent impairment and non-economic loss.\n\n## INTERIM AND FINAL ASSESSMENTS\n\n18         On the written request of the employee under subsection 40(1) of the Seafarers Act, an interim determination must be made by the employer of the degree of permanent impairment suffered and an assessment made of an amount of compensation payable to the employee, where:\n\na)      a determination has been made that an employee has suffered a permanent impairment as a result of an injury;\n\nb)      the degree of that impairment is equal to or more than 10%; and\n\nc)       a final determination of the degree of permanent impairment has not been made.\n\n19         When a final determination of the degree of permanent impairment is made by the employer, there is payable to the employee, under subsection 40(3) of the Seafarers Act, an amount equal to the difference, if any, between the final determination and the interim assessment.\n\n## INCREASE IN DEGREE OF WHOLE PERSON IMPAIRMENT\n\n20         Where a final assessment of the degree of permanent impairment has been made by the employer and the level of whole person permanent impairment subsequently increases by 10% or more in respect of the same injury, the employee may request, pursuant to subsection 40(4) of the Seafarers Act, another assessment for compensation for permanent impairment and non-economic loss. Additional compensation is payable for the increased level of whole person impairment only.\n\n21         See [Application of this Guide](#_APPLICATION_OF_THIS) above as to assessments of the degree of permanent impairment made under the previous editions of the Guide.\n\n## SURVIVAL OF CLAIMS\n\n22         The Seafarers Act provides for the survival of certain claims for compensation. If an employee suffers an injury resulting in permanent impairment, and the employee dies:\n\na)      before a claim for permanent impairment compensation has been made—the employee’s legal personal representative may make such a claim (see subsection 64(1) and the definition of ‘claimant’ in subsection 3(1)); or\n\nb)      after a claim for permanent impairment compensation has been made—the employee’s personal representative may continue with the claim (see subsection 64(2) and the definition of ‘claimant’ in subsection 3(1)).\n\n23         In either case, if an amount of compensation is determined by the employer to be payable under section 39 of the Seafarers Act in respect of the claim, subject to section 134, the amount is payable to the deceased employee’s estate (subsections 64(3) and 134(1)). No compensation under section 41 would be payable to the deceased employee’s estate for any non-economic loss (subsections 64(4)).\n\n# PRINCIPLES OF ASSESSMENT\n\n## IMPAIRMENT AND NON-ECONOMIC LOSS\n\n24         In the Seafarers Act, ‘impairment’ means ‘the loss, the loss of the use, or the damage or malfunction, of any part of the body or of the whole or part of any bodily system or function’ (subsection 3(1)). The term relates to the health status of an individual and includes anatomical loss, anatomical abnormality, physiological abnormality, and psychological abnormality. The degree of impairment is assessed by reference to the impact of that loss, damage or malfunction by reference to the functional capacities of a normal healthy person.\n\n25         In the Seafarers Act, ‘non-economic loss’, in relation to an employee who has suffered an injury resulting in a permanent impairment, means ‘loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware’ (subsection 3(1)). The term deals with the effects of the impairment on the employee’s life.\n\n26         Non-economic loss may be characterised as the ‘lifestyle effects’ of an injury or impairment. Lifestyle effects are a measure of an individual’s mobility and enjoyment of, and participation in, social relationships, and recreation and leisure activities. The employee must be aware of the losses suffered. While employees may have equal ratings of whole person impairment it would not be unusual for them to receive different ratings for non-economic loss because of their different lifestyles.\n\n## EMPLOYABILITY AND INCAPACITY\n\n27         The concepts of ‘employability’ and ‘incapacity for work’ are not the tests for the assessment of impairment and non- economic loss. Incapacity for work is influenced by factors other than the degree of impairment and is compensated by weekly payments which are separate and independent to permanent impairment entitlements.\n\n## PERMANENT IMPAIRMENT\n\n28         Compensation is only payable for an impairment resulting from an injury which is permanent. In the Seafarers Act, ‘permanent’ means ‘likely to continue indefinitely’ (subsection 3(1)).\n\n29         For the purpose of determining whether an impairment is permanent under the Seafarers Act, the assessor must have regard to all of the matters in subsection 39(2), namely:\n\na)      the duration of the impairment;\n\nb)      the likelihood of improvement in the employee’s condition;\n\nc)       whether the employee has undertaken all reasonable rehabilitative treatment for the impairment; and\n\nd)      any other relevant matters.\n\n30         The assessor should also have regard to the nature and effect of the impairment, and the extent, if any, to which it may reasonably be capable of being reduced or removed (including by surgery, medication or rehabilitative treatment).\n\n31         In the case of a deceased employee, the assessor must still have regard to all of the matters specified in subsection 39(2) of the Seafarers Act. Consequently, assessing the degree of permanent impairment of the employee immediately prior to death will not necessarily be appropriate. For example:\n\na)      if there was a likelihood of improvement in the employee’s condition or the employee had not undertaken all reasonable rehabilitative treatment for the impairment - the degree of impairment of the employee immediately prior to death will not be appropriate if the degree of permanent impairment resulting from the injury was likely to be less after the improvement or treatment; or\n\nb)      if the injury resulted in systemic failure of vital organs leading to the employee’s death - the degree of impairment of the employee immediately prior to death will be appropriate if the degree of permanent impairment resulting from the injury was not likely to have improved or responded to treatment.\n\n32         Whatever the cause of death, the assessor must only assess the permanent impairment resulting from the injury The assessor should, where possible, assess the degree of permanent impairment resulting from the injury by reference to the available evidence (for example, clinical records, investigations, reported histories) and/or by using clinical judgment. For the purposes of the Seafarers Act and this Guide, death is not an impairment that is compensable under section 39 of the Act. Compensation for an injury resulting in death is dealt with separately in sections 29 and 30 of the Act.\n\n## PRE-EXISTING CONDITIONS AND AGGRAVATION\n\n33         Where a pre-existing condition (including an underlying condition or pre-existing injury) is aggravated by employment, such that the aggravation is an injury, only the permanent impairment resulting from the injury is to be included in the assessment of the degree of permanent impairment of the employee. However, an assessment should not be made unless the aggravation is permanent.\n\n34         Where the employee’s impairment is entirely attributable to the pre-existing condition, or to the natural progression of the pre-existing condition, the degree of permanent impairment of the employee resulting from the injury is 0%.\n\n35         Where the pre-existing condition was previously asymptomatic, all the permanent impairment resulting from the injury is to be included in the assessment of the degree of permanent impairment of the employee.\n\n","sortOrder":8},{"sectionNumber":"36","sectionType":"section","heading":"Where the pre-existing condition was previously symptomatic, the following method must be applied:","content":"36         Where the pre-existing condition was previously symptomatic, the following method must be applied:\n\na)      The assessor should, where possible, assess the degree of permanent impairment resulting from the pre-existing condition by reference to the available evidence (for example, clinical records, investigations, reported histories) and/or by using clinical judgment.\n\nb)      Where it is possible to assess the degree of permanent impairment resulting from the pre-existing condition, the assessor should, where possible, isolate the permanent impairment resulting from the injury (for example, by comparing the degree of permanent impairment resulting from the pre-existing condition with the degree of permanent impairment resulting from the injury to assess whether there has been an increase in the employee’s whole person impairment). Only the permanent impairment resulting from the injury is to be included in the assessment of the degree of permanent impairment of the employee.\n\nc)       Where it is not possible to assess the degree of permanent impairment resulting from the pre-existing condition, or it is not possible to isolate the permanent impairment resulting from the injury, the assessment of the degree of permanent impairment of the employee resulting from the injury is to be made by reference to the totality of effects of the pre-existing condition and the injury.\n\nd)      The percentage of permanent impairment suffered by an employee as a result of a particular injury ascertained by applying this method may be 0%.\n\n## PRE-EXISTING CONDITIONS AND INJURY OTHER THAN AGGRAVATION, TO SAME BODY PART, SYSTEM OR FUNCTION\n\n37         Where a pre-existing condition (including an underlying condition but excluding a pre-existing injury) results in permanent impairment, and the employee subsequently suffers an injury which results in permanent impairment to the same body part, system or function (but the injury is not an aggravation of the pre-existing condition), only the permanent impairment resulting from the injury is to be included in the assessment of the degree of permanent impairment of the employee.\n\n","sortOrder":9},{"sectionNumber":"38","sectionType":"section","heading":"In these circumstances, the following method must be applied:","content":"38         In these circumstances, the following method must be applied:\n\na)      The assessor should, where possible, assess the degree of permanent impairment resulting from the pre-existing condition by reference to the available evidence (for example, clinical records, investigations, reported histories) and/or by using clinical judgment.\n\nb)      Where it is possible to assess the degree of permanent impairment resulting from the pre-existing condition, the assessor should, where possible, isolate the permanent impairment resulting from the injury (for example, by comparing the degree of permanent impairment resulting from the pre-existing condition with the degree of permanent impairment resulting from the injury to assess whether there has been an increase in the employee’s whole person impairment). Only the permanent impairment resulting from the injury is to be included in the assessment of the degree of permanent impairment of the employee.\n\nc)       Where it is not possible to assess the degree of permanent impairment resulting from the pre-existing condition, or it is not possible to isolate the permanent impairment resulting from the injury, the assessment of the degree of permanent impairment of the employee resulting from the injury is to be made by reference to the totality of effects of the pre-existing condition and the injury.\n\nd)      The percentage of permanent impairment suffered by an employee as a result of a particular injury ascertained by applying this method may be 0%.\n\n39         Where a pre-existing injury results in permanent impairment, and the employee subsequently suffers an injury which results in permanent impairment to the same body part, system or function (but the subsequent injury is not an aggravation of the pre-existing injury), the permanent impairment resulting from the pre-existing injury must be disregarded when assessing the degree of permanent impairment of the employee resulting from the subsequent injury. The subsequent injury should be assessed by reference to the functional capacities of a normal healthy person. The WPI rating for the pre-existing injury and the WPI rating for the subsequent injury may be added.\n\n## THE IMPAIRMENT TABLES\n\n40         [Division 1](#_DIVISION_1__) of this Guide is based on the concept of whole person impairment which is drawn from the AMA5.\n\n41         [Division 1](#_DIVISION_1__) assembles into groups, according to body system, detailed descriptions of impairments. The extent of each impairment is expressed as a percentage value of the whole, normal, healthy person. Thus, a percentage value can be assigned to an impairment by reference to the relevant description in this Guide.\n\n42         It may be necessary in some cases to have regard to a number of chapters within this Guide when assessing the degree of whole person impairment which results from an injury.\n\n43         Where a table specifies a degree of impairment because of a surgical procedure, the same degree of impairment applies if the same loss of function has occurred due to a different medical procedure or treatment.\n\n## MALIGNANCIES AND CONDITIONS RESULTING IN MAJOR SYSTEMIC FAILURE\n\n44         Conditions such as cancer, HIV infection, diabetes, asbestosis, mesothelioma and others, often with terminal consequences, may result in failure or impairment of multiple body parts or systems.\n\n45         Assessments should be made of the impairment suffered in each of the affected body parts and systems and combined using the combined values chart in [Appendix 1](#_bookmark300) to this Guide.\n\n## PERCENTAGES OF IMPAIRMENT\n\n46         Most tables in [Division 1](#_DIVISION_1__) of this Guide provide impairment values expressed as fixed percentages. Where such a table is applicable in respect of a particular impairment, there is no discretion to choose an impairment value not specified in that table. For example, where 10% and 20% are the specified values, there is no discretion to determine the degree of impairment as 15%.\n\n47         Where a table provides for impairment values within a range, consideration will need to be given to all criteria applicable to the condition, which includes performing activities of daily living and an estimate of the degree to which the medical impairment interferes with these activities. In some cases, additional information may be required to determine where to place an individual within the range. The assessor must provide written reason why they consider the selected point within the range as clinically justifiable.\n\n## COMPARING ASSESSMENTS UNDER ALTERNATIVE TABLES\n\n48         Unless there are instructions in this Guide to the contrary, where two or more tables (or combinations of tables) are equally applicable to an impairment, the relevant authority will determine the degree of permanent impairment under the table or tables which yields or yield the most favourable result to the employee. The assessor (if not the relevant authority) should therefore provide assessments under all applicable tables to allow the relevant authority to make this determination.\n\n## COMBINED VALUES\n\n49         Impairment is system or function based. A single injury may give rise to multiple losses of function and, therefore, multiple impairments. When more than one table applies in respect of that injury, separate scores should be allocated to each functional impairment. To obtain the whole person impairment in respect of that injury, those scores are then combined using the combined values chart in [Appendix 1](#_bookmark300) to this Guide unless the notes in the instructions in this Guide specifically stipulate that the scores are to be added. (For instance, see [Section 9.8.1 (Abnormal motion of digits)](#_Abnormal_motion_of).)\n\n50         It is important to note that whenever the notes in the relevant section in [Division 1](#_DIVISION_1__) refer to combined ratings, the combined values chart in [Appendix 1](#_bookmark300) to this Guide must be used, even if no reference is made to the use of that chart.\n\n## CALCULATING THE ASSESSMENT\n\n","sortOrder":10},{"sectionNumber":"51","sectionType":"section","heading":"Where relevant, a statement is included in the chapters of [Division 1](#_DIVISION_1__) which indicates:","content":"51         Where relevant, a statement is included in the chapters of [Division 1](#_DIVISION_1__) which indicates:\n\na)      the manner in which tables within that chapter may (or may not) be combined; and\n\nb)      whether an assessment made in that chapter can be combined with an assessment made in another chapter in assessing the degree of whole person impairment.\n\n52         There are some special circumstances where addition of scores rather than combination is required. These circumstances are specified in the relevant chapters in this Guide.\n\n## ORDERING OF ADDITIONAL INVESTIGATIONS\n\n53         As a general principle, the assessor should not order additional radiographic or other investigations solely for impairment evaluation purposes, unless the investigations are specifically required in the relevant chapter of this Guide.\n\n## EXCEPTIONS TO USE OF THIS GUIDE\n\n54         In the event that an impairment is of a kind that cannot be assessed in accordance with the provisions of this Guide, the assessment is to be made under the AMA5.\n\n","sortOrder":11},{"sectionNumber":"55","sectionType":"section","heading":"An assessment is not to be made using the AMA5 for:","content":"55         An assessment is not to be made using the AMA5 for:\n\na)      mental and behavioural impairments (psychiatric conditions) – see [Chapter 5 – Psychiatric conditions](#_CHAPTER_5__);\n\nb)      impairments of the visual system – see [Chapter 6 – The visual system](#_CHAPTER_6__);\n\nc)       hearing impairment – see [Chapter 7 – Ear, nose and throat disorders](#_CHAPTER_7__); or\n\nd)      chronic pain conditions, except in the case of migraine or tension headaches – see [Section 9.13.3 (Chronic pain](#_Chronic_pain_conditions) [conditions)](#_bookmark203).\n\n56         In the event that an impairment is of a kind that cannot be assessed in accordance with either the provisions of this Guide or the AMA5 (that is, where an assessment of 0% or more is not possible), the assessor should use their use clinical judgment, comparing measurable permanent impairment resulting from the injury to measurable permanent impairment resulting from similar conditions with similar impairment of body part, system or function.\n\n57         For further information relating to the application of this Guide, please contact the Seacare Authority Secretariat on 02 6275 0070 or email <seacare@comcare.gov.au>.\n\n# LIST OF REFERENCES\n\n58         Abramson MJ et al, 1996, ‘Evaluation of impairment, disability and handicap caused by respiratory disease’, Australian and New Zealand Journal of Medicine, 26, 697-701.\n\n59         American Academy of Sleep Medicine, 1999, ‘Sleep related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research’, Sleep, 22, 667-689.\n\n60         American Medical Association, 1995, Guides to the Evaluation of Permanent Impairment, 4th edition, Chicago: American Medical Association.\n\n61         American Medical Association, 2001, Guides to the Evaluation of Permanent Impairment, 5th edition, Chicago: American Medical Association.\n\n62         American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria, 1986, ‘Evaluation of impairment/ disability secondary to respiratory disorders’, American Review of Respiratory Diseases, 133, 1205-09\n\n63         American Thoracic Society, 1993, ‘Guidelines for the evaluation of impairment/disability in patients with asthma’, American Review of Respiratory Diseases, 147, 1056-61.\n\n64         Cummings J, Mega M, Gray K, Rosenberg-Thompson S, Carusi D, Gornbein J, ‘The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia’, Neurology, 1994, 44, 2308-2314.\n\n65         Ensalada LH, ‘Complex regional pain syndrome’, in Brigham CR, ed, The Guides Casebook, Chicago, Ill: American Medical Association, 1999, 14.\n\n","sortOrder":12},{"sectionNumber":"66","sectionType":"section","heading":"Johns MW, 1991, ‘A new method for measuring daytime sleepiness: the Epworth sleepiness scale’, Sleep, 14, 540-5.","content":"66         Johns MW, 1991, ‘A new method for measuring daytime sleepiness: the Epworth sleepiness scale’, Sleep, 14, 540-5.\n\n","sortOrder":13},{"sectionNumber":"67","sectionType":"section","heading":"Morris JC, 1993, ‘The Clinical Dementia Rating (CDR): current version and scoring rules’, Neurology, 43(11), 2412-2414.","content":"67         Morris JC, 1993, ‘The Clinical Dementia Rating (CDR): current version and scoring rules’, Neurology, 43(11), 2412-2414.\n\n68         National Asthma Council, 2002, Asthma Management Handbook 2002, 5th edition, Melbourne: National Asthma Council of Australia.\n\n# GLOSSARY\n\nIn this Guide:\n\nActivities of daily living means those activities that an employee needs to perform to function in a non-specific environment (that is, to live). Performance of activities of daily living is measured by reference to primary biological and psychosocial function.\n\nAggravation includes acceleration or recurrence (Seafarers Act, subsection 3(1)). See also the [Principles of Assessment](#_bookmark9).\n\nAilment means any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development) (Seafarers Act, subsection 3(1)).\n\nAMA4 means the Fourth Edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (1995) and any errata published prior to the commencement date.\n\nAMA5 means the Fifth Edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (2001) and any errata published prior to the commencement date.\n\nAssessor in relation to an employee means:\n\na)       a legally qualified medical practitioner or audiologist, other than the employee, who is registered to practise a health profession with the Australian Health Practitioner Regulation Agency;\n\nb)       the employer in relation to the employee;\n\nc)       a member within the meaning of section 3 of the Administrative Appeals Tribunal Act 1975.\n\nBinaural hearing loss means hearing loss affecting both ears. For the purposes of this Guide, binaural hearing loss does not include tinnitus.\n\nCommencement date has the meaning given in section 2 of the instrument titled Seafarers Rehabilitation and Compensation Act 1992 – Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0.\n\nDisease has its ordinary meaning in [Division 1](#_DIVISION_1__) of this Guide.\n\nImpairment means the loss, the loss of the use, or the damage or malfunction, of any part of the body or of any bodily system or function or part of such system or function (Seafarers Act, subsection 3(1)). See also the [Principles of Assessment](#_bookmark9).\n\nInjury in relation to an employee means an injury suffered by the employee in respect of which compensation is payable under the Seafarers Act (Seafarers Act, subsection 3(1) and sections 6 and 7; Seafarers Rehabilitation and Compensation (Transitional Provisions and Consequential Amendments) Act 1992, sections 6 and 7).\n\nLoss of amenities in relation to an employee means the effects on the employee’s mobility, social relationships and recreation and leisure activities. See also the [Principles of Assessment](#_bookmark9).\n\nMedical treatment has its ordinary meaning in [Division 1](#_DIVISION_1__) of this Guide.\n\nNon-economic loss (NEL) in relation to an employee who has suffered an injury resulting in a permanent impairment, means loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware (Seafarers Act, subsection 3(1)). See also the [Principles of Assessment](#_bookmark9).\n\nPain means physical pain.\n\nPermanent means ‘likely to continue indefinitely’ (Seafarers Act, subsection 3(1)). See also the [Principles of Assessment](#_bookmark9).\n\nSeafarers Act means the Seafarers Rehabilitation and Compensation Act 1992.\n\nSuffering means the mental distress resulting from the injury or impairment.\n\nWhole person impairment (WPI) is the methodology used for expressing the degree of impairment of an employee, resulting from an injury, as a percentage. WPI is based on the AMA5. WPI is a medical quantification of the nature and extent of the effect of an injury on the employee’s functional capacity including activities of daily living. This Guide presents descriptions of impairments in chapters and tables according to body system. The extent of each impairment is expressed as a percentage value of the functional capacity of a normal healthy person. See also the [Principles of Assessment](#_bookmark9).\n\n# DIVISION 1 – ASSESSMENT OF THE DEGREE OF THE PERMANENT IMPAIRMENT OF AN EMPLOYEE RESULTING FROM AN INJURY\n\n## CHAPTER 1 – THE CARDIOVASCULAR SYSTEM\n\n### 1.0        Introduction\n\n69         In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n70         WPI ratings derived from tables in this chapter may be combined with WPI ratings from other tables where there is co-existent disease (for example, cardiomyopathy, ischaemic heart disease, congenital heart disease, valvular heart disease).\n\n71         For the purposes of [Chapter 1 – The cardiovascular system](#_CHAPTER_1__), activities of daily living are those in [Figure 1-A](#Figure_1_A).\n\nFigure 1-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\n72         [Chapter 1 – The cardiovascular system](#_CHAPTER_1__) does not cover impairments arising from cardiomyopathy, congenital heart disease, valvular heart disease, and pericardial heart disease. Where relevant, the degree of impairment arising from these conditions should be assessed in accordance with the appropriate table from the AMA5.\n\n73         For post-thrombotic syndrome, assessments under [Table 1.4: Peripheral vascular disease of the lower extremities](#Table_1_4) and [Table 1.5: Peripheral vascular disease of the upper extremities](#Table_1_5) are an alternative to [Table 13.4: Thrombotic disorders](#Table_13_4) (see [Chapter 13 – The haematopoietic system](#_CHAPTER_13__)). WPI ratings from Table 1.4 and Table 1.5 may not be combined with a WPI rating from Table 13.4. Table 1.4 and Table 1.5 should be used as the primary guide for assessing peripheral complications of thrombosis.\n\n74         Employees who have permanent cardiac limitation secondary to massive pulmonary embolism should be assessed under [Chapter 1 – The cardiovascular system](#_CHAPTER_1__). A WPI rating assessed in these circumstances may not be combined with a rating from [Table 13.4: Thrombotic disorders](#_bookmark280).\n\n### 1.1        Coronary artery disease\n\n","sortOrder":14},{"sectionNumber":"75","sectionType":"section","heading":"Steps for assessment are as follows.","content":"75         Steps for assessment are as follows.\n\n| Step 1 | Using [Figure 1-B: Symptomatic level of activity in METS according to age and gender](#Figure_1_B), assess the symptomatic level of activity in METS according to age and gender. Figure 1-B may be used to assess conditions affecting left ventricular function (LVF) (including ischaemic heart disease, rheumatic heart disease, and hypertension). |\n| Step 2 | Using [Table 1.1: Coronary artery disease](#Table_1_1), refer to any one of pathology (column 3), drug therapy (column 4), or intervention (column 5), to identify the degree of impairment within the range of impairments for that symptomatic level of activity. |\n\n76         [Figure 1-B: Symptomatic level of activity in METS according to age and gender](#_bookmark22) may be used for the assessment of symptomatic impairment caused by ischaemic heart disease, hypertension, cardiomyopathy, or rheumatic heart disease.\n\nFigure 1-B: Symptomatic level of activity in METS according to age and gender\n\n- Age and gender Symptomatic level of activity in METS\n- 1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 10+\n- 18-30 M D D D C C B B B A A\n- 18-30 F D D C C B B A A A\n- 31-40 M D D D C C B B A A\n- 31-40 F D D C B B B A\n- 41-50 M D D C C B B A A\n- 41-50 F D D C B B A A\n- 51-60 M D D C B B A A A\n- 51-60 F D D C B B A A\n- 61-70 M D D C B B A A\n- 61-70 F D D B B A A\n- 70+ M D C B B A\n- 70+ F D C B A A\n\nTable 1.1: Coronary artery disease\n\nSee notes to Table 1.1 for further details regarding abbreviations and symbols used in columns 3, 4 and 5.\n\n| Column 1<br>%WPI | Column 2<br>Level of activity in METS for age and gender | Column 3<br>Pathology | Column 4<br>Drug therapy | Column 5<br>Intervention |\n| 5 | A | Not applicable | Not applicable | Not applicable |\n| 10 | A | + | + | Not applicable |\n| 15 | A | ++ | ++ | PTCA |\n| 20 | A | +++ | +++ | CABG/Tx |\n| 25 | B | + | + | Not applicable |\n| 30 | B | ++ | ++ | PTCA |\n| 40 | B | +++ | +++ | CABG/Tx |\n| 50 | C | + | + | Not applicable |\n| 60 | C | ++ | ++ | PTCA |\n| 65 | C | +++ | +++ | CABG/Tx |\n| 75 | D | + | + | Not applicable |\n| 85 | D | ++ | ++ | PTCA |\n| 95 | D | +++ | +++ | CABG/Tx |\n\nNotes to Table 1.1\n\n1. In Table 1.1, ‘not applicable’ means the criterion is not applicable to the specified level of impairment.\n2. Pathology – column 3.\n\n(i)        Coronary artery disease:\n\n+ either <50% stenosis in one or more coronary arteries, or single vessel disease >50% stenosis (except proximal left anterior descending (LAD) and left main coronary artery (LMCA)\n\n++ either >50% stenosis in two vessels, or >50% stenosis in proximal LAD, or <50% stenosis in LMCA\n\n+++ either >50% stenosis in 3 vessels, or LMCA >50% stenosis, or severe diffuse end organ disease.\n\n(ii)      Ischaemic left ventricular dysfunction:\n\n+ left ventricular ejection fraction (LVEF) 40-50%\n\n++ LVEF 30-40%\n\n+++ either LVEF <30%, or LV aneurysm.\n\n(iii)     Myocardial infarction (MI):\n\n+ no previous MI\n\n++ previous possible MI (equivocal changes in ECG/cardiac enzymes)\n\n+++ previous definite MI (unequivocal changes in ECG/cardiac enzymes: typical evolution of ST/T segments, or development of significant Q waves, or enzyme rise >3 times upper limit of normal).\n\n(iv)     Arrhythmias:\n\nAssessed under [Table 1.3: Arrhythmias](#Table_1_3).\n\n3.     Drug therapy (continuous) – column 4:\n\n+ one or two drugs\n\n++ three or four drugs\n\n+++ five or more drugs.\n\n4.     Intervention – column 5:\n\n‘PTCA’ means percutaneous transluminal coronary angioplasty and/or stenting.\n\n‘CABG’ means coronary artery bypass grafting.\n\n‘Tx’ means heart transplant.\n\n### 1.2        Hypertension\n\n77         Either diastolic hypertension (see [Section 1.2.1](#_Diastolic_hypertension)) or systolic hypertension (see [Section 1.2.2](#_Systolic_hypertension)) may be assessed, whichever provides the higher WPI rating.\n\n#### 1.2.1    Diastolic hypertension\n\n","sortOrder":15},{"sectionNumber":"78","sectionType":"section","heading":"Hypertensive cardiomyopathy can be assessed using the AMA5.","content":"78         Hypertensive cardiomyopathy can be assessed using the AMA5.\n\n79         Functional class (assessed in accordance with [Figure 1-B: Symptomatic level of activity in METS according to age and gender](#Figure_1_B)) is the primary criterion for assessment. Level of diastolic blood pressure (DBP) and therapy (see [Table 1.2.1: Diastolic hypertension](#Table_1_2_1)) are secondary criteria for assessment.\n\n80         For assessment use either usual DBP, or therapy, for a given functional class, whichever provides the greater WPI rating. If DBP is consistently >120 on optimal therapy, one higher functional class may be assigned.\n\nTable 1.2.1: Diastolic hypertension\n\nSee note to Table 1.2.1 for explanation of symbols used in the final column (drug therapy).\n\n| %WPI | Level of activity in METS<br>for age and gender | Usual DBP | Drug therapy |\n| 5 | A | >90 | + |\n| 10 | A | >100 | ++ |\n| 15 | A | >110 | +++ |\n| 20 | B | >90 | + |\n| 25 | B | >100 | ++ |\n| 30 | B | >110 | +++ |\n| 35 | C | >90 | + |\n| 40 | C | >100 | ++ |\n| 45 | C | >110 | +++ |\n| 50 | D | >90 | + |\n| 55 | D | >100 | ++ |\n| 60 | D | >110 | +++ |\n\nNote to Table 1.2.1\n\n5.     Drug therapy (continuous) – final column of Table 1.2.1:\n\n+ one drug\n\n++ two drugs\n\n+++ three or more drugs.\n\n#### 1.2.2    Systolic hypertension\n\n","sortOrder":16},{"sectionNumber":"81","sectionType":"section","heading":"Hypertensive cardiomyopathy can be assessed using the AMA5.","content":"81         Hypertensive cardiomyopathy can be assessed using the AMA5.\n\n82         Functional class (assessed in accordance with [Figure 1-B: Symptomatic level of activity in METS according to age and gender](#Figure_1_B)) is the primary criterion for assessment. Level of systolic blood pressure (SBP) and therapy (see [Table 1.2.2: Systolic hypertension](#Table_1_2_2)) are secondary criteria for assessment.\n\nTable 1.2.2: Systolic hypertension\n\nSee note to Table 1.2.2 for explanation of symbols used in the final column (drug therapy).\n\n| %WPI | Symptomatic level of activity in METS for age and gender | Usual SBP | Drug therapy |\n| 5 | A | >160 | + |\n| 10 | A | >160 | ++ |\n| 15 | A | >160 | +++ |\n| 20 | B | >170 | + |\n| 25 | B | >170 | ++ |\n| 30 | B | >170 | +++ |\n| 35 | C | >180 | + |\n| 40 | C | >180 | ++ |\n| 45 | C | >180 | +++ |\n| 50 | D | >190 | + |\n| 55 | D | >190 | ++ |\n| 60 | D | >190 | +++ |\n\nNote to Table 1.2.2\n\n1. Drug therapy (continuous) – final column of Table 1.2.2:\n\n+ one drug\n\n++ two drugs\n\n+++ three or more drugs.\n\n### 1.3        Arrhythmias\n\n","sortOrder":17},{"sectionNumber":"83","sectionType":"section","heading":"Underlying cardiac disease can be assessed using other tables in [Chapter 1 – The cardiovascular system](#_bookmark19).","content":"83         Underlying cardiac disease can be assessed using other tables in [Chapter 1 – The cardiovascular system](#_bookmark19).\n\n84         Functional class (assessed under [Figure 1-C: Definitions of functional class](#Figure_1_C)), and therapy (see [Table 1.3: Arrhythmias](#Table_1_3)), are used to assess the WPI rating.\n\nFigure 1-C: Definitions of functional class\n\n| Functional class | Symptoms (all required) |\n| I | No limitation of physical activity. |\n| II | Slight limitation of physical activity.<br>Comfortable at rest and with ordinary, light activities of daily living.<br>Greater activity causes symptoms. |\n| III | Marked limitation of physical activity.<br>Comfortable at rest.<br>Ordinary activity causes symptoms. |\n| IV | Inability to carry out any physical activity without discomfort. |\n\nTable 1.3: Arrhythmias\n\nSee note to Table 1.3 for explanation of symbols used in the final column (therapy).\n\n| %WPI | Functional class | Therapy |\n| 5 | I | Nil |\n| 10 | I | Drug(s) |\n| 15 | I | Surgery/cath/PPM/Device |\n| 20 | II | Nil |\n| 30 | II | Drug(s) |\n| 40 | II | Surgery/cath/PPM/Device |\n| 45 | III | Nil |\n| 50 | III | Drug(s) |\n| 55 | III | Surgery/cath/PPM/Device |\n| 60 | IV | Not applicable |\n\nNote to Table 1.3\n\n1. Therapy – final column of Table 1.3:\n\n‘cath’ means either catheter ablation or catheter-associated therapy for arrhythmia.\n\n‘PPM’ means permanent pacemaker.\n\n‘Device’ means implanted defibrillator.\n\n### 1.4        Peripheral vascular disease of the lower extremities\n\n85         Amputees should not be assessed under [Table 1.4: Peripheral vascular disease of the lower extremities](#_bookmark36). They should be assessed under [Table 9.5: Lower extremity amputations](#Table_9_5) (see [Chapter 9 – The musculoskeletal system](#_CHAPTER_9__)).\n\n86         A WPI rating from [Table 1.4: Peripheral vascular disease of the lower extremities](#_bookmark36) may not be combined with a WPI rating from [Table 13.4: Thrombotic disorders](#_bookmark280) (see [Chapter 13 – The haematopoietic system](#_CHAPTER_13__)).\n\nTable 1.4: Peripheral vascular disease of the lower extremities\n\n| %WPI | Signs and symptoms |\n| 0 | The employee experiences neither intermittent claudication nor ischaemic pain at rest. |\n| 5 | The employee has no difficulty with distances but experiences ischaemic pain on climbing either steps or gradients. |\n| 10 | The employee experiences claudication on walking 200m or more at an average pace on level ground. |\n| 20 | The employee experiences claudication on walking more than 100m but less than 200m at average pace on level ground. |\n| 30 | The employee experiences claudication on walking more than 75m but less than 100m at average pace on level ground. |\n| 40 | The employee experiences claudication on walking more than 50m but less than 75m at average pace on level ground. |\n| 50 | The employee experiences claudication on walking more than 25m but less than 50m at average pace on level ground. |\n| 60 | The employee experiences claudication on walking less than 25m at average pace on level ground. |\n| 70 | The employee experiences ischaemic pain at rest. |\n\n### 1.5        Peripheral vascular disease of the upper extremities\n\n87         Amputees should not be assessed under [Table 1.5: Peripheral vascular disease of the upper extremities](#_bookmark38). They should be assessed under [Table 9.12.1: Upper extremity amputations](#Table_9_12_1) or [Table 9.12.2: Amputation of digits](#Table_9_12_2) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)).\n\n88         A WPI rating from [Table 1.5: Peripheral vascular disease of the upper extremities](#_bookmark38) may not be combined with a WPI rating from [Table 13.4: Thrombotic disorders](#_bookmark280) (see [Chapter 13 – The haematopoietic system](#_CHAPTER_13__)).\n\nTable 1.5: Peripheral vascular disease of the upper extremities\n\n| %WPI | Symptoms | Signs |\n| 5 | Either no claudication or transient oedema. | Calcification of arteries on X-ray. |\n| 10 | Either no claudication or persistent oedema controlled by support. | Dilatation of either arteries or veins. |\n| 15 | As above. | Either loss of pulse or healed ulcer or surgery. |\n| 20 | Either claudication on strenuous exercise or persistent oedema uncontrolled by support. | Either calcification of arteries on X-ray or dilatation of either arteries or veins. |\n| 30 | As above. | Superficial ulcer. |\n| 40 | As above. | Either deep or widespread ulcer or surgery. |\n| 45 | Claudication on mild-moderate exertion. | Either calcification of arteries on X-ray or dilatation of either arteries or veins. |\n| 50 | As above. | Superficial ulcer. |\n| 55 | As above. | Either deep or widespread ulcer or surgery. |\n| 60 | Rest pain or unable to exercise. | Not applicable |\n\n### 1.6        Raynaud’s disease\n\n89         Functional class (assessed in accordance with [Figure 1-C: Definitions of functional class](#Figure_1_C)) is the primary criterion for assessment. Signs of vasospastic disease and therapy (see [Table 1.6: Raynaud’s disease](#Table_1_6)) are secondary criteria for assessment.\n\nFigure 1-C: Definitions of functional class\n\nSee note to Figure 1-C for further information.\n\n| Functional class | Symptoms (all required) |\n| I | No limitation of physical activity. |\n| II | Slight limitation of physical activity.<br>Comfortable at rest and with ordinary, light activities of daily living.<br>Greater activity causes symptoms. |\n| III | Marked limitation of physical activity.<br>Comfortable at rest.<br>Ordinary activity causes symptoms. |\n| IV | Inability to carry out any physical activity without discomfort. |\n\nNote to Figure 1-C\n\n1. Figure 1-C also appears in [Section 1.3 (Arrhythmias)](#_Arrhythmias). It is repeated here for ease of reference\n\nTable 1.6: Raynaud’s disease\n\nSee note to Table 1.6 for further information.\n\n| %WPI | Functional class | Signs | Therapy |\n| 5 | I | Nil. | Nil. |\n| 10 | I | Nil. | Drug(s). |\n| 15 | I | Nil. | Surgery. |\n| 20 | II | Neither ulceration nor trophic changes. | Drug(s). |\n| 25 | II | Either ulceration or trophic changes. | Drug(s). |\n| 30 | II | Not applicable | Surgery. |\n| 35 | III | Neither ulceration nor trophic changes. | Drug(s). |\n| 40 | III | Either ulceration or trophic changes. | Drug(s). |\n| 45 | III | Not applicable | Surgery. |\n| 50 | IV | Not applicable | Not applicable |\n\nNote to Table 1.6\n\n1. Therapy – final column of Table 1.6:\n\n‘Surgery’ includes sympathectomy and local debridement.\n\n‘Drug(s)’ means continuous therapy with one or more drugs.\n\n## CHAPTER 2 – THE RESPIRATORY SYSTEM\n\n### 2.0        Introduction\n\n90         In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n","sortOrder":18},{"sectionNumber":"91","sectionType":"section","heading":"The measure of impairment is the reduction in physiological function below that found in health.","content":"91         The measure of impairment is the reduction in physiological function below that found in health.\n\n92         Respiratory impairment is quantified by the degree to which measurements of respiratory function are changed by the compensable injury or injuries, relative to values obtained in a healthy reference population of similar individuals.\n\n93         Conditions such as chronic obstructive airways disease and chronic bronchitis are to be assessed according to the methods used to measure loss of respiratory function.\n\n94         Employees who have permanent respiratory limitation secondary to massive pulmonary embolism should be assessed under [Chapter 2 – The respiratory system](#_CHAPTER_2__). Any WPI rating awarded in these circumstances may not be combined with a WPI rating from [Table 13.4: Thrombotic disorders](#_bookmark280) (see [Chapter 13 – The haematopoietic system](#_CHAPTER_13__)).\n\n### 2.1        Assessing impairment of respiratory function\n\n#### 2.1.1    Measurements\n\n","sortOrder":19},{"sectionNumber":"95","sectionType":"section","heading":"The most commonly recommended measurements for determining respiratory impairment are:","content":"95         The most commonly recommended measurements for determining respiratory impairment are:\n\na)      spirometry with measurement of the forced expiratory volume at 1 second (FEV1) and forced vital capacity (FVC); and\n\nb)      the transfer factor, or diffusing capacity of the lung, for carbon monoxide (TlCO), measured by the single breath method.\n\n","sortOrder":20},{"sectionNumber":"96","sectionType":"section","heading":"However, the measurements used must be derived from either:","content":"96         However, the measurements used must be derived from either:\n\na)      the tests prescribed below where relevant (for example, in assessing asthma); or\n\nb)      where a test is not prescribed, from tests appropriate to assessing the impairments caused by the particular compensable condition or conditions.\n\n","sortOrder":21},{"sectionNumber":"97","sectionType":"section","heading":"Other measurements commonly used to assess impairment include:","content":"97         Other measurements commonly used to assess impairment include:\n\na)      the lung volumes;\n\nb)      total lung capacity (TLC) and residual volume (RV); and\n\nc)       the response to a maximum exercise test including measurement of the oxygen consumption at the maximum workload able to be achieved (VO2 max), and the degree of arterial oxygen desaturation during exercise.\n\n","sortOrder":22},{"sectionNumber":"98","sectionType":"section","heading":"On occasion, other measurements may be needed to define impairment accurately. For example:","content":"98         On occasion, other measurements may be needed to define impairment accurately. For example:\n\na)      the elastic and flow resistive properties of the lungs;\n\nb)      respiratory muscle strength;\n\nc)       arterial blood gases;\n\nd)      polysomnography (sleep studies);\n\ne)      echocardiography with estimation of pulmonary artery pressure; and\n\nf)        quantitative ventilation-perfusion scans of the lung.\n\n99         Measurement of the partial pressures of oxygen and carbon dioxide in arterial blood (PaO2 and PaCO2 respectively) are not usually required to assign impairment ratings accurately. However, individual variation may result in severe impairment in gas exchange when other measures of function indicate only moderate impairment. Arterial PaO2 of <55mm Hg and/or PaCO2 >50mm Hg, despite optimal treatment, is evidence of severe impairment and attracts a WPI rating of 70%.\n\n","sortOrder":23},{"sectionNumber":"100","sectionType":"section","heading":"Measurements of arterial blood gases should be performed on two occasions, with the employee seated.","content":"100     Measurements of arterial blood gases should be performed on two occasions, with the employee seated.\n\n#### 2.1.2    Methods of measurement\n\n101     Measurements must be performed in a manner consistent with the methods used by a respiratory function laboratory accredited by one or more of the following bodies:\n\na)      the Thoracic Society of Australia and New Zealand;\n\nb)      the Australasian Sleep Association; or\n\nc)       the Australian Council on Healthcare Standards.\n\n102     Methods of measurement should conform to internationally recognised standards in relation to the equipment used, the procedure, and analysis of the data. Reference values (‘predicted’ normal values) should be representative of the healthy population and be appropriate for ethnicity where possible. Laboratories providing measurements used to assess impairment should state the method(s) of measurement used, and the source of the reference values used.\n\n#### 2.1.3    Impairment rating\n\n103     Several professional groups have published criteria for rating the severity of impairment based on spirometry, gas transfer and VO2 max. These professional groups include the Thoracic Society of Australia and New Zealand (Abramson, 1996), the American Thoracic Society (American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria, 1986), and the American Medical Association (2001). In general, measurements are expressed as a percentage of the predicted value (%P) and, where several measurements are performed, the most abnormal result is used to classify the degree of impairment.\n\n104     Severity of impairment is rated as shown in [Table 2.1: Conversion of respiratory function values to impairment](#Table_2_1). This generic table can be used to assign WPI ratings using any valid measurement for which there are predicted normal data.\n\nTable 2.1: Conversion of respiratory function values to impairment\n\nSee note to Table 2.1 for further information.\n\n| %WPI | Respiratory function %P |\n| 0 | >85 |\n| 10 | 85 to 76 |\n| 20 | 75 to 66 |\n| 30 | 65 to 56 |\n| 40 | 55 to 51 |\n| 50 | 50 to 44 |\n| 60 | 45 to 41 |\n| 70 | 40 to 36 |\n| 80 | ≤35 |\n\nNote to Table 2.1\n\n1. %P = percentage of mean value for healthy individuals of the same age, height and sex.\n\n### 2.2        Asthma and other hyper-reactive airways diseases\n\n105     Assessment of impairment due to asthma can be confounded by the natural history of occupational asthma, by variably severe airflow obstruction, and therefore variable FEV1, and by response to treatment.\n\n","sortOrder":24},{"sectionNumber":"106","sectionType":"section","heading":"For hyper-reactivity of airways due to occupational exposures, assessment of impairment is made after:","content":"106     For hyper-reactivity of airways due to occupational exposures, assessment of impairment is made after:\n\na)      the diagnosis and cause are established;\n\nb)      exposure to the provoking factors is eliminated; and\n\nc)       appropriate treatment of asthma is implemented.\n\n107     Appropriate treatment follows the guidelines in the Asthma Management Handbook 2002 (National Asthma Council, 2002, 5th edition, Melbourne: National Asthma Council of Australia), a later edition of those guidelines, or later guidelines widely accepted by the medical profession as representing best practice.\n\n108     Permanent impairment should not be assessed until 2 years after cessation of exposure to provoking factors as severity may decrease during this period.\n\n109     An impairment rating scale is set out in [Figure 2-A: Calculating asthma impairment score](#Figure_2_A) and [Table 2.2: WPI derived from asthma impairment score](#Table_2_2). The scale used in Figure 2-A and Table 2.2 is modified to account for frequency of increased impairment from asthma despite optimal treatment.\n\n","sortOrder":25},{"sectionNumber":"110","sectionType":"section","heading":"A score reflecting impairment from asthma is calculated by:","content":"110     A score reflecting impairment from asthma is calculated by:\n\na)      adding the points scored for reduction in FEV1 %P;\n\nand either\n\ni)        change in FEV1 with bronchodilator (reversibility);\n\nor\n\nii)      degree of bronchial hyperreactivity defined by the cumulative dose of metacholine, or histamine, required to decrease baseline FEV1 by at least 20%;\n\nand\n\nb)      measurement of FEV1, or peak flow (PF) rate, measured by the employee morning and evening, before and after aerosol bronchodilator, for at least 30 days.\n\n111     The number of days on which any valid measurement of FEV1 or PF is less than 0.85 x the mean of the six highest values of FEV1 or PF during the monitoring period is to be expressed as a percentage of total days in the monitoring period.\n\n112     The maximum impairment score from [Figure 2-A: Calculating asthma impairment score](#Figure_2_A) is 11. One additional point is given, yielding a score of 12, if asthma cannot be controlled adequately with maximal treatment. The score from Figure 2-A is converted to a WPI rating using [Table 2.2: WPI derived from asthma impairment score](#Table_2_2).\n\nFigure 2-A: Calculating asthma impairment score\n\nSee notes to Figure 2-A for further information.\n\n| Score | FEV1, % P  after bronchodilator | FEV1, % change in FEV1  with bronchodilator | PD20 or µmol | % of days lowest FEV1*  is ≤0.85 highest FEV1 |\n| 0 | >85 | <10 | >4.0 | <6 |\n| 1 | 76 to 85 | 10 to 19 | 0.26 to 4.0 | 6 to 24 |\n| 2 | 66 to 75 | 20 to 29 | 0.063 to 0.25 | 25 to 34 |\n| 3 | 56 to 65 | ≥30 | ≤ 0.062 | 35 to 44 |\n| 4 | ≤55 |  |  | ≥45 |\n\nNotes to Figure 2-A\n\n1. Figure 2-A is based on scales proposed by: the American Thoracic Society (1993), as adapted in Tables 5-9 and 5-10 of the AMA5; and the Thoracic Society of Australia and New Zealand (Abramson, 1996).\n\n2.     %P = percent predicted normal value.\n\n3.     PD20 = cumulative dose of inhaled metacholine aerosol causing a 20% decrease in FEV1.\n\n4.     * monitored twice daily before and after aerosol bronchodilator for at least 30 days during adequate treatment.\n\n5.     % of days = proportion of days any value of FEV1 (or of peak flow rate) is less than highest repeatable FEV1 (or peak flow rate) x 0.85.\n\nTable 2.2: WPI derived from asthma impairment score\n\n| %WPI | Asthma impairment score |\n| 0 | 0 |\n| 10 | 1 |\n| 20 | 2 |\n| 30 | 3 |\n| 40 | 4 |\n| 45 | 5 |\n| 50 | 6 |\n| 55 | 7 |\n| 60 | 8 |\n| 65 | 9 |\n| 70 | 10 |\n| 75 | 11 |\n| 80 | 12 |\n\n### 2.3        Lung cancer and mesothelioma\n\n113     Employees with lung cancers (other than mesothelioma) are considered severely impaired at the time of diagnosis and are given a WPI rating of 70%.\n\n114     If there is evidence of tumour, or if tumour recurs one year after diagnosis is established, then the employee remains severely impaired and the WPI rating is increased to 80%.\n\n","sortOrder":26},{"sectionNumber":"115","sectionType":"section","heading":"Employees with mesothelioma are considered severely impaired and a WPI rating of 85% is awarded upon diagnosis.","content":"115     Employees with mesothelioma are considered severely impaired and a WPI rating of 85% is awarded upon diagnosis.\n\n### 2.4        Breathing disorders associated with sleep\n\n116     Some disorders such as obstructive sleep apnoea, central sleep apnoea, and hypoventilation during sleep, can cause impairment which is not quantifiable by standard measurements of respiratory function such as spirometry, diffusing capacity, or response to exercise.\n\n117     Obstructive sleep apnoea should be assessed using [Table 2.4: WPI derived from obstructive sleep apnoea score](#Table_2_4). Central sleep apnoea should be assessed using [Table 12.1.3: Sleep and arousal disorders](#Table_12_1_3) (see [Chapter 12 –](#_bookmark241)[The neurological system](#_CHAPTER_12__)).\n\n118     An overnight sleep study is used to define the severity of sleep-related disorders of breathing and can be used to define impairment after appropriate treatment has been implemented. During the overnight sleep study there is continuous monitoring of breathing pattern, respiratory effort, arterial oxygen saturation, electrocardiogram, and sleep state. Results of sleep studies cannot readily be expressed in terms of a percentage of predicted values. Consequently, impairment is rated by assigning scores to the degree of abnormality at sleep study ([Figure 2-B: Calculating obstructive sleep apnoea score](#Figure_2_B) and [Table 2.4: WPI derived from obstructive sleep apnoea score](#Table_2_4)). These ratings are based on frequency of disordered breathing, frequency of sleep disturbance, degree of hypoxaemia and, as appropriate, hypercapnoea during sleep. In addition, degree of daytime sleepiness is assessed using the Epworth sleepiness scale (Johns, 1991).\n\n119     Where vascular morbidity is present (for example, high blood pressure or myocardial infarction) and is attributable to sleep apnoea, impairment should be assessed using the relevant table in [Chapter 1 – The cardiovascular system](#_CHAPTER_1__).\n\n120     The total score derived from [Figure 2-B: Calculating obstructive sleep apnoea score](#Figure_2_B) is the sum of the scores from each column: the maximum score is 12. This score is converted to a WPI rating using [Table 2.4: WPI derived from obstructive sleep apnoea score](#Table_2_4).\n\nFigure 2-B: Calculating obstructive sleep apnoea score\n\nSee notes Figure 2-B for further information.\n\n| Score | Epworth sleepiness score | Apnoeas +  hypopnoeas/hr of sleep | Respiratory arousals*  /hr of sleep | Cumulative sleep time, mins, with SaO2 <90% # |\n| 0 | <5 | <5 | <5 | 0 |\n| 1 | 5 to 10 | 5 to 15 | 5 to 15 | <15 |\n| 2 | 11 to 17 | 16 to 30 | 16 to 30 | 15 to 45 |\n| 3 | >17 | >30 | >30 | >45 |\n\nNotes to Figure 2-B\n\n1. * An arousal within 3 seconds of a sequence of breaths which meet the criteria for an apnoea, an hypopnoea, or a respiratory effort related arousal, as defined by the American Academy of Sleep Medicine (1999).\n\n2.     # SaO2 = arterial oxygen saturation measured with a pulse oximeter.\n\nTable 2.4: WPI derived from obstructive sleep apnoea score\n\n| %WPI | Sleep apnoea score |\n| 0 | 0 |\n| 10 | 1 |\n| 20 | 2 |\n| 30 | 3 |\n| 40 | 4 |\n| 45 | 5 |\n| 50 | 6 |\n| 55 | 7 |\n| 60 | 8 |\n| 65 | 9 |\n| 70 | 10 |\n| 75 | 11 |\n| 80 | 12 |\n\n## CHAPTER 3 – THE ENDOCRINE SYSTEM\n\n### 3.0        Introduction\n\n121     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n122     The impairment resulting from an endocrine system condition (such as peripheral neuropathy, or peripheral vascular disease) must also be assessed under the relevant tables in other chapters, including tables in [Chapter 10 – The urinary system](#_CHAPTER_10__).\n\n123     In this circumstance, using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings derived from the relevant tables in other chapters are combined with WPI ratings from tables in [Chapter 3 – The endocrine system](#_CHAPTER_3__).\n\n### 3.1        Thyroid and parathyroid glands\n\n124     Hyperthyroidism is not considered to cause permanent impairment because the condition is usually amenable to treatment. Where visual and/or cosmetic effects resulting from exophthalmos persist following correction of the hyperthyroidism, a WPI rating may be derived from:\n\na)      [Chapter 4 – Disfigurement and skin disorders](#_CHAPTER_4__); and\n\nb)      [Chapter 6 – The visual system](#_bookmark75) (see [Section 6.5 (Other conditions causing permanent deformities causing up to 10% of the whole person)](#_bookmark92)).\n\n125     Hyperparathyroidism is usually amenable to correction by surgery. If surgery fails, or the employee cannot undergo surgery for sound medical reasons, long-term therapy may be needed. If so, permanent impairment can be assessed after stabilisation of the condition with medication, in accordance with the criteria in [Table 3.1: Thyroid and parathyroid glands](#Table_3_1).\n\n126     Where an employee has more than one of the conditions in [Table 3.1: Thyroid and parathyroid glands](#Table_3_1), combine the WPI ratings using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n127     Permanent secondary impairment resulting from persistent hyperparathyroidism (such as renal calculi or renal failure) should be assessed under the relevant system (for example, [Chapter 10 – The urinary system](#_bookmark222)).\n\nTable 3.1: Thyroid and parathyroid glands\n\nSee note to Table 3.1 for further information.\n\n| 0 | Hyperparathyroidism – symptoms and signs readily controlled by medication or other treatment such as surgery.<br>or<br>Hypoparathyroidism – symptoms and signs readily controlled by medication.<br>or<br>Hypothyroidism adequately controlled by replacement therapy. |\n| 10–15 | Hypothyroidism where the presence of a disease in another body system prevents adequate replacement therapy.<br>or<br>Hyperparathyroidism – persisting mild hypercalcaemia, despite medication.<br>or<br>Hypoparathyroidism – symptoms and signs such as intermittent hyper or hypocalcaemia not readily controlled by medication. |\n| 30 | Hyperparathyroidism – persisting severe hypercalcaemia with serum calcium above 3.0mmol/l, despite medication. |\n\nNote to Table 3.1\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n### 3.2        Adrenal cortex and medulla\n\n128     Where Cushing’s syndrome is present, [Table 3.2: Adrenal cortex and medulla](#Table_3_2) should be used to evaluate impairment from the general effects of hypersecretion of adrenal steroids (for example, myopathy, easy bruising, and obesity).\n\n129     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings derived from [Table 3.2: Adrenal cortex and medulla](#Table_3_2) may be combined with WPI ratings for specific associated secondary impairments (for example, fractures or diabetes mellitus).\n\nTable 3.2: Adrenal cortex and medulla\n\n| 0 | Cushing’s syndrome – surgically corrected by removal of adrenal adenoma or removal of the source of ectopic ACTH secretion.<br>or<br>Phaeochromocytoma – benign tumour, surgically removed or removable where hypertension has not led to the development of permanent cardiovascular disease. |\n| 5 | Hypoadrenalism – symptoms and signs readily controlled with replacement therapy.<br>or<br>Cushing’s syndrome due to moderate doses of glucocorticoids (for example, less than equivalent of 15mg of prednisolone per day) where glucocorticoids will be required long-term. |\n| 10 | Cushing’s syndrome – surgically corrected by removal of pituitary adenoma or adrenal carcinoma. |\n| 15 | Cushing’s syndrome – due to:<br>bilateral adrenal hyperplasia treated by adrenalectomy; orlarge doses of glucocorticoids (for example, equivalent of at least 15mg of prednisolone per day) where glucocorticoids will be required long-term; orinadequate removal of source of ectopic ACTH secretion.<br>or<br>Phaeochromocytoma – malignant tumour where signs and symptoms of catecholamine excess can be controlled by blocking agents.<br>or<br>Hypoadrenalism – recurrent episodes of adrenal crisis during acute illness or in response to significant stress. |\n| 70 | Phaeochromocytoma – metastatic malignant tumour where signs and symptoms of catecholamine excess cannot be controlled by blocking agents or other treatment. |\n\n### 3.3        Pancreas (diabetes mellitus)\n\n130     Where diabetic retinopathy has led to visual impairment, the visual impairment should be assessed using [Chapter 6 – The visual system](#_CHAPTER_6__).\n\n131     Where diabetes has led to secondary impairment of renal function, that impairment should be assessed using [Chapter](#_bookmark223) [10 – The urinary system](#_bookmark222).\n\n132     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings derived under [Table 3.1: Thyroid and parathyroid glands](#Table_3_1) and [Table 3.2: Adrenal cortex and medulla](#Table_3_2) may be combined with WPI ratings from [Table 3.3: Pancreas (diabetes mellitus)](#Table_3_3).\n\n133     Microangiopathy may be manifest as retinopathy (background, proliferative, or maculopathy) and/or albuminuria measured with a timed specimen of urine. Where there is an overnight collection, the upper limit of normal is 20µg/minute. Where a 24 hour specimen is collected, the upper limit of normal is 30mg/day. Albuminuria must be documented in at least two out of three consecutive urine specimens collected.\n\nTable 3.3: Pancreas (diabetes mellitus)\n\nSee notes to Table 3.3 for further information.\n\n| %WPI | Type | Therapy | Microvascular complications |\n| 5 | Type 2 | Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control. | Microangiopathy is not present. |\n| 10 | Type 2 | Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control. | Microangiopathy and/or significant neuropathy are present. |\n| 15 | Type 1 | Dietary restrictions and insulin give satisfactory control. | Microangiopathy is not present. |\n| 20 | Type 1<br>Type 2 | Dietary restrictions and insulin give satisfactory control.<br>Type 2 where dietary restrictions and insulin and/or oral hypoglycaemic agents give satisfactory control. | Microangiopathy and/or significant neuropathy are present. |\n| 25 | Type 1 | Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented. | Microangiopathy is not present. |\n| 30 | Type 1 | Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented. | Microangiopathy is present. |\n| 40 | Type 1 | Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented. | Microangiopathy is present as well as significant neuropathy. |\n| 50 |  | Symptomatic hypoglycaemia due to metastatic tumour (usually insulinoma), uncontrolled by medication (such as diazoxide). |  |\n\nNotes to Table 3.3\n\n1. For the purposes of Table 3.3, the degree of control is defined by reference to the glycated haemoglobin measurement (HbA1c) where:\n\n(i)        4%-6% is the non-diabetic range; and\n\n(ii)      <8% is indicative of satisfactory control for the purposes of this table.\n\n2.     ‘Significant neuropathy’ means persistent symptoms of peripheral or autonomic neuropathy which interfere with quality of life to a considerable degree.\n\n3.     ‘Type 2’ means non-insulin dependent diabetes mellitus.\n\n4.     ‘Type 1’ means insulin dependent diabetes mellitus and other forms of diabetes requiring insulin, such as Cystic Fibrosis related diabetes and Type 3c diabetes.\n\n### 3.4        Gonads and mammary glands\n\n134     Impairments resulting from inability to reproduce, and other impairments associated with gonadal dysfunction, are assessed under [Chapter 11 – The reproductive system](#_CHAPTER_11__).\n\n135     Loss of one or both breasts in females should also be assessed using [Table 4.3: Bodily disfigurement](#Table_4_3) (see [Chapter 4 – Disfigurement and skin disorders](#_CHAPTER_4__)). Using the combined values chart (see [Appendix 1](#_bookmark300)), a WPI rating derived from Table 4.3 may be combined with a WPI rating derived from [Table 3.4: Gonads and mammary glands](#Table_3_4).\n\nTable 3.4: Gonads and mammary glands\n\n| 0 | Diminished or absent level of gonadal hormones in either sex.<br>or<br>Abnormally high level of gonadal hormones in either sex. |\n| 5 | Loss of one or both breasts in male.<br>or<br>Loss of whole or part of one breast in female.<br>or<br>Gynaecomastia in male where pain interferes with everyday activities – not controlled by medication. |\n| 10 | Loss of whole or part of both breasts in female. |\n\n## CHAPTER 4 – DISFIGUREMENT AND SKIN DISORDERS\n\n### 4.0        Introduction\n\n136     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n137     Impairments assessed under [Chapter 4 – Disfigurement and skin disorders](#_CHAPTER_4__) include those resulting from an endocrine system condition. A WPI rating from a table in [Chapter 3 – The endocrine system](#_CHAPTER_3__) may be combined with WPI ratings assessed under Chapter 4.\n\n","sortOrder":27},{"sectionNumber":"138","sectionType":"section","heading":"Loss of one or both breasts in females should be assessed under both:","content":"138     Loss of one or both breasts in females should be assessed under both:\n\na)      [Table 3.4: Gonads and mammary glands](#Table_3_4) (see [Chapter 3 – The endocrine system](#_CHAPTER_3__)); and\n\nb)      [Table 4.3: Bodily disfigurement](#Table_4_3);\n\nand the resulting WPI ratings combined.\n\n139     In cases where two or three of [Table 4.1: Skin disorders](#Table_4_1), [Table 4.2: Facial disfigurement](#Table_4_2) and [Table 4.3: Bodily disfigurement](#Table_4_3) apply to the injury resulting in impairment, WPI ratings from each table may be combined using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n140     WPI ratings awarded under [Table 4.2: Facial disfigurement](#Table_4_2) may not be combined with WPI ratings arising under [Section 6.4 (Other ocular abnormalities)](#_Other_ocular_abnormalities) or [Section 6.5 (Other conditions causing permanent deformities causing up to 10% impairment of the whole person)](#_bookmark92) (see [Chapter 6 – The visual system](#_bookmark75))\n\n### 4.1        Skin disorders\n\n","sortOrder":28},{"sectionNumber":"141","sectionType":"section","heading":"For the purposes of [Table 4.1: Skin disorders](#Table_4_1):","content":"141     For the purposes of [Table 4.1: Skin disorders](#Table_4_1):\n\na)      ‘intermittent treatment’ means a course of treatment leading to a break, treatment alternately ceasing and beginning again;\n\nb)      ‘constant treatment’ means treatment that continues on a regular basis without interruption; and\n\nc)       ‘complex treatment’ means treatment that requires regular and close supervision, usually by a dermatologist. Such supervision could involve regular blood tests and relevant regular physical examinations, such as blood pressure measurement. Complex treatments would be expected to have potential adverse side effects. Categories of drugs forming a part of, or the whole of, complex treatment would include high doses of systemic corticosteroids, or immunosuppressive medications such as azathioprine, methotrexate and cyclosporin. Phototherapy, photochemotherapy, or photophoresis, would also be considered complex treatments.\n\n142     Column 4 in [Table 4.1: Skin disorders](#Table_4_1) is referenced to [Figure 4-A: Activities of daily living](#Figure_4_A).\n\nTable 4.1: Skin disorders\n\n| %WPI | Signs and symptoms | Requirement for treatment | Column 4 Activities of daily living affected |\n| 0 | Absent | None, intermittent | up to 2 |\n| 5 | Absent | Constant | up to 2 |\n| 5 | Intermittent | Intermittent or constant | up to 2 |\n| 10 | Present on a daily basis for periods aggregating 3 or more months per year, but less than 6 months per year. | Intermittent or constant | 1 or more |\n| 15 | Present on a daily basis for period aggregating 6 or more months per year, but less than 9 months per year. | Intermittent or constant | 1 or more |\n| 20 | Present on a daily basis for periods aggregating 9 months per year or more. | Intermittent or constant | 1 or more |\n| 25 | Present on a daily basis for periods aggregating 9 months per year or more. | Constant | 4 or more |\n| 30 | Present on a daily basis for period aggregating 9 months per year or more. | Constant and complex | 6 or more |\n\nFigure 4-A: Activities of daily living\n\nSee Column 4 in Table 4.1.\n\n| %WPI | Activities | Examples |\n| 1 | Self care, personal hygiene | Bathing, grooming, dressing, eating, eliminating. |\n| 2 | Communication | Hearing, speaking, reading, writing, using keyboard. |\n| 3 | Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n| 4 | Sensory function | Tactile feeling. |\n| 5 | Hand functions | Grasping, holding, pinching, percussive movements, sensory discrimination. |\n| 6 | Travel | Driving or travelling as a passenger. |\n| 7 | Sexual function | Participating in desired sexual activity. |\n| 8 | Sleep | Having a restful sleep pattern. |\n| 9 | Social and recreational | Participating in individual or group activities, sports activities, hobbies. |\n\n### 4.2        Facial disfigurement\n\nTable 4.2: Facial disfigurement\n\n| 0 | No structural changes.<br>Normal facial appearance.<br>Hyperpigmentation, depigmentation, redness or telangiectasis occupying less than 10% of facial area (excluding actinic damage).<br>Scarring that does not significantly alter the appearance of the face. |\n| 5 | Hyperpigmentation, depigmentation, redness or telangiectasis occupying 10% or more of the facial area (excluding actinic damage).<br>or<br>Scars and/or skin grafts occupying less than 5% of facial area that significantly alter the appearance of the face.<br>or<br>Depressed cheek, nasal or frontal bones.<br>or<br>Total or partial loss of one external ear. |\n| 10 | Scars and/or skin grafts occupying 5-15% of facial area that significantly alter the appearance of the face.<br>or<br>Total or partial loss of both external ears.<br>or<br>Loss of less than 50% of the nose. |\n| 15 | Scars and/or skin grafts occupying 15-25% of facial area that significantly alter the appearance of the face.<br>or<br>Loss of 50-75% of the nose. |\n| 20 | Scars and/or skin grafts occupying more than 25% of facial area that significantly alter the appearance of the face.<br>or<br>Loss of more than 75% of the nose. |\n\n### 4.3        Bodily disfigurement\n\nTable 4.3: Bodily disfigurement\n\n| 0 | Normal body appearance.<br>Scars and/or skin grafts occupying less than 10% of body area. |\n| 5 | Scars and/or skin grafts occupying 11% to 20% of body surface. |\n| 10 | Scars and/or skin grafts occupying 21% to 40% of body area.<br>or<br>Tissue loss causing noticeable unilateral alteration of body silhouette. |\n| 15 | Scars and/or skin grafts occupying 41% to 60% of body area. |\n| 20 | Scars and/or skin grafts occupying 61% to 80% of body area.<br>or<br>Tissue loss causing noticeable bilateral alteration of body silhouette. |\n| 25 | Scars and/or skin grafts occupying more than 80% of body surface area. |\n\n## CHAPTER 5 – PSYCHIATRIC CONDITIONS\n\n### 5.0        Introduction\n\n143     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n144     For the purposes of [Chapter 5 – Psychiatric conditions](#_CHAPTER_5__), activities of daily living are those in [Figure 5-A](#Figure_5_A). The examples provided below are not exhaustive and should not be seen as a substitute for assessor discretion when making decisions about impairment ratings.\n\nFigure 5-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\n### 5.1        Psychiatric conditions\n\nTable 5.1: Psychiatric conditions\n\nSee notes to Table 5.1 for further information.\n\n| %WPI | Description of level of impairment |\n| 0 | Reactions to stresses of daily living without loss of personal or social efficiency.<br>and<br>Capable of performing activities of daily living without supervision or assistance. |\n| 5 | Despite the presence of one of the following employee is capable of performing activities of daily living without supervision or assistance:<br>reactions to stresses of daily living with minor loss of personal or social efficiencylack of conscience directed behaviour without harm to community or selfminor distortions of thinking. |\n| 10 | Despite the presence of more than one of the following employee is capable of performing activities of daily living without supervision or assistance:<br>reactions to stresses of daily living with minor loss of personal or social efficiencylack of conscience directed behaviour without harm to community or selfminor distortions of thinking. |\n| 15 | Any one of the following accompanied by a need for some supervision and direction in activities of daily living:<br>reactions to stresses of daily living which cause modification to daily living patternsmarked disturbances in thinkingdefinite disturbance in behaviour. |\n| 20 | Any two of the following accompanied by a need for some supervision and direction in activities of daily living:<br>reactions to stresses of daily living which cause modification of daily living patternsmarked disturbance in thinkingdefinite disturbance in behaviour. |\n| 25 | All of the following accompanied by a need for some supervision and direction in activities of daily living:<br>reactions to stresses of daily living which cause modification of daily living patternsmarked disturbances in thinkingdefinite disturbances in behaviour. |\n| 30 | Any one of the following accompanied by a need for supervision and direction in activities of daily living:<br>hospital dischargees who require daily medication or regular therapy to avoid readmissionloss of self-control and/or inability to learn from experience resulting in potential for considerable damage to self or community. |\n| 40 | More than one of the following accompanied by a need for supervision and direction in activities of daily living:<br>hospital dischargees who require daily medication or regular therapy to avoid readmissionloss of self-control and/or inability to learn from experience resulting in potential for considerable damage to self or community. |\n| 50 | One of the following:<br>severe disturbances of thinking and/or behaviour entailing potential or actual harm to self and/or othersneed for supervision and direction in a confined environment. |\n| 60 | Both of the following:<br>severe disturbances of thinking and/or behaviour which entail potential or actual harm to self and/or othersneed for supervision and direction in a confined environment. |\n| 90 | Very severe disturbance in all aspects of thinking and behaviour requiring constant supervision and care in a confined environment, and assistance with all activities of daily living |\n\nNotes to Table 5.1\n\n1. Table 5.1 includes psychoses, neuroses, personality disorders and other diagnosable conditions. The assessment should be made on optimum medication at a stage where the condition is reasonably stable.\n2. ‘Supervision’ means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.\n3. ‘Assistance’ means the provision of assistance to the employee in performing the activities of daily living by a suitable person, responsible in whole or in part for the care of the employee.\n4. ‘Direction’ means the provision of direction to the employee by a suitably qualified person, responsible in whole or in part for the care of the employee.\n5. ‘Suitable person’ means a person capable of responsibly caring for the employee in an appropriate way.\n6. ‘Suitably qualified person’ means a person with the necessary qualifications, experience and skills to provide appropriate direction to the employee. Such persons include medical practitioners, nursing staff and clinical psychologists.\n\n## CHAPTER 6 – THE VISUAL SYSTEM\n\n### 6.0        Introduction\n\n145     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n146     [Chapter 6 – The visual system](#_bookmark75) is based on the AMA4 and provides a standard method for examining the visual system, and for calculating the extent of any visual impairment. Impairment is any loss or abnormality in the anatomy or function of the visual system. The visual system includes the eyes, the ocular adnexa, and the visual pathways.\n\n147     All visual tests are standardised and impairment assessment follows a strict protocol in order to ensure that different ophthalmologists can closely reproduce results. Wherever possible, impairment assessment should be performed by an ophthalmologist.\n\n","sortOrder":29},{"sectionNumber":"148","sectionType":"section","heading":"Visual impairment exists when there is deviation from any of the normal functions of the eye.","content":"148     Visual impairment exists when there is deviation from any of the normal functions of the eye.\n\n149     Among the types of visual impairment listed below, the first three (Sections 6.1 to 6.3) contribute the most to the overall impairment:\n\na)      [Section 6.1 (Central visual acuity)](#_Central_visual_acuity);\n\nb)      [Section 6.2 (Determining loss of monocular visual field)](#_Determining_loss_of);\n\nc)       [Section 6.3 (Abnormal ocular motility and binocular diplopia)](#_Abnormal_ocular_motility);\n\nd)      [Section 6.4 (Other ocular abnormalities)](#_Other_ocular_abnormalities);\n\ne)      [Section 6.5 (Other conditions causing permanent deformities causing up to 10% impairment of the whole person)](#_bookmark92).\n\n150     Impairments assessed under [Chapter 6 – The visual system](#_bookmark75) include those resulting from an endocrine system condition. An impairment assessed under [Chapter 3 – The endocrine system](#_CHAPTER_3__) may be combined with those assessed under Chapter 6.\n\n151     WPI ratings from [Table 4.2: Facial disfigurement](#Table_4_2) (see [Chapter 4 – Disfigurement and skin disorders](#_CHAPTER_4__)), may not be combined with WPI ratings arising from either:\n\na)      [Section 6.4 (Other ocular abnormalities)](#_Other_ocular_abnormalities); or\n\nb)      [Section 6.5 (Other conditions causing permanent deformities causing up to 10% impairment of the whole person)](#_bookmark92).\n\n152     Facial nerve injury complicated by visual changes, such as occurs with corneal desiccation and scarring, rates as a significant impairment. Such an impairment is assessed under [Chapter 6 – The visual system](#_bookmark75) and a resulting WPI rating may be combined with a WPI rating from [Table 12.5.4: The facial nerve (VII)](#Table_12_5_4) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\nSteps in determining whole person impairment\n\n153     See [Figure 6-A](#Figure_6_A) for steps in deriving a visual system impairment rating. Use [Table 6.1: Conversion of the visual system to WPI rating](#Table_6_1) to convert a visual system impairment rating to a WPI rating.\n\nFigure 6-A: Steps for calculating impairment of the visual system\n\n| Step 1 | Assess and record the percentage loss of central vision for each eye separately, combining the losses of near and distance vision. Refer to [Figure 6-C: Percentage loss of central vision in one eye](#Figure_6_C). |\n| Step 2 | Assess and record the percentage loss of visual fields for each eye separately (monocular) or for both eyes together (binocular). |\n| Step 3 | Using the combined values chart (see [Appendix 1](#_bookmark300)), combine the results from Step 1 and Step 2 for each eye if any central vision and visual field impairment is present. |\n| Step 4 | Assess and record the percentage loss of ocular motility. |\n| Step 5 | Using the combined values chart (see [Appendix 1](#_bookmark300)), combine the result of Step 3 with Step 4 if there is any ocular motility impairment. |\n| Step 6 | Assess and record the percentage loss if other ocular impairments are present. |\n| Step 7 | Using the combined values chart (see [Appendix 1](#_bookmark300)), combine the result of Step 5 with Step 6 if any other ocular impairment is present. |\n| Step 8 | Assess the visual impairment for both eyes. The visual impairment for both eyes is calculated by the formula:<br>![Start formula start fraction open round bracket 3 times open round bracket impairment of better eye close round bracket plus open round bracket impairment of worse eye close round bracket close round bracket over 4 end fraction equals visual impairment system end formula](image.003.png)<br>Alternatively use [Figure 6-F: Calculation of visual system impairment for both eyes](#Figure_6_F). |\n| Step 9 | Convert the visual impairment for both eyes to a WPI rating using [Table 6.1: Conversion of the visual system to WPI rating](#Table_6_1). |\n| Step 10 | Using the combined values chart (see [Appendix 1](#_bookmark300)), combine the result of Step 9 with any impairment (up to 10% maximum) arising from other conditions causing permanent deformities (see [Section 6.5 (Other conditions causing permanent deformities causing up to 10% impairment of the whole person)](#_bookmark92)). |\n\nTable 6.1: Conversion of the visual system to WPI rating\n\nSource: AMA4 (Table 6, Chapter 8, page 218).\n\n| Visual  system | %WPI | Visual  system | %WPI | Visual  system | %WPI | Visual  system | %WPI |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| 0 | 0 |  |  |  |  |  |  |\n| 1 | 1 | 26 | 25 | 51 | 48 | 76 | 72 |\n| 2 | 2 | 27 | 25 | 52 | 49 | 77 | 73 |\n| 3 | 3 | 28 | 26 | 53 | 50 | 78 | 74 |\n| 4 | 4 | 29 | 27 | 54 | 51 | 79 | 75 |\n| 5 | 5 | 30 | 28 | 55 | 52 | 80 | 76 |\n| 6 | 6 | 31 | 29 | 56 | 53 | 81 | 76 |\n| 7 | 7 | 32 | 30 | 57 | 54 | 82 | 77 |\n| 8 | 8 | 33 | 31 | 58 | 55 | 83 | 78 |\n| 9 | 8 | 34 | 32 | 59 | 56 | 84 | 79 |\n| 10 | 9 | 35 | 33 | 60 | 57 | 85 | 80 |\n| 11 | 10 | 36 | 34 | 61 | 58 | 86 | 81 |\n| 12 | 11 | 37 | 35 | 62 | 59 | 87 | 82 |\n| 13 | 12 | 38 | 36 | 63 | 59 | 88 | 83 |\n| 14 | 13 | 39 | 37 | 64 | 60 | 89 | 84 |\n| 15 | 14 | 40 | 38 | 65 | 61 | 90 | 85 |\n| 16 | 15 | 41 | 39 | 66 | 62 | 91 | 85 |\n| 17 | 16 | 42 | 40 | 67 | 63 | 92 | 85 |\n| 18 | 17 | 43 | 41 | 68 | 64 | 93 | 85 |\n| 19 | 18 | 44 | 42 | 69 | 65 | 94 | 85 |\n| 20 | 19 | 45 | 42 | 70 | 66 | 95 | 85 |\n| 21 | 20 | 46 | 43 | 71 | 67 | 96 | 85 |\n| 22 | 21 | 47 | 44 | 72 | 68 | 97 | 85 |\n| 23 | 22 | 48 | 45 | 73 | 69 | 98 | 85 |\n| 24 | 23 | 49 | 46 | 74 | 70 | 99 | 85 |\n| 25 | 24 | 50 | 47 | 75 | 71 | 100 | 85 |\n\n### 6.1        Central visual acuity\n\n","sortOrder":30},{"sectionNumber":"154","sectionType":"section","heading":"A Snellen test chart is used to measure the distance of visual acuity. The test distance is six metres.","content":"154     A Snellen test chart is used to measure the distance of visual acuity. The test distance is six metres.\n\n155     The near vision is measured using a LogMar reading card. If Near Snellen, Jaeger, Sloan or Roman reading cards are used the results need to be converted to LogMar (see [Figure 6-B: Revised LogMar equivalent for different reading cards](#Figure_6_B)). The distance in the near reading test is not fixed: the reading distance should be recorded by the ophthalmologist.\n\n156     Central vision should be tested and recorded for distant and near objects. The employee should be refracted and tested with loose lenses, phoropter, or with their own glasses, provided their correction is accurate.\n\n157     If an employee wears contact lenses each day and wishes to wear them for the test, this is acceptable for measuring acuity. In certain ocular conditions (particularly in the presence of corneal abnormalities) contact lens-corrected vision may be better than that obtained with spectacle correction. However, if an employee does not already wear contact lenses, they should not be fitted for an impairment assessment.\n\nFigure 6-B: Revised LogMar equivalent for different reading cards\n\n| LogMar | Near Snellen | Equivalent to Snellen | N. | Points Roman | Revised Jaeger standard |\n| --- | --- | --- | --- | --- | --- |\n| 0.3 | 14/14 | 6/6 | N5 | 3 | 1 |\n| 0.4 | 14/18 | 6/7.5 | N6 | 4 | 2 |\n| 0.5 | 14/21 | 6/9 | N7 | 5 | 3 |\n| 0.6 | 14/24 | 6/12 | N8 | 6 | 4 |\n| 0.65 | 14/28 | 6/15 | N9 | 7 | 5 |\n| 0.7 | 14/35 | 6/18 | N10 | 8 | 6 |\n| 0.725 | 14/40 | 6/24 | N12 | 9 | 7 |\n| 0.75 | 14/45 | 6/30 | N15 | 10 | 8 |\n| 0.8 | 14/60 | 6/36 | N17 | 11 | 9 |\n| 0.9 | 14/70 | 6/48 | N18 | 12 | 10 |\n| 1.0 | 14/80 | 6/60 | N20 | 13 | 11 |\n| 1.1 | 14/88 | 6/90 | N24 | 14 | 12 |\n| 1.3 | 14/112 | 6/120 | N40 | 21 | 13 |\n| 1.6 | 14/140 | 6/240 | N80 | 23 | 14 |\n\n#### 6.1.1   Determining the loss of central vision in one eye\n\n","sortOrder":31},{"sectionNumber":"158","sectionType":"section","heading":"The following steps are taken to assess loss of central vision in one eye.","content":"158     The following steps are taken to assess loss of central vision in one eye.\n\n| Step 1 | Measure the central acuity for distance and near, correcting for any refractive errors and presbyopia, and record the result. |\n| Step 2 | Consult [Figure 6-C: Percentage loss of central vision in one eye](#Figure_6_C) to derive the overall loss, combining the values for corrected near and distance acuities. |\n| Step 3 | If monocular aphakia or pseudoaphakia is present then add 50% to the percentage loss of central vision obtained from [Figure 6-C: Percentage loss of central vision in one eye](#Figure_6_C). |\n\nFigure 6-C: Percentage loss of central vision in one eye\n\n- Distance vision (metric 6) Revised LogMar standard for near vision\n- 0.3 0.4 0.4 0.5 0.6 0.7 0.7 0.7 0.8 0.9 1.0 1.1 1.3 1.6\n- 6/5 0 0 3 4 5 25 27 30 40 43 44 45 48 49\n- 6/6 0 0 3 4 5 25 27 30 40 43 44 46 48 49\n- 6/7.5 3 3 5 6 8 28 30 33 43 45 46 48 50 52\n- 6/10 5 5 8 9 10 30 32 35 45 48 49 50 53 54\n- 6/12 8 8 10 11 13 33 35 38 48 50 5 53 55 57\n- 6/15 13 13 15 16 18 38 40 43 53 55 56 58 60 62\n- 6/20 16 16 18 20 22 41 44 46 56 59 60 61 64 65\n- 6/22 18 18 21 22 23 43 46 48 58 61 62 63 66 67\n- 6/24 20 20 23 24 25 45 47 50 60 63 64 65 68 69\n- 6/30 25 25 28 29 30 50 52 55 58 68 69 70 73 74\n- 6/38 30 30 33 34 35 55 57 60 70 73 74 75 78 79\n- 6/50 34 34 37 38 39 59 61 64 74 77 78 79 82 83\n- 6/60 40 40 43 44 45 65 67 70 80 83 84 85 88 89\n- 6/90 43 43 45 46 48 68 70 73 83 85 86 88 90 92\n- 6/120 45 45 48 49 50 70 72 75 85 88 89 90 93 94\n- 6/240 48 48 50 51 53 73 75 78 88 90 91 93 95 97\n\n### 6.2        Determining loss of monocular visual fields\n\n159     There are many ways of measuring the visual field. The most common are the manual Goldman Field and the Humphrey, Octopus and Medmont computerised field analysers. If using a computerised field it is necessary to test at least a 30-2 threshold.\n\n160     An Esterman Binocular Field is suitable for the majority of visual field impairment assessments. The field is tested with the employee wearing spectacles and both eyes open. The binocular field result is assessed by using the Esterman 120‑unit binocular grid, and the dot count is multiplied by 5/6 to obtain the percentage of retained or lost field. Note that binocular field-testing is not recommended when diplopia is present.\n\n161     If the automated 30-2 Threshold Field is normal, and the ocular history and examination do not suggest lesions that would affect the outer part of the field, it is acceptable to conclude that the entire field is normal. Whatever technique is used to measure the visual field, the test should be performed by an ophthalmologist.\n\n162     The normal visual field meridians in each of eight principal meridians are given in [Figure 6-D: Normal extent of the visual field](#Figure_6_D). The total, summed over 8 meridians is 500.\n\nFigure 6-D: Normal extent of the visual field\n\n| Direction of vision | Degrees of field |\n| Temporally | 85 |\n| Down temporally | 85 |\n| Direct down | 65 |\n| Down nasally | 50 |\n| Nasally | 60 |\n| Up nasally | 55 |\n| Direct up | 45 |\n| Up temporally | 55 |\n| Total | 500 |\n\n","sortOrder":32},{"sectionNumber":"163","sectionType":"section","heading":"The percentage of retained vision is calculated using the following steps.","content":"163     The percentage of retained vision is calculated using the following steps.\n\n| Step 1 | Add the extent of the visual field along each of the 8 meridians (while considering the maximum normal values for the meridians given in [Figure 6-D: Normal extent of the visual field](#Figure_6_D)). |\n| Step 2 | Divide by 5 to assess the percentage of visual field perception that remains. |\n| Step 3 | To obtain the percentage of visual field loss, subtract the percentage of visual field remaining from 100%. |\n\n","sortOrder":33},{"sectionNumber":"164","sectionType":"section","heading":"These steps are based upon the following formulae:","content":"164     These steps are based upon the following formulae:\n\n![Start formula start fraction total visual field over 5 end fraction equals percentage of remaining visual field end formula](image.004.png)\n\n![Start formula 100 minus open round bracket percentage of remaining visual field close round bracket equals percentage of visual field lost end formula](image.005.png)\n\n### 6.3        Abnormal ocular motility and binocular diplopia\n\n165     Diplopia within the central 30° is measured by an ophthalmologist with a tangent screen. Unless there is diplopia within 30° of the centre of fixation, the diplopia does not cause significant visual impairment. The exception is when looking downwards. Double vision within the central 20° signifies the maximum loss of ocular motility (that is, a 50% loss of ocular motility in one eye).\n\n166     If the diplopia is not within the central 20°, the presence of diplopia is then plotted along the 8 meridians (see [Figure 6‑E: Percentage loss of ocular motility of one eye in diplopia fields](#Figure_6_E)). The largest percentage on any of the meridians in which there is double vision is the impairment percentage for loss of ocular motility.\n\nFigure 6-E: Percentage loss of ocular motility of one eye in diplopia fields\n\nAdapted from AMA4 (Chapter 8, page 217).\n\n![A circular graphic containing whole person impairment percentage ratings used to work out the percentage loss of ocular motility of one eye in diplopia fields](image.006.png)\n\n### 6.4        Other ocular abnormalities\n\n167     If an ocular adnexal disturbance or deformity interferes with visual function and is not reflected in diminished visual acuity, decreased visual fields, or ocular motility abnormalities with diplopia, then the significance of the disturbance or deformity should be evaluated by an examining ophthalmologist. In that situation, using the combined values chart (see [Appendix 1](#_bookmark300)), an ophthalmologist may combine up to an additional 10% impairment for each affected eye.\n\n168     Problems in the visual system should also be taken into account where they result in symptoms such as epiphora, photophobia, metamorphopsia, and convergence insufficiency.\n\n### 6.5        Other conditions causing permanent deformities causing up to 10% impairment of the whole person\n\n169     Using the combined values chart (see [Appendix 1](#_bookmark300)), an additional WPI of up to 10% may be combined with WPI ratings for conditions such as permanent deformities of the orbit, scars, and other cosmetic deformities that do not otherwise alter ocular function.\n\n### 6.6        Calculation of visual system impairment for both eyes\n\n170     [Figure 6-F: Calculation of visual system impairment for both eyes](#Figure_6_F) (from the AMA4) was established using the equation:\n\n![Start formula start fraction open round bracket 3 times open round bracket impairment of better eye close round bracket plus open round bracket impairment of worse eye close round bracket close round bracket over 4 end fraction equals visual impairment system end formula](image.003.png)\n\n","sortOrder":34},{"sectionNumber":"171","sectionType":"section","heading":"Percentages for the worse eye are read from the side of the table.","content":"171     Percentages for the worse eye are read from the side of the table.\n\n","sortOrder":35},{"sectionNumber":"172","sectionType":"section","heading":"Percentages for the better eye are read from the bottom of the table.","content":"172     Percentages for the better eye are read from the bottom of the table.\n\n173     The impairment of the visual system is at the intersection of the column for the worse eye and the row for the better eye.\n\n174     For example, for a 40% impairment of one eye and 10% impairment of the other eye, read down the table until you come to the large value (40%). Follow across the row until it is intersected with the column designated by 10% at the bottom of the page (18%). Thus, the impairment to the visual system is 18%.\n\nFigure 6-F: Calculation of visual system impairment for both eyes\n\n![A numerical matrix with percentage impairment better eye on the X axis and percentage impairment worse eye on the Y axis and corresponding whole person impairment ratings used to calculate the visual system impairment for both eyes established using the formula described in paragraph 172](image.007.png)\n\nFigure 6-F: Calculation of visual system impairment for both eyes (continued)\n\n![The first of two continuations of a numerical matrix with percentage impairment better eye on the X axis and percentage impairment worse eye on the Y axis and corresponding whole person impairment ratings used to calculate the visual system impairment for both eyes established using the formula described in paragraph 172](image.008.png)\n\nFigure 6-F: Calculation of visual system impairment for both eyes (continued)\n\n![The final continuations of a numerical matrix with percentage impairment better eye on the X axis and percentage impairment worse eye on the Y axis and corresponding whole person impairment ratings used to calculate the visual system impairment for both eyes established using the formula described in paragraph 172](image.009.png)\n\n## CHAPTER 7 – EAR, NOSE AND THROAT DISORDERS\n\n### 7.0        Introduction\n\n175     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n176     [Table 12.5.5: The auditory nerve (VIII)](#Table_12_5_5) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)) should be used to assess both Menière’s disease, and true vertigo consequent upon a disturbance of vestibular function.\n\n177     Unless they cause interference with balance, speech, respiration or hearing, the following conditions attract a WPI rating of 0%:\n\na)      rhinitis;\n\nb)      sinusitis;\n\nc)       laryngitis;\n\nd)      pharyngitis;\n\ne)      otitis media or externa (whether permanent or intermittent).\n\n178     If interference with balance, speech, respiration or hearing is present, these conditions attract WPI ratings based on the degree of interference with balance, speech, respiration or hearing as described in the tables in [Chapter 7 – Ear, nose and throat disorders](#_bookmark96).\n\n### 7.1        Hearing loss\n\n179     Hearing loss is to be assessed in accordance with the current procedures from Australian Hearing Services (Hearing Australia).\n\n","sortOrder":36},{"sectionNumber":"180","sectionType":"section","heading":"Once the percentage of binaural hearing loss has been calculated, it is then converted to a WPI rating.","content":"180     Once the percentage of binaural hearing loss has been calculated, it is then converted to a WPI rating.\n\n","sortOrder":37},{"sectionNumber":"181","sectionType":"section","heading":"The calculation for converting the percentage of binaural hearing loss to a WPI rating is:","content":"181     The calculation for converting the percentage of binaural hearing loss to a WPI rating is:\n\n![Start formula start fraction open round bracket percentage of binaural hearing loss close round bracket over 2 end fraction end formula ](image.010.png)\n\n### 7.2        Tinnitus\n\n182     [Table 7.2: Tinnitus](#Table_7_7) is used to assess impairment arising as a result of tinnitus in the presence of unilateral or bilateral hearing loss.\n\nTable 7.2: Tinnitus\n\n| 0 | Continuous tinnitus which has nuisance value but can be forgotten or ignored with background noise or a low level noise generator. |\n| 5 | Severe continuous tinnitus which causes extreme distress, interferes with concentration and is not assisted by a low level noise generator. |\n\n### 7.3        Olfaction and taste\n\n183     Only complete loss of olfaction or taste attracts a WPI rating. If the employee is able to detect any odour or taste, even if unable to identify it, the degree of permanent impairment of the employee resulting from the injury is 0%.\n\n184     WPI ratings from this table may not be combined with WPI ratings for the same condition from either [Table 12.5.1: The olfactory nerve (I)](#Table_12_5_1) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)) or [Table 12.5.4: Facial nerve (VIII)](#Table_12_5_4) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\nTable 7.3: Olfaction and taste\n\n| 5 | Complete loss of olfaction.<br>or<br>Complete loss of taste. |\n| 10 | Complete loss of olfaction.<br>and<br>Complete loss of taste. |\n\n### 7.4        Speech\n\n185     [Table 7.4: Speech](#Table_7_4) is used to assess impairment resulting from interference with speech from local lesions of the organs of speech.\n\n186     For the purposes of [Table 7.4: Speech](#Table_7_4), ‘speech’ means the capacity to produce vocal signals that can be heard, understood, and sustained over a useful period of time.\n\n187     [Table 7.4: Speech](#Table_7_4) must not be used to assess speech impairment resulting from a lesion of the central nervous system. In such cases, assessment should be made under [Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#Table_12_3) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n188     WPI ratings from [Table 7.4: Speech](#Table_7_4) may not be combined with WPI ratings from [Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#Table_12_3) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n189     If there are two separate conditions (one local, and the other a central nervous system condition) interfering with speech production, speech production should be assessed under both [Table 7.4: Speech](#Table_7_4) and [Table 12.3: Criteria for](#_bookmark254) [rating impairment due to aphasia or dysphasia](#_bookmark254). The greater value is the WPI rating due to speech impairment from all causes.\n\n","sortOrder":38},{"sectionNumber":"190","sectionType":"section","heading":"WPI ratings from within [Table 7.4: Speech](#Table_7_4) may not be combined with each other.","content":"190     WPI ratings from within [Table 7.4: Speech](#Table_7_4) may not be combined with each other.\n\n191     If the major problem is one of audibility, intelligibility, or functional efficiency of speech, the criteria appropriate to the area should be used to assess impairment.\n\n192     If there are problems in more than one area, each area (audibility, intelligibility, and functional efficiency) should be assessed, and the highest value selected as the WPI rating.\n\nTable 7.4: Speech\n\n- %WPI Criteria\n- Audibility Intelligibility Functional efficiency\n- 0 Audible in most situations, although may require effort. Generally intelligible, although some sounds are difficult and some repetition may be needed. Speech can be sustained except for slowness and some hesitancy.\n- 10 Audible in quiet situations but problems with audibility in noisy environments. Intelligible although inaccuracies may be frequent and there are obvious difficulties with articulation. Speech can be sustained but is often discontinuous, interrupted, hesitant and/or slow.\n- 15 Voice tires rapidly, tends to become inaudible after a few seconds.Volume generally low. Intelligible to family and close friends but strangers find speech generally unintelligible even with repetition. Difficulty sustaining speech for more than brief periods even when speaking very slowly.\n- 20 Volume very low.Can whisper or produce volume that can be heard only with difficulty by close listener orby telephone. Mostly unintelligible, except for a few words. Laboured speech.Rate of sustained speech impractically slow.\n- 30 Inaudible. Unintelligible. No sustained speech.\n\n### 7.5        Air passage defects\n\n193     [Table 7.5: Air passage defects](#Table_7_5) assesses permanent impairment relating to defects of the air passages. Impairments of the lower airways and lung parenchyma are dealt with in [Chapter 2 – The respiratory system](#_bookmark42).\n\n194     Permanent tracheostomy, or other respiratory stoma, attracts a permanent WPI rating of 25% which may be combined with other values derived from [Table 7.5: Air passage defects](#Table_7_5).\n\n","sortOrder":39},{"sectionNumber":"195","sectionType":"section","heading":"An employee is placed in an impairment category based on the criteria in [Table 7.5: Air passage defects](#Table_7_5).","content":"195     An employee is placed in an impairment category based on the criteria in [Table 7.5: Air passage defects](#Table_7_5).\n\n196     [Table 7.5: Air passage defects](#Table_7_5) applies only to permanent partial obstruction of one or more of the following structures:\n\na)      oropharynx;\n\nb)      laryngopharynx;\n\nc)       larynx;\n\nd)      trachea.\n\n197     [Table 7.5: Air passage defects](#Table_7_5) does not apply to nasal obstruction. Nasal obstruction is assessed under [Table 7.6: Nasal passage defects](#Table_7_6).\n\n198     Prophylactic restriction of activity, such as sporting activity, does not attract the same WPI rating as dyspnoea on participation in the activity.\n\nTable 7.5: Air passage defects\n\nSee note to Table 7.5 for further information.\n\n- Criteria %WPI\n- 0 10 30 40 50 70 90\n- Ventilation required No No No No No No Yes\n- Dyspnoea at rest No No No No Yes Yes (severe) NA\n- Dyspnoea with dressing or grooming No No No Yes Yes (severe) NA NA\n- Dyspnoea with walking 200m or climbing eight steps No No Yes NA NA NA NA\n- Dyspnoea with hurrying, hill climbing or sporting activity No Yes NA NA NA NA NA\n\nNote to Table 7.5\n\n1. ‘NA’ means not applicable.\n\n### 7.6        Nasal passage defects\n\n199     [Table 7.6: Nasal passage defects](#Table_7_6) applies only to nasal obstruction.\n\nTable 7.6: Nasal passage defects\n\n| %WPI | Criterion |\n| 3 | Continuous nasal obstruction of sufficient severity to cause mouth breathing at rest. |\n\n### 7.7        Chewing and swallowing\n\n200     [Table 7.7: Chewing and swallowing](#Table_7_7) is used to assess impairment resulting from facial muscle damage or loss, dental and oral problems, and temporomandibular joint dysfunction.\n\n201     WPI ratings derived from [Table 7.7: Chewing and swallowing](#Table_7_7) may be combined with WPI ratings derived from [Table 8.4: Surgically created stomas](#Table_8_4) (see [Chapter 8 – The digestive system](#_CHAPTER_8__)).\n\n202     For the same condition, WPI ratings derived from [Table 7.7: Chewing and swallowing](#Table_7_7) may not be combined with WPI ratings from [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\nTable 7.7: Chewing and swallowing\n\n| 0 | No interference. Food of any desired type may be eaten without difficulty. |\n| 2 | Very tough or hard food has to be avoided but diet is otherwise as desired. |\n| 5 | Diet is limited to soft foods. |\n| 10 | Diet is limited to pureed foods. |\n| 20 | Diet is limited to liquid foods. |\n| 40 | No oral ingestion of food or fluid is possible. Food can only be ingested by means of a nasogastric, gastrostomy, oesophagostomy or other tube. |\n\n## CHAPTER 8 – THE DIGESTIVE SYSTEM\n\n### 8.0        Introduction\n\n203     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n204     For the purposes of [Chapter 8 – The digestive system](#_CHAPTER_8__), activities of daily living are those in [Figure 8-A](#Figure_8_A).\n\nFigure 8-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\n205     [Table 8.1: Upper digestive tract – oesophagus, stomach, duodenum, small intestine and pancreas](#Table_8_1), [Table 8.2: Lower gastrointestinal tract – colon and rectum](#Table_8_2) and [Table 8.3: Lower gastrointestinal tract – anus](#Table_8_3) refer to primary and secondary criteria. All criteria from both categories (except where otherwise stipulated) must be met before a WPI rating can be assigned.\n\n206     Where the condition being assessed interferes with chewing and/or swallowing, assessment is made under whichever of the following tables describes the impairment more specifically:\n\na)      [Table 7.7: Chewing and swallowing](#Table_7_7) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96));\n\nb)      [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n207     For the same condition, WPI ratings derived from [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6) may not be combined with WPI ratings derived from [Table 7.7: Chewing and swallowing](#Table_7_7).\n\n208     Other complications of bleeding disorders assessed under [Table 13.3: Haemorrhagic disorders and platelet disorders](#Table_13_3) [(see Chapter 13 – The haematopoietic system](#_bookmark273)) may also be assessed under tables in [Chapter 8 – The digestive system](#_CHAPTER_8__), according to the site of the blood loss. The WPI rating so obtained may be combined with the WPI rating obtained from Table 13.3.\n\n209     Where applicable, Body Mass Index (BMI) values are used as the objective assessment for weight. See [Figure 8-B: Body Mass Index criteria](#Figure_8_B) for calculation of BMI values.\n\n#### 8.0.1    Calculation of Body Mass Index (BMI)\n\n","sortOrder":40},{"sectionNumber":"210","sectionType":"section","heading":"Body Mass Index (BMI) is calculated as follows:","content":"210     Body Mass Index (BMI) is calculated as follows:\n\n![Start formula start fraction weight in kilograms over height in metres squared end fraction end formula ](image.011.png)\n\n","sortOrder":41},{"sectionNumber":"211","sectionType":"section","heading":"The value obtained should be rounded to the nearest whole number.","content":"211     The value obtained should be rounded to the nearest whole number.\n\nFigure 8-B: Body Mass Index criteria\n\n| BMI | Category | Health risk |\n| <18 | Very underweight. | Long-term hazard to health. |\n| 18-20 | Underweight. | Low risk to health. |\n| 20-25 | Acceptable. | Least risk for morbidity and minimal mortality. |\n| 25-30 | Overweight. | Low risk to health. |\n| 30-40 | Morbid obesity. | High degree of risk to health. |\n\n### 8.1        Upper digestive tract – oesophagus, stomach, duodenum, small intestine and pancreas\n\nTable 8.1: Upper digestive tract – oesophagus, stomach, duodenum, small intestine and pancreas\n\nSee notes to Table 8.1 for further information.\n\n| 0 | Symptoms of upper digestive tract disease with or without anatomical loss or pathological alteration present. | Continuous drug treatment not required to control symptoms. |\n| 10 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | One of the following:<br>Continuous drug treatment required to control symptoms, signs or nutritional deficiencyAppropriate dietary modifications required to control symptoms or signs. |\n| 20 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | Both of the following:<br>Continuous drug treatment required to control symptoms, signs or nutritional deficiencyAppropriate dietary modifications required to control symptoms or signs. |\n| 30 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | Any one of the following:<br>Continuous drug treatment does not completely control symptoms, signs or nutritional deficiencyAppropriate dietary modifications do not completely control symptoms, signs or nutritional deficiencyWeight loss with a BMI<20. |\n| 40 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | Any two of the following:<br>Continuous drug treatment does not completely control symptoms, signs or nutritional deficiencyAppropriate dietary modifications do not completely control symptoms, signs or nutritional deficiencyWeight loss with a BMI<20. |\n| 50 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | All of the following:<br>Continuous drug treatment does not completely control symptoms, signs or nutritional deficiencyAppropriate dietary modifications do not completely control symptoms, signs or nutritional deficiencyWeight loss with a BMI<20. |\n| 60 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | All of the following:<br>Continuous drug treatment has little effect on symptoms, signs or nutritional deficiencyAppropriate dietary modifications have little effect on symptoms, signs or nutritional deficiencyAssistance required with most or all activities of daily livingWeight loss with a BMI<20. |\n| 70 | Symptoms of upper digestive tract disease, with anatomical loss or pathological alteration present. | All of the following:<br>Severe impairment of nutritional status uncontrolled by any treatment or dietary modificationsAssistance required with all activities of daily livingWeight loss with a BMI<20. |\n\nNotes to Table 8.1\n\n1. Continuous drug treatment includes H2 receptor antagonists, proton pump inhibitors, corticosteroids, and pancreatic enzyme supplementation.\n2. Continuous drug treatment does not include antacids, or mixed antacid and alginic acid preparations.\n3. Modified diet does not include the avoidance of a few, or selected, food items. It refers to special diets devised to manage symptoms of the disease and maximise nutrition (for example, lactose-free diet, gluten-free diet).\n\n### 8.2        Lower gastrointestinal tract – colon and rectum\n\nTable 8.2: Lower gastrointestinal tract – colon and rectum\n\nSee notes to Table 8.2 for further information.\n\n| 0 | Signs and/or symptoms of colonic or rectal disease occur infrequently, and/or are of brief duration. | No requirement for any of the following as short term treatment:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>No systemic manifestations.<br>and<br>Weight and nutrition can be maintained at desirable levels. |\n| 10 | Signs and/or symptoms of colonic or rectal disease occur more frequently, and/or are of longer duration. | Generally no requirement for any of the following as long-term treatment to control disease although may be needed short term:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>No systemic manifestations.<br>and<br>Weight and nutrition can be maintained at desirable levels. |\n| 20 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | Requirement for at least one of the following as long-term treatment to control disease:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>No systemic manifestations.<br>and<br>Weight and nutrition can be maintained at desirable levels. |\n| 30 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | Requirement for all of the following as long-term treatment to control disease:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>No systemic manifestations.<br>and<br>Weight and nutrition can be maintained at desirable levels. |\n| 40 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | Requirement for all of the following as long-term treatment to control disease:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>Presence of one of the following:<br>Systemic manifestations (for example, fever, anaemia)Weight loss with a BMI<20. |\n| 50 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | Requirement for all of the following as long-term treatment to control disease:<br>Limitation of activities of daily livingModified dietMedication.<br>and<br>Presence of both of the following:<br>Systemic manifestations (for example, fever, anaemia)Weight loss with a BMI<20. |\n| 60 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | None of the following long-term treatments control the disease:<br>Modified dietMedication.<br>and<br>Presence of at least one of the following:<br>Limitation of activities of daily livingSystemic manifestations (for example, fever, anaemia)Weight loss with a BMI<20. |\n| 70 | Objective evidence of colonic or rectal disease, with anatomical loss or alteration. | None of the following long-term treatments control the disease:<br>Modified dietMedication.<br>and<br>Presence of all of the following:<br>Systemic manifestations (for example, fever, anaemia)Assistance required with activities of daily livingWeight loss with a BMI<20. |\n\nNotes to Table 8.2\n\n1. Medication does not include fibre supplements, vitamins or other nutritional supplements (unless there is a demonstrated vitamin deficiency), or over the counter preparations.\n2. Modified diet does not include the avoidance of a few, or selected food items. It refers to special diets devised to manage the symptoms of the disease and maximise nutrition (for example, lactose free diet, gluten free diet).\n\n### 8.3        Lower gastrointestinal tract – anus\n\n212     Where the anal disorder is part of a colo-rectal disorder (for example, Crohn’s Disease), WPI ratings from [Table 8.2: Lower gastrointestinal tract – colon and rectum](#Table_8_2) and [Table 8.3: Lower gastrointestinal tract – anus](#Table_8_3) may be combined using the combined values chart (see [Appendix 1](#_bookmark300)).\n\nTable 8.3: Lower gastrointestinal tract – anus\n\n| 0 | Signs of organic anal disease are absent.<br>or<br>There is no anatomical loss or alteration. | Incontinence of flatus, or other mild or intermittent anal symptoms which can be controlled by treatment. |\n| 10 | Signs of organic anal disease are present.<br>or<br>There is anatomical loss or alteration. | Mild incontinence of flatus.<br>and/or<br>Mild incontinence of liquid stool.<br>and<br>Mild or intermittent anal symptoms controlled by treatment. |\n| 20 | Signs of organic anal disease are present.<br>or<br>There is anatomical loss or alteration. | Moderate daily faecal incontinence requiring continual treatment.<br>or<br>Continual anal symptoms incompletely controlled by treatment. |\n| 30 | Signs of organic anal disease are present.<br>or<br>There is anatomical loss or alteration. | Moderate daily faecal incontinence requiring continual treatment.<br>and<br>Continual anal symptoms incompletely controlled by treatment. |\n| 40 | Signs of organic anal disease are present.<br>and<br>There is anatomical loss or alteration. | Total faecal incontinence despite treatment.<br>or<br>Signs of organic anal disease with severe symptoms unresponsive or not amenable to treatment. |\n\n### 8.4        Surgically created stomas\n\n213     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings obtained from [Table 8.4: Surgically created stomas](#Table_8_4) may be combined with WPI ratings from other digestive system tables in [Chapter 8 – The digestive system](#_CHAPTER_8__), and with WPI ratings from [Table 7.7: Chewing and swallowing](#Table_7_7) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)).\n\nTable 8.4: Surgically created stomas\n\nSee note to Table 8.4 for further information.\n\n| 10 | Colostomy. |\n| 15 | Ileostomy.<br>or<br>Ileal pouch-anal anastomosis. |\n| 20 | Jejunostomy.<br>or<br>Gastrostomy.<br>or<br>Oesophagostomy. |\n\nNote to Table 8.4\n\n1. Assessment for surgically created stomas is only allowed when the stoma is permanent and not a defunctioning or temporary stoma.\n\n### 8.5        Liver – chronic hepatitis and parenchymal liver disease\n\nTable 8.5: Chronic hepatitis and parenchymal liver disease\n\nSee notes to Table 8.5 for further information.\n\n| %WPI | Primary criteria<br>(all criteria must be present) | Secondary criteria<br>(all criteria must be present) |\n| 0 | Evidence of persistent or intermittent liver disease.<br>Histological severity – very mild. | Liver function tests may be normal or mildly abnormal.<br>No history of jaundice, ascites or bleeding oesophageal varices in the last three years.<br>Adequate nutritional state. |\n| 10–15 | Evidence of persistent liver disease. Histological severity – mild. | Biochemistry abnormal.<br>No history of jaundice, ascites, or bleeding oesophageal varices in the last three years.<br>Adequate nutritional state. |\n| 30 | Evidence of chronic liver disease. Histological severity – moderate. | Biochemistry abnormal.<br>History of jaundice, ascites or bleeding oesophageal varices in the last 12 months.<br>Adequate nutritional state |\n| 40 | Evidence of progressive, chronic liver disease. Histological severity – severe. | Biochemistry abnormal.<br>History of jaundice ascites, or bleeding oesophageal varices in the last 12 months.<br>Adequate nutritional state. Easily fatigued. |\n| 50 | Evidence of progressive, chronic liver disease. Histological severity – chronic hepatitis with cirrhosis. | Biochemistry abnormal.<br>History of jaundice ascites, and/or bleeding oesophageal varices in the last 12 months.<br>Nutritional state adversely affected. Fatigue and physical weakness. |\n| 65 | Evidence of progressive, chronic liver disease. Histological severity – chronic hepatitis with cirrhosis.<br>Persistent signs of hepatic insufficiency. | Biochemistry abnormal.<br>History of jaundice, ascites and/or bleeding oesophageal varices in the last 12 months.<br>Nutritional state adversely affected. Profound fatigue and physical weakness. |\n| 75 | Evidence of advanced, irreparable chronic liver disease.<br>Histological severity – chronic hepatitis with cirrhosis.<br>Persistent signs of advanced hepatic insufficiency. | Biochemistry abnormal.<br>History of jaundice, ascites and/or bleeding oesophageal varices in the last 12 months.<br>Nutritional state adversely affected. Profound fatigue and physical weakness.<br>Assistance required with activities of daily living. |\n\nNotes to Table 8.5\n\n1. Signs of liver disease include: the stigmata of liver disease (spider angiomata, palmar erythema, and gynaecomastia); jaundice; palpably enlarged liver; evidence of abnormal liver size on ultrasound; evidence of intrahepatic lesions on ultrasound or positive antibodies to any of the viruses known to have the potential to cause chronic liver disease.\n2. Jaundice does not include a mild elevation of plasma bilirubin with normal liver enzymes.\n3. Liver function tests include estimates of total bilirubin, albumin, alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), and gamma glutamyl transferase (GGT).\n4. All the criteria, both primary and secondary, must be present before a particular WPI rating can be allocated. However, liver biopsy is not mandatory and should not be undertaken solely for the purpose of permanent impairment assessment.\n5. Where liver biopsy has not been undertaken the histological criteria may be disregarded.\n6. Assessors should refer to the [Principles of Assessment](#_PRINCIPLES_OF_ASSESSMENT) for guidance on awarding an impairment value within a range.\n\n### 8.6        Biliary tract\n\nTable 8.6: Biliary tract\n\nSee note to Table 8.6 for further information.\n\n| 0 | Cholecystectomy with no biliary tract sequelae. |\n| 10 | History of biliary type pain without identifiable biliary disease.<br>or<br>Documented history of one to three episodes of biliary colic per year with identifiable biliary disease. |\n| 20 | Documented history of four to six episodes of biliary colic per year with identifiable biliary disease. |\n| 30 | Documented history of more than six episodes of biliary colic per year with identifiable biliary disease. |\n| 40 | Permanent irreparable obstruction of the hepatic or common bile duct with recurrent cholangitis or permanent stent. |\n| 50 | Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice with intermittent hepatic insufficiency. |\n| 65 | Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice and hepatic insufficiency. |\n| 75 | Permanent and irreparable common bile duct obstruction with advanced liver disease manifest as persistent jaundice and hepatic insufficiency. |\n\nNote to Table 8.6\n\n1. Biliary tract dysfunction should only be assessed after cholecystectomy or other appropriate biliary tract surgery, except where there are sound medical reasons for not undertaking surgery.\n\n### 8.7        Hernias of the abdominal wall\n\nTable 8.7: Hernias of the abdominal wall\n\nSee note to Table 8.7 for further information.\n\n| 5 | Abdominal wall defect with slight protrusion of abdominal contents palpable with increased abdominal pressure, readily reducible. |\n| 10 | Palpable abdominal wall defect with frequent or persistent protrusion of abdominal contents with increased abdominal pressure, manually reducible. |\n| 25 | Palpable abdominal wall defect with persistent, irreducible or irreparable protrusion of abdominal contents at the site of defect, causing limitation of activities of daily living. |\n\nNote to Table 8.7\n\n1. Hernias should be assessed only after surgical repair, except where there are sound medical reasons for repair not being undertaken.\n\n## CHAPTER 9 – THE MUSCULOSKELETAL SYSTEM\n\n### 9.0        Introduction\n\n214     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n215     [Chapter 9 – The musculoskeletal system](#_bookmark123) is divided into three parts:\n\na)      [Part I – The lower extremities](#_PART_I__);\n\nb)      [Part II – Upper extremities](#_PART_II__); and\n\nc)       [Part III – The spine](#_PART_III__).\n\n216     The range of motion to be measured is the range of active motion. The assessor should be satisfied that the claimant is making an appropriate effort to demonstrate the maximal range and that the measurements are consistent (that is, several repetitions). The normal ranges of motion of individual joints in the musculoskeletal system are set out on the next page.\n\n217     Peripheral vascular disease affecting lower and upper extremities is assessed under [Table 1.4: Peripheral vascular disease of the lower extremities](#Table_1_4) and [Table 1.5: Peripheral vascular disease of the upper extremities](#Table_1_5) (see [Chapter 1 – The cardiovascular system](#_bookmark19)).\n\n218     For the purposes of [Chapter 9 – The musculoskeletal system](#_bookmark123), activities of daily living are those in [Figure 9-A](#Figure_9_A).\n\nFigure 9-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\nFigure 9-B: Tables of normal ranges of motion of joints\n\n| Table | Joint | Plane | ROM from | ROM through | ROM to |\n| --- | --- | --- | --- | --- | --- |\n| 9.1 | Hindfoot/Ankle (subtalar) | Frontal | Eversion 20° | 0° | Inversion 30° |\n| 9.2 | Ankle (talocrural) | Sagittal | Extension 20° | 0° | Flexion 40° |\n| 9.3 | Knee | Sagittal | Extension 0° |  | Flexion 150° |\n| 9.4 | Hip | Rotation | External Rotation 50° | 0° | Internal Rotation 40° |\n| 9.4 | Hip | Frontal | Abduction 40° | 0° | Adduction 20° |\n| 9.4 | Hip | Sagittal | Extension 30° | 0° | Flexion 100° |\n| 9.8.1.a | Thumb – IP joint |  | Extension 30° | 0° | Flexion 80° |\n| 9.8.1.a | Thumb – MP joint |  | Extension 40° | 0° | Flexion 60° |\n| 9.8.1.b | Thumb – radial abduction/ adduction |  | 15° (full radial adduction) |  | 50° (full radial abduction) |\n| 9.8.1.b | Thumb adduction |  | 0cm |  | 8cm |\n| 9.8.1.b | Thumb opposition |  | 0cm |  | 8cm |\n| 9.8.1.c | Index and middle fingers – DIP joint |  | Extension 30° | 0° | Flexion 70° |\n| 9.8.1.c | Index and middle fingers – PIP joint |  | Extension 30° | 0° | Flexion 100° |\n| 9.8.1.c | Index and middle fingers – MP joint |  | Extension 20° | 0° | Flexion 90° |\n| 9.8.1.d | Ring and little fingers – DIP joint |  | Extension 30° | 0° | Flexion 70° |\n| 9.8.1.d | Ring and little fingers – PIP joint |  | Extension 30° | 0° | Flexion 100° |\n| 9.8.1.d | Ring and little fingers – MP joint |  | Extension 20° | 0° | Flexion 90° |\n| 9.9.1.a | Wrist | Sagittal | Extension 60° | 0° | Flexion 60° |\n| 9.9.1.b | Wrist | Frontal | Radial Deviation 20° | 0° | Ulnar deviation 30° |\n| 9.10.1.a | Elbow | Sagittal | Extension 0° | 0° | Flexion 140° |\n| 9.10.1.b | Elbow (forearm) | Rotation | Supination 80° | 0° | Pronation 80° |\n| 9.11.1.a | Shoulder | Sagittal | Extension 40° | 0° | Flexion 180° |\n| 9.11.1.b | Shoulder | Rotation | External rotation 90° | 0° | Internal Rotation 90° |\n| 9.11.1.c | Shoulder | Frontal | Abduction 180° | 0° | Adduction 50° |\n\n### PART I – THE LOWER EXTREMITIES – FEET AND TOES, ANKLES, KNEES AND HIPS\n\n### PART I – INTRODUCTION\n\n219     The impairments assessed for each region in the lower extremity are combined to obtain the overall impairment of the lower extremity for the individual extremity, subject to the notes accompanying the applicable tables, or any indication that combination is not permitted.\n\n220     Where a hip or knee arthroplasty procedure has been undertaken, assess the lower extremity impairment rating for arthroplasty in accordance with the AMA5, then convert that rating into a WPI rating using Table 17-33 of the AMA5.\n\n221     A WPI rating for one lower extremity may be combined with a WPI rating for the other lower extremity, except in the case of WPI ratings under [Table 9.7: Lower extremity function](#Table_9_7), where the notes accompanying Table 9.7 are followed.\n\n222     WPI ratings from [Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) or [Table 9.4: Hips](#Table_9_4) may not be combined with a WPI rating under [Table 9.7: Lower extremity function](#Table_9_7) if they assess the same condition in the same lower extremity.\n\n223     Where a condition cannot be assessed under [Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) or [Table 9.4: Hips](#Table_9_4), an assessment may be made under the provisions of the AMA5.\n\n224     If the assessor considers that the impairment is not adequately assessed using [Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) or [Table 9.4: Hips](#Table_9_4), and the condition does not cause a reduction in the range of motion of a joint but there is significant interference with gait, the assessor should consider the effect of the injury on gait and assess the WPI rating using [Table 9.7: Lower extremity function](#Table_9_7). Table 9.7 cannot be used if the condition causes a reduction in the range of motion of a joint and an assessment can be made under any one or more of Table 9.1, Table 9.2, Table 9.3 or Table 9.4.\n\n225     If permanent, conditions such as sesamoiditis, plantar fasciitis, plantar tendonitis, and pes planus, should be assessed under [Table 9.7: Lower extremity function](#Table_9_7).\n\n226     All ankylosis assessments from [Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) and [Table 9.4: Hips](#Table_9_4) are alternative assessments to those for abnormal motion of the individual joints.\n\n227     The maximum WPI rating for a single lower extremity in [Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) and [Table 9.4: Hips](#Table_9_4) is 40%, including combined WPI ratings.\n\n228     A chronic pain condition affecting the lower extremities should be assessed using the same methodology as for the upper extremity in accordance with [Section 9.13.3 (Chronic pain conditions)](#_bookmark203).\n\nSteps in calculating lower extremity impairment\n\n| Step 1 | Add abnormal motion/ankylosis impairment values within an individual joint. |\n| Step 2 | Combine abnormal motion/ankylosis impairment values for different joints in the toes. |\n| Step 3 | Add impairment values obtained for each individual toe and combine this value with the impairment values for other joints in the foot to obtain the total abnormal motion/ankylosis impairment assessment for a foot. |\n| Step 4 | Combine with abnormal motion/ankylosis impairment assessments for different regions in the lower extremity (that is, knee and hip). |\n| Step 5 | Combine with impairment values for peripheral nerve injuries. |\n| Step 6 | Combine with impairment values for amputation. |\n\n### 9.1        Feet and toes\n\n229     [Table 9.1: Feet and toes](#Table_9_1) assesses impairments to range of motion of the feet and toes, including ankylosis of one or more joints.\n\n230     In relation to impairment constituted by the loss, or the loss of the use, of a toe, the threshold for compensation for an injury resulting in a permanent impairment constituted by such a loss is 1% WPI under this Guide.\n\n231     The maximum WPI rating under [Table 9.1: Feet and toes](#Table_9_1) is 2% for an injury resulting in impairment of two or more of the 2nd, 3rd, 4th and 5th toes of one foot.\n\n232     In the case of toes, the ankylosis referred to in [Table 9.1: Feet and toes](#Table_9_1) is that of the metatarso-phalangeal joint.\n\n233     Ankylosis of the interphalangeal joints of the 2nd, 3rd, 4th or 5th toe attracts a WPI rating of 0%. The position of function is the neutral position.\n\nTable 9.1: Feet and toes\n\n| 0 | Ankylosis of any one of the 2nd, 3rd, 4th or 5th toes in position of function. |\n| 1 | Interphalangeal flexion of the 1st toe restricted to less than 20°.<br>Metatarso-phalangeal extension of the 1st toe restricted to a range of 15°-30°.<br>Metatarso-phalangeal extension of any one of the 2nd, 3rd, 4th and 5th toes restricted to less than 10°. Subtalar inversion restricted to a range of 10°-20°.<br>Subtalar eversion restricted to less than 10°.<br>Ankylosis of:<br>any one of the 2nd, 3rd, 4th or 5th toes in full extension or full flexionany two of the 2nd, 3rd, 4th or 5th toes in position of functionthe 2nd, 3rd and 4th toes in position of function. |\n| 2 | Metatarso-phalangeal extension of the 1st toe restricted to less than 15°.<br>Metatarso-phalangeal extension of any two of the 2nd, 3rd, 4th or 5th toes restricted to less than 10°. Subtalar inversion restricted to less than 10°.<br>Ankylosis of:<br>any two of the 2nd, 3rd or 4th toes, plus the 5th toe, in position of functionany two of the 2nd, 3rd, 4th or 5th toes in full extension or full flexionall four of the 2nd, 3rd, 4th and 5th toes in position of functionthe 2nd toe with any two of the 3rd, 4th or 5th toes in full extensionthe 3rd, 4th and 5th toes in full extension or full flexionthe 2nd and 3rd toes with either of the 4th or 5th toes in full flexion. |\n| 3 | Ankylosis of:<br>all four of the 2nd, 3rd, 4th and 5th toes in full flexion or full extensionthe 2nd toe with the 4th and 5th toes in full flexion. |\n| 4 | Ankylosis of:<br>the 1st toe in position of function or full extensionthe 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in position of function. |\n| 5 | Ankylosis of:<br>the 1st toe in full flexionthe 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in full extensionthe 1st toe with any two or three of the 2nd, 3rd, 4th or 5th toes in position of function. |\n| 6 | Ankylosis of:<br>the 1st toe with any two or three of the 2nd, 3rd, 4th or 5th toes in full extensionthe 1st toe with all four of the 2nd, 3rd, 4th and 5th toes in position of functionthe 1st toe with any one of the 2nd, 3rd, 4th or 5th toes in full flexion. |\n| 7 | Ankylosis of:<br>the 1st toe with any two of the 2nd, 3rd, 4th or 5th toes in full flexionthe 1st toe with all four of the 2nd, 3rd, 4th and 5th toes in full extension. |\n| 8 | Ankylosis of the 1st toe with any three or all four of the 2nd, 3rd, 4th and 5th toes in full flexion. |\n| 10 | Ankylosis of hindfoot with tibia-os calcis angle of 100° to 110°. |\n| 15 | Ankylosis of hindfoot with tibia-os calcis angle of 90° to 95°. |\n| 20 | Ankylosis of hindfoot with tibia-os calcis angle of less than 90°. |\n\n### 9.2        Ankles\n\n234     [Table 9.2: Ankles](#Table_9_2) assesses impairments to range of motion and deformity of the ankle, as well as ankylosis. Ankle deformity with movement is assessed separately from ankylosis.\n\n235     Ankylosis in the optimal position is equivalent to a WPI of 4%. The optimal position is the neutral position without flexion, extension, varus or valgus. This is the base level of ankylosis impairment in the ankle.\n\n236     When ankylosis is not in the optimal position, add the relevant WPI ratings from [Table 9.2: Ankles](#Table_9_2) for ankylosis in each direction. Then add the base figure of 4% WPI for ankylosis in the optimal position.\n\n237     The maximum WPI rating for multiple impairments of the ankle and hindfoot is 25% WPI. If the total WPI rating obtained by adding different WPI ratings is higher than 25% WPI, then the final WPI rating for the ankle is 25%.\n\nTable 9.2: Ankles\n\n| %WPI | Criteria<br>(one required – different conditions may be assessed separately – but see notes on ankylosis above) |\n| 3 | Plantar flexion capability restricted to 15°-20°.<br>Dorsiflexion restricted to less than 10°. |\n| 4 | Ankylosis in optimal position only (see paragraph 235 above). |\n| 5 | Deformity with:<br>varus angulation of 10°valgus angulation of 10°-20°.<br>Ankylosis not in optimal position:<br>in less than 10° of internal malrotationin 15° of external malrotation. |\n| 6 | Plantar flexion capability restricted to 10° or less.<br>Plantar flexion contracture of 10°-15°. |\n| 7 | Ankylosis not in optimal position:<br>in 10° to 15° of dorsiflexion or plantar flexion. |\n| 10 | Deformity with varus angulation of 15°-20°.<br>Ankylosis not in optimal position:<br>in varus angulation of 5°in valgus angulation of 10° to 15°in 10° to 15° of internal malrotationin 20° to 25° of external malrotation |\n| 12 | Plantar flexion contracture of at least 20°. |\n| 15 | Ankylosis not in optimal position:<br>in 20° to 25° of plantar flexionin at least 20° of dorsiflexionin varus angulation of 10° to 15°in valgus angulation of 20° to 25°in 20° to 25° of internal malrotationin 30° to 35° of external malrotation. |\n| 17 | Ankylosis not in optimal position:<br>in varus angulation of 20° to 25°. |\n| 20 | Deformity with varus angulation of 25° or greater. |\n| 21 | Ankylosis not in optimal position:<br>in varus angulation of at least 30°in at least 30° of plantar flexionin valgus angulation of at least 30°in at least 30° of internal malrotationin at least 40° of external malrotation. |\n\n### 9.3        Knees\n\n238     [Table 9.3: Knees](#Table_9_3) assesses impairments to range of motion and deformity of the knee, as well as ankylosis. Knee deformity with movement is assessed separately from ankylosis. ‘Deformity’ is measured by the femoral-tibial angle: 3°‑10° valgus is considered normal.\n\n239     Ankylosis in the optimal position is equivalent to 27% WPI. The optimal position is 10°-15° of flexion with good alignment. This is the base level of ankylosis impairment in the knee. When ankylosis is not in the optimal position, add the relevant WPI ratings from [Table 9.3: Knees](#Table_9_3) for ankylosis in each direction. Then add the base figure of 27% WPI for ankylosis in the optimal position.\n\n240     The maximum WPI rating for multiple impairments of the knee is 40% WPI. If the total WPI rating obtained by adding different WPI ratings is over 40%, then the final WPI rating for the knee is 40%.\n\nTable 9.3: Knees\n\n| 5 | Flexion of 80°-105°.<br>Flexion contracture of 5°.<br>Deformity with:<br>varus angulation of 2° valgus-0° (neutral)valgus angulation of 10°-12°.<br>Ankylosis not in optimal position:<br>in 10° to 15° of internal malrotationin 10° to 15° of external malrotationin less than 10° of varusin 10° to 15° of valgusin 20° to 25° of flexion. |\n| 10 | Flexion of 60°-75°.<br>Flexion contracture of 10°-15°.<br>Deformity with:<br>varus angulation of 1°-7°valgus angulation of 13°-15°.<br>Ankylosis not in optimal position:<br>in 20° to 25° of internal malrotationin 20° to 25° of external malrotationin 10° to 15° of varusin 20° to 25° of valgusin 30° to 35° of flexion. |\n| 13 | Ankylosis not in optimal position:<br>in at least 30° of internal malrotationin at least 30° of external malrotationin at least 20° of varusin at least 30° of valgusin at least 40° of flexion. |\n| 14 | Flexion of 30°-55°.<br>Flexion contracture of 20° or greater.<br>Deformity with:<br>varus angulation of 8°-12°valgus angulation of 16°-20°. |\n| 20 | Flexion of less than 30°.<br>Deformity with:<br>varus angulation of more than 12°valgus angulation of more than 20°. |\n| 27 | Ankylosis in optimal position only (see paragraph 239 above). |\n\n### 9.4        Hips\n\n241     [Table 9.4: Hips](#Table_9_4) assesses impairments of range of motion and deformity of the hip, as well as ankylosis. Hip deformity with movement is assessed separately from ankylosis.\n\n242     Ankylosis in the optimal position is 20% WPI. The optimal position is 25°-40° of flexion with neutral rotation, abduction and adduction. This is the base level of ankylosis impairment in the hip. When ankylosis is not in the optimal position, add the relevant WPI ratings from Table 9.4 for ankylosis in each direction. Then add the base figure of 20% WPI for ankylosis in the optimal position.\n\n243     The maximum WPI rating for multiple impairments of the hip is 40%. If the total WPI rating obtained by adding different WPI ratings is over 40%, then the final WPI rating for the hip is 40%.\n\nTable 9.4: Hips\n\n| 2 | Flexion restricted to 80°-100°.<br>Flexion contracture of 10°-15°.<br>Internal rotation restricted to 10°-15°.<br>External rotation restricted to 20°-30°.<br>Abduction restricted to 15°‑25°.<br>Adduction restricted to 15° or less.<br>Abduction contracture of 5° or less. |\n| 5 | Flexion restricted to 50°-70°.<br>Flexion contracture of 20°-25°.<br>Internal rotation restricted to less than 10°.<br>External rotation restricted to less than 20°.<br>Abduction restricted to 5°-10°.<br>Abduction contracture of 6°-10°.<br>Ankylosis not in optimal position:<br>in 20° to 40° of flexionin at least 5° of internal rotationin 10°-15° of external rotation. |\n| 10 | Flexion restricted to less than 50°.<br>Flexion contracture of 30° or more.<br>Abduction restricted to less than 5°.<br>Abduction contracture of 11°-20°.<br>Ankylosis not in optimal position:<br>in 10° to 50° of flexionin at least 10° of internal rotationin at least 20° of external rotationin 5°-10° of abductionin at least 5° of adduction. |\n| 15 | Abduction contracture of more than 20°.<br>Ankylosis not in optimal position:<br>in 0° to 60° of flexionin at least 20° of internal rotationin at least 30° of external rotationin 15°-20° of abductionin at least 10° of adduction. |\n| 20 | Ankylosis in optimal position (see paragraph 242 above).<br>Ankylosis not in optimal position:<br>in at least 70° of flexionin at least 30° of internal rotationin at least 40° of external rotationin at least 25° of abductionin at least 15° of adduction. |\n\n### 9.5        Lower extremity amputations\n\n244     [Table 9.5: Lower extremity amputations](#Table_9_5) is the only table used to assess impairment arising from amputations in the lower extremity.\n\n245     [Table 9.7: Lower extremity function](#Table_9_7) must not be used in cases involving amputations.\n\n246     A WPI rating from [Table 9.5: Lower extremity amputations](#Table_9_5) may be combined with other WPI ratings for lower extremity conditions above the amputation site.\n\nTable 9.5: Lower extremity amputations\n\n| 0 | Amputation through:<br>interphalangeal joint (distal or proximal) of any one of 2nd, 3rd, 4th or 5th toesany phalanx of any one of the 2nd, 3rd, 4th or 5th toes.<br>Amputation of any portion of soft tissue of any toe. |\n| 1 | Amputation of any one of the 2nd, 3rd, 4th or 5th toes at the metatarso-phalangeal joint. |\n| 2 | Amputation of:<br>the first toe at the interphalangeal jointany toe except the first toe through the metatarsalany two of the 2nd, 3rd, 4th or 5th toes at the metatarso-phalangeal joint. |\n| 3 | Amputation of any three of the 2nd, 3rd, 4th and 5th toes at the metatarso-phalangeal joint. |\n| 4 | Amputation of all four of the 2nd, 3rd, 4th and 5th toes at the metatarso-phalangeal joint. |\n| 5 | Amputation of the first toe at the metatarso-phalangeal joint. |\n| 8 | Amputation of the first metatarsal (first toe). |\n| 10 | Amputation of all toes of one foot at the metatarso-phalangeal joints. |\n| 16 | Transmetatarsal amputation. |\n| 18 | Midfoot amputation. |\n| 25 | Syme amputation of hindfoot. |\n| 28 | Amputation of lower leg more than 7.5cm below knee. |\n| 32 | Amputation of lower leg 7.5cm or less below knee.<br>Knee disarticulation.<br>Amputation above knee distal to midthigh. |\n| 36 | Amputation above knee through midthigh. |\n| 40 | Amputation above knee proximal to midthigh.<br>Hip disarticulation. |\n| 50 | Hemipelvectomy. |\n\n### 9.6        Spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities\n\n247     The grading system set out in [Figure 9-C](#Figure_9_C) is to be used with [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1), [Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2a) and [Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2b).\n\nFigure 9-C: Grading system\n\n| Grading | Sensory deficits or pain Criteria | Motor function Criteria |\n| 0 | No sensation.<br>or<br>Severe pain that prevents all activity. | No contraction. |\n| 1 | No protective sensibility with abnormal sensations.<br>or<br>Severe pain that prevents most activity. | A flicker. |\n| 2 | Decreased protective sensibility with abnormal sensations.<br>or<br>Severe pain that prevents some activity. | Active movement with gravity eliminated. |\n| 3 | Diminished light touch and two-point discrimination with some abnormal sensations.<br>or<br>Slight pain that interferes with some activity. | Active movement against gravity. |\n| 4 | Diminished light touch with or without minimal abnormal sensations.<br>or<br>Pain that is forgotten during activity. | Active movement against gravity and resistance. |\n| 5 | Normal sensation.<br>or<br>No pain. | Normal power. |\n\n#### 9.6.1   Spinal nerve root impairment affecting the lower extremity\n\n248     [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1) is to be used where there is involvement of a single spinal nerve. Where there are multiple nerves involved, the respective WPI ratings for each involved nerve may be combined.\n\n249     Values obtained for pain, discomfort and/or sensory loss may be combined with values obtained for loss of strength, using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n250     Where the same nerve root is assessed, [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1) must not be used in conjunction with [Table 9.17: Lumbar spine](#Table_9_17).\n\nTable 9.6.1: Spinal nerve root impairment affecting the lower extremity\n\n- Impairment causing pain, discomfort and/or sensory loss Grading Impairment causing loss of strength Grading\n- 5 4 3 2 1 0 5 4 3 2 1 0\n- Nerve root %WPI %WPI Nerve root\n- L3 0 1 1 2 3 3 0 2 3 5 7 8 L3\n- L4 0 1 1 2 3 3 0 3 6 8 12 14 L4\n- L5 0 1 1 2 3 3 0 3 6 9 13 15 L5\n- S1 0 1 1 2 3 3 0 2 3 5 7 8 S1\n\n#### 9.6.2   Peripheral nerve injuries affecting the lower extremities\n\n251     WPI ratings obtained for sensory impairment may be combined with WPI ratings for dysaesthesia, and the total combined with WPI ratings for motor impairment, using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n252     Where the same nerve is assessed, [Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2a) and [Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2b) must not be used in conjunction with [Table 9.17: Lumbar spine](#Table_9_17).\n\n","sortOrder":42},{"sectionNumber":"253","sectionType":"section","heading":"Use the grading system shown in [Figure 9-C](#Figure_9_C).","content":"253     Use the grading system shown in [Figure 9-C](#Figure_9_C).\n\nTable 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities\n\n- Sensory grading Dysaesthesia grading\n- 5 4 3 2 1 0 5 4 3 2 1 0\n- Nerve %WPI %WPI Nerve\n- Femoral 0 0 0 1 1 1 0 1 1 2 3 3 Femoral\n- Lateral femoral cutaneous 0 0 0 1 1 1 0 1 1 2 3 3 Lateral femoral cutaneous\n- Sciatic 0 1 3 5 6 7 0 1 2 4 5 5 Sciatic\n- Common peroneal 0 0 1 1 2 2 0 0 1 1 2 2 Common peroneal\n- Tibial 0 1 2 4 4 5 0 1 1 3 3 3 Tibial\n- Superficial peroneal 0 0 1 1 2 2 0 0 1 1 2 2 Superficial peroneal\n- Sural 0 0 0 1 1 1 0 0 1 1 2 2 Sural\n- Medial plantar 0 0 1 1 2 2 0 0 1 1 2 2 Medial plantar\n- Lateral plantar 0 0 1 1 2 2 0 0 1 1 2 2 Lateral plantar\n\nTable 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities\n\n- Motor grading\n- Femoral 0 3 6 9 13 15\n- Obturator 0 1 1 2 3 3\n- Superior gluteal 0 5 10 15 21 25\n- Inferior gluteal 0 3 6 9 13 15\n- Sciatic 0 6 12 18 26 30\n- Common peroneal 0 3 6 9 13 15\n- Tibial 0 3 6 9 13 15\n- Medial plantar 0 0 1 1 2 2\n- Lateral plantar 0 0 1 1 2 2\n\n### 9.7        Lower extremity function\n\n254     [Table 9.7: Lower extremity function](#Table_9_7) should only be used to assess impairment from objectively identified orthopaedic or neurological conditions arising in and affecting the lower extremities. It may not be used to assess impairment from conditions manifesting principally as pain with no clinically demonstrable lower extremity pathology.\n\n255     A secondary dysfunction (that is, impairment) consequent to disuse is only assessable under [Table 9.7: Lower extremity function](#Table_9_7) if this dysfunction is permanent and there are objective clinical findings that can be validly assessed using other tables in [Part I – The lower extremities – feet and toes, ankles, knees and hips](#_PART_I__) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)). The impairments resulting from an injury assessed in this way are to be combined using the combined values table (see [Appendix 1](#_bookmark300)).\n\n256     If permanent, conditions such as sesamoiditis, plantar fasciitis, plantar tendonitis, and pes planus, should be assessed under [Table 9.7: Lower extremity function](#Table_9_7).\n\n257     [Table 9.7: Lower extremity function](#Table_9_7) must not be used in cases involving amputations.\n\n258     A single assessment only may be made under [Table 9.7: Lower extremity function](#Table_9_7), regardless of whether one or two extremities are affected by the injury. The impairment assessed under Table 9.7 is of overall lower extremity function, rather than that of individual extremities. However, where a pre-existing injury results in permanent impairment to the same lower extremity function the subsequent injury should be assessed by reference to the functional capacities of a normal healthy person (see [Principles of Assessment](#_bookmark9), paragraph 39 above).\n\n259     Before using [Table 9.7: Lower extremity function](#Table_9_7) the assessor should check the instructions (see [Part I – Introduction](#_bookmark128)) preceding the specific joint impairment tables ([Table 9.1: Feet and toes](#Table_9_1), [Table 9.2: Ankles](#Table_9_2), [Table 9.3: Knees](#Table_9_3) and [Table 9.4: Hips](#Table_9_4)) and use Table 9.7 strictly in accordance with those instructions. In particular, Table 9.7 cannot be used where the condition causes a reduction in the range of motion of a joint and an assessment can be made under any one or more of Table 9.1, Table 9.2, Table 9.3 or Table 9.4.\n\n260     Where only one limb is affected, regardless of the number of impairments found in that limb, the limb should be assessed using the relevant tables other than [Table 9.7: Lower extremity function](#Table_9_7) and all impairments combined using the combined values table (see [Appendix 1](#_bookmark300)). The combined impairment rating should then be compared with the rating taken from the relevant row in Table 9.7 and the higher rating obtained from the two methods chosen.\n\n261     Where both limbs are affected, each limb should be assessed using the relevant tables other than [Table 9.7: Lower extremity function](#Table_9_7) and all impairments in both limbs combined using the combined values table (see [Appendix 1](#_bookmark300)). The combined impairment rating should then be compared with the rating taken from the relevant row in Table 9.7 and the higher rating obtained from the two methods chosen.\n\n262     [Table 9.7: Lower extremity function](#Table_9_7) may be used to assess lower extremity impairment arising as a result of spinal cord damage. Observe the special procedure set out in the introduction to Part III of this Chapter (see [Part III – Introduction](#_bookmark211)). However, Table 9.7 may not be used to assess lower extremity impairment arising as a result of nerve root compression, or other neurological sequelae of other spinal conditions. These should be assessed under:\n\na)      tables dealing with spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities:\n\ni)        [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1); or\n\nii)      [Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2a); or\n\niii)     [Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2b); or\n\nb)      [Table 9.15: Cervical spine – diagnosis-related estimates](#Table_9_15); or\n\nc)       [Table 9.16: Thoracic spine – diagnosis-related estimates](#Table_9_16); or\n\nd)      [Table 9.17: Lumbar spine – diagnosis-related estimates](#Table_9_17).\n\n263     To fulfil the requirements of a WPI rating in [Table 9.7: Lower extremity function](#Table_9_7), there must be one major criterion and at least two minor criteria present (where minor criteria are listed).\n\n264     ‘Manifest difficulty’ is difficulty (such as stumbling, or an altered gait) evident to the assessor. The difficulty must be tested clinically: history alone cannot be relied upon in the assessment.\n\nTable 9.7: Lower extremity function\n\n| %WPI | Major criteria (at least one required) | Minor criteria (at least two required where listed) |\n| 0 | Walks at a normal pace in comparison with peers on level ground or uneven ground and can avoid obstacles.<br>or<br>Distance walked is not restricted by the condition being assessed (although other factors such as the level of fitness may cause restriction). |  |\n| 5 | Walks at a normal pace in comparison with peers on level ground but has manifest difficulty negotiating uneven ground and avoiding obstacles.<br>or<br>Walking is restricted to 1000m or less (may be able to walk further after resting). | Legs give way or lock occasionally without causing falls.<br>and<br>Can negotiate three or more stairs or a ramp (up and down) without the use of a walking aid or hand rails. |\n| 10 | Walks at a normal pace in comparison with peers on level ground but is unable to negotiate uneven ground without use of a walking aid or personal assistant.<br>or<br>Walking is restricted to 500m or less (may be able to walk further after resting). | Legs give way or lock occasionally without causing falls.<br>and<br>Is unable to negotiate three or more stairs or a ramp (up and down) without the use of a walking aid or hand rails. |\n| 20 | Walks at a moderately reduced pace in comparison with peers on level ground.<br>or<br>Walking is restricted to 250m or less (may be able to walk further after resting). | At least two of the following:<br>Legs give way occasionally, causing falls.Is unable to negotiate three or more stairs or a ramp (up and down) without use of a walking aid or hand rails.Is unable to rise from sitting to standing position without use of one hand but can stand without support. |\n| 30 | Walks at a significantly reduced pace in comparison with peers on level ground.<br>or<br>Walking is restricted to 100m or less (may be able to walk further after resting). | At least two of the following:<br>Legs give way frequently, causing falls.Demonstrated medical need for a brace or walking aid (walking stick or crutches) on level ground.Is unable to negotiate three or more stairs or a ramp (up and down) without assistance from another person.Is unable to rise from sitting to standing position without use of both hands but can stand without support. |\n| 40 | Walks at a greatly reduced pace in comparison with peers on level ground.<br>or<br>Walking is restricted to 50m or less (may be able to walk further after resting). | At least two of the following:<br>Is restricted to walking around house and yard.Demonstrated medical need for a walking aid (walking stick or crutches) when walking on level ground.Is unable to negotiate three or more stairs or a ramp (up and down) under any circumstances.Is unable to rise from sitting to standing position without personal assistance and is unable to stand without support. |\n| 50 | Walks at a very slow pace in comparison with peers on level ground.<br>or<br>Walking is restricted to 25m or less (may be able to walk further after resting). | At least two of the following:<br>Is restricted to walking around house.Demonstrated medical need for a quad stick or walking frame as support when standing and walking.Is unable to negotiate any steps or ramps.Is unable to rise from sitting to standing position without personal assistance and is unable to stand without support. |\n| 60 | Can stand with support of personal assistant but is unable to walk. |  |\n| 65 | Unable to stand or walk. |  |\n\n### PART II – THE UPPER EXTREMITIES – HANDS AND FINGERS, WRISTS, ELBOWS AND SHOULDERS\n\n### PART II – INTRODUCTION\n\n","sortOrder":43},{"sectionNumber":"265","sectionType":"section","heading":"The impairments assessed for each region in each upper extremity are combined (that is, hand, wrist, elbow, shoulder).","content":"265     The impairments assessed for each region in each upper extremity are combined (that is, hand, wrist, elbow, shoulder).\n\n266     The WPI rating for one upper extremity may be combined with a WPI rating for the other upper extremity, except in the case of assessments under [Table 9.14: Upper extremity function](#Table_9_14), where the notes appearing prior to Table 9.14 are to be followed.\n\n267     WPI ratings from the following tables may not be combined with a WPI rating under [Table 9.14: Upper extremity function](#Table_9_14) if they assess the same condition in the same upper extremity:\n\na)      tables dealing with abnormal motion of digits:\n\ni)        [Table 9.8.1a: Abnormal motion/ankylosis of the thumb – IP and MP joints](#Table_9_8_1a);\n\nii)      [Table 9.8.1b: Radial abduction/adduction/opposition of the thumb – abnormal motion/ankylosis](#Table_9_8_1b);\n\niii)     [Table 9.8.1c: Abnormal motion/ankylosis of the fingers – index and middle fingers](#Table_9_8_1c);\n\niv)     [Table 9.8.1d: Abnormal motion/ankylosis of the fingers – ring and little fingers](#Table_9_8_1d);\n\nb)      tables dealing with sensory losses in thumb and fingers:\n\ni)        [Table 9.8.2a: Sensory losses in the thumb](#Table_9_8_2a);\n\nii)      [Table 9.8.2b: Sensory losses in the index and middle fingers](#Table_9_8_2b);\n\niii)     [Table 9.8.2c: Sensory losses in the little finger](#Table_9_8_2c);\n\niv)     [Table 9.8.2d: Sensory losses in the ring finger](#Table_9_8_2d);\n\nc)       tables dealing with wrists:\n\ni)        [Table 9.9.1a: Wrist flexion/extension](#Table_9_9_1a);\n\nii)      [Table 9.9.1b: Radial and ulnar deviation of wrist joint](#Table_9_9_1b);\n\nd)      tables dealing with elbows:\n\ni)        [Table 9.10.1a: Elbow – flexion/extension](#Table_9_10_1a);\n\nii)      [Table 9.10.1b: Pronation and supination of forearm](#Table_9_10_1b);\n\ne)      tables dealing with shoulders:\n\ni)        [Table 9.11.1a: Shoulder – flexion/extension](#Table_9_11_1a);\n\nii)      [Table 9.11.1b: Shoulder – internal/external rotation](#Table_9_11_1b);\n\niii)     [Table 9.11.1c: Shoulder – abduction/adduction](#Table_9_11_1c).\n\n268     If the assessor considers that the impairment is not adequately assessed using one of the tables in [Section 9.9 (Wrists)](#_Wrists), [Section 9.10 (Elbows)](#_Elbows) or [Section 9.11 (Shoulders)](#_Shoulders), and the condition involves objectively demonstrated joint instability, objectively demonstrated arthritis or where the employee has had an arthroplasty, the assessor may consider the effect of the injury on upper extremity function instead and assess the WPI rating using [Table 9.14: Upper extremity function](#Table_9_14). Table 9.14 cannot be used unless the condition involves objectively demonstrated joint instability or arthritis or the employee has had an arthroplasty.\n\n269     Where a condition cannot be assessed under a specific table in the upper extremities group, an assessment may be made under the provisions of the AMA5.\n\n270     All ankylosis assessments from tables in the upper extremities group are alternative assessments to those for abnormal motion of the individual joints.\n\n","sortOrder":44},{"sectionNumber":"271","sectionType":"section","heading":"The maximum WPI rating for a single upper extremity is 60%, including combined WPI ratings.","content":"271     The maximum WPI rating for a single upper extremity is 60%, including combined WPI ratings.\n\nSteps in calculating upper extremity impairment\n\n272     Note that sensory loss in the digit is assessed either as a digit impairment or as a peripheral nerve impairment as appropriate, but not both.\n\n| Step 1 | Add abnormal motion/ankylosis impairment values within an individual joint. |\n| Step 2 | Add abnormal motion/ankylosis impairment values for different joints in the thumb. |\n| Step 3 | Combine impairment values for different joints in the other four digits. |\n| Step 4 | Combine impairment values for each digit for sensory loss due to digital nerve injury and/or amputation. |\n| Step 5 | Add impairment values for each digit to obtain the total hand assessment. |\n| Step 6 | Combine with impairment values for different regions in the upper extremity. |\n\n### 9.8        Hands and fingers\n\n","sortOrder":45},{"sectionNumber":"273","sectionType":"section","heading":"Add the WPI ratings for each individual digit to obtain the total WPI rating for the hand.","content":"273     Add the WPI ratings for each individual digit to obtain the total WPI rating for the hand.\n\n","sortOrder":46},{"sectionNumber":"274","sectionType":"section","heading":"WPI ratings for abnormal motion or ankylosis of digits are combined with those for sensory losses in the same digits.","content":"274     WPI ratings for abnormal motion or ankylosis of digits are combined with those for sensory losses in the same digits.\n\n#### 9.8.1   Abnormal motion of digits\n\n275     The following tables assess impairments to range of motion of the digits of the hand, including ankylosis of one or more joints:\n\na)      [Table 9.8.1a: Abnormal motion/ankylosis of the thumb – IP and MP joints](#Table_9_8_1a);\n\nb)      [Table 9.8.1b: Radial abduction/adduction/opposition of the thumb – abnormal motion/ankylosis](#Table_9_8_1b);\n\nc)       [Table 9.8.1c: Abnormal motion/ankylosis of the fingers – index and middle fingers](#Table_9_8_1c); and\n\nd)      [Table 9.8.1d: Abnormal motion/ankylosis of the fingers – ring and little fingers](#Table_9_8_1d).\n\n276     Impairment values for flexion and extension losses in each individual joint are added to obtain the total WPI rating for loss of range of motion of that joint.\n\n277     Where there is abnormal motion or ankylosis of more than one joint of the same finger, the WPI ratings for abnormal motion or ankylosis are combined to obtain the WPI rating for that finger.\n\n278     Where there is abnormal motion or ankylosis of more than one joint of the thumb, the WPI ratings for abnormal motion or ankylosis are added to obtain the WPI rating for the thumb.\n\nTable 9.8.1a: Abnormal motion/ankylosis of the thumb – IP and MP joints\n\nSee notes to Table 9.8.1a for further information.\n\n- Direction IP joint MP joint Direction\n- Extension/ hyper-extension Ankylosis Loss of extension Loss of flexion Ankylosis Loss of extension Loss of flexion Extension/ hyper-extension\n- %WPI %WPI %WPI %WPI %WPI %WPI\n- 2 0 2 40°\n- 30° 3 0 3 2 0 2 30°\n- 20° 3 0 3 2 0 2 20°\n- 10° 2 0 2 2 0 2 10°\n- 0° 2 0 2 1 0 1 0°\n- 10° 2 1 1 1 0 1 10°\n- 20° 2 1 1 1 0 1 20°\n- 30° 2 1 1 1 1 1 30°\n- 40° 2 2 1 2 1 1 40°\n- 50° 2 2 1 2 2 0 50°\n- 60° 3 2 0 2 2 0 60°\n- 70° 3 3 0\n- 80° 3 3 0\n\nTable 9.8.1b: Radial abduction/adduction/opposition of the thumb – abnormal motion/ankylosis\n\nSee notes to Table 9.8.1b for further information.\n\n| 0 | Loss of less than 10° of radial adduction.<br>Loss of less than 35° of radial abduction.<br>Lack of less than 3cm adduction.<br>Thumb opposition of more than 6cm. |\n| 1 | Loss of 10°-20° of radial adduction.<br>Loss of 35°-40° of radial abduction.<br>Lack of 3-5cm adduction.<br>Thumb opposition of 5-6cm.<br>Ankylosis in 30°-35° of radial abduction. |\n| 2 | Loss of 25° or more of radial adduction.<br>Loss of 45° or more of radial abduction.<br>Lack of 6cm adduction.<br>Ankylosis in 15°-25°, or 40°-50° of radial abduction.<br>Ankylosis in 4cm of adduction.<br>Thumb opposition of 4cm. |\n| 3 | Lack of 7cm adduction.<br>Thumb opposition of 3cm.<br>Ankylosis in 3cm or 5cm of adduction. |\n| 4 | Lack of 8cm adduction.<br>Ankylosis in 0-2cm or 6-8cm of adduction. |\n| 5 | Thumb opposition of 2cm.<br>Ankylosis in thumb opposition of 5-6cm. |\n| 6 | Ankylosis in thumb opposition of 4cm or 7cm. |\n| 7 | Thumb opposition of 1cm.<br>Ankylosis in thumb opposition of 3cm or 8cm. |\n| 8 | Ankylosis in thumb opposition of 1 or 2cm. |\n| 10 | Thumb opposition of 0cm.<br>Ankylosis in thumb opposition of 0cm. |\n\nTable 9.8.1c: Abnormal motion/ankylosis of the fingers – index and middle fingers\n\nSee notes to Table 9.8.1c for further information.\n\n- Direction Index and middle fingers Direction\n- Extension/ hyper-extension DIP joint PIP joint MP joint Extension/ hyper-extension\n- Ankylosis Loss of extension Loss of flexion Ankylosis Loss of extension Loss of flexion Ankylosis Loss of extension Loss of flexion\n- %WPI %WPI %WPI %WPI %WPI %WPI %WPI %WPI %WPI\n- 30° 5 0 5 8 0 8 30°\n- 20° 4 0 4 8 0 8 7 0 7 20°\n- 10° 4 0 4 7 0 7 6 1 6 10°\n- 0° 4 0 4 7 0 7 6 1 5 0°\n- 10° 4 0 3 6 1 6 5 1 5 10°\n- 20° 3 1 3 6 1 5 5 1 4 20°\n- 30° 4 1 2 6 1 4 5 1 4 30°\n- 40° 4 2 2 5 2 4 6 3 3 40°\n- 50° 4 3 1 6 3 3 7 4 2 50°\n- 60° 4 4 1 7 4 3 8 6 2 60°\n- 70° 5 5 0 7 5 2 8 8 1 70°\n- 80° 8 7 1 10 9 1 80°\n- 90° 8 8 1 11 11 0 90°\n- 100° 8 8 0 100°\n\n \n\nTable 9.8.1d: Abnormal motion/ankylosis of the fingers – ring and little fingers\n\nSee notes to Table 9.8.1d for further information.\n\n- Direction Ring and little fingers Direction\n- Extension/ hyper-extension DIP joint PIP joint MP joint Extension/ hyper-extension\n- Ankylosis Loss of extension Loss of flexion Ankylosis Loss of extension Loss of flexion Ankylosis Loss of extension Loss of flexion\n- %WPI %WPI %WPI %WPI %WPI %WPI %WPI %WPI %WPI\n- 30° 3 0 3 4 0 4 30°\n- 20° 2 0 2 4 0 4 3 0 3 20°\n- 10° 2 0 2 4 0 4 3 0 3 10°\n- 0° 2 0 2 3 0 3 3 1 3 0°\n- 10° 2 0 2 3 0 3 3 1 2 10°\n- 20° 2 0 2 3 1 3 3 1 2 20°\n- 30° 2 1 1 3 1 2 3 1 2 30°\n- 40° 2 1 1 3 1 2 3 2 2 40°\n- 50° 2 2 1 3 2 2 3 2 1 50°\n- 60° 2 2 1 3 2 1 4 3 1 60°\n- 70° 3 3 0 4 3 1 4 4 1 70°\n- 80° 4 3 1 5 5 1 80°\n- 90° 4 4 1 5 5 0 90°\n- 100° 4 4 0 100°\n\nNotes to Tables 9.8.1a, 9.8.1b, 9.8.1c and 9.8.1d\n\n1. Abbreviations:\n\nIP = interphalangeal.\n\nMP = metacarpo-phalangeal.\n\nCMC = carpometacarpal.\n\nPIP = Proximal interphalangeal.\n\nDIP = Distal interphalangeal.\n\n2.     Thumb adduction is the smallest possible distance from the flexor crease of the IP joint of the thumb to the distal palmar crease over the level of the MP joint of the little finger. The normal range of adduction of the thumb is from 8cm to 0cm.\n\n3.     Thumb radial abduction is the largest angle of separation actively formed between the first and second metacarpals in the coronal plane. The normal angle of radial abduction is 50°. The smallest angle of thumb radial adduction is 15°.\n\n4.     Opposition of the thumb is measured as the largest achievable distance between the flexor crease of the IP joint of the thumb to the distal palmar crease directly over the third MP joint. The normal range of opposition of the thumb is from 0cm to 8cm. In the case of employees with small hands, compare the loss of opposition with the normal range of opposition in the unaffected hand.\n\n5.     Optimal positions of thumb and fingers:\n\n- Joint Optimal position Joint Optimal position\n- Thumb IP 20° of flexion Finger DIP 20° of flexion\n- Thumb MP 20° of flexion Finger PIP 40° of flexion\n- Thumb CMC 30°-35° of radial abduction Finger MP 30° of flexion\n\n#### 9.8.2   Sensory losses in the thumb and fingers\n\n","sortOrder":47},{"sectionNumber":"279","sectionType":"section","heading":"The following tables assess sensory losses in the thumb and fingers due to digital nerve lesions only:","content":"279     The following tables assess sensory losses in the thumb and fingers due to digital nerve lesions only:\n\na)      [Table 9.8.2a: Sensory losses in the thumb](#Table_9_8_2a);\n\nb)      [Table 9.8.2b: Sensory losses in the index and middle fingers](#Table_9_8_2b);\n\nc)       [Table 9.8.2c: Sensory losses in the little finger](#Table_9_8_2c); and\n\nd)      [Table 9.8.2d: Sensory losses in the ring finger](#Table_9_8_2d).\n\n280     Sensory losses due to peripheral nerve lesions are assessed under tables dealing with neurological impairments affecting the upper extremities:\n\na)      [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1);\n\nb)      [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a); and\n\nc)       [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b).\n\n","sortOrder":48},{"sectionNumber":"281","sectionType":"section","heading":"The two-point discrimination test is used to assess sensory loss:","content":"281     The two-point discrimination test is used to assess sensory loss:\n\na)      Total sensory loss = two-point discrimination of greater than 15mm;\n\nb)      Partial sensory loss = two-point discrimination of 7mm to 15mm.\n\n","sortOrder":49},{"sectionNumber":"282","sectionType":"section","heading":"Two-point discrimination of less than 7mm is not treated as an impairment.","content":"282     Two-point discrimination of less than 7mm is not treated as an impairment.\n\n283     Transverse sensory loss involves both digital nerves (ulnar and radial). Longitudinal sensory loss involves a single digital nerve (ulnar or radial).\n\n284     Assess the percentage of digit length involved using the method in the AMA5 and consult [Table 9.8.2a: Sensory losses in the thumb](#Table_9_8_2a), [Table 9.8.2b: Sensory losses in the index and middle fingers](#Table_9_8_2b), [Table 9.8.2c: Sensory losses in the little finger](#Table_9_8_2c) and [Table 9.8.2d: Sensory losses in the ring finger](#Table_9_8_2d), using the corresponding WPI rating for the nerve or nerves involved.\n\n285     WPI ratings for transverse sensory loss may not be combined with WPI ratings for longitudinal sensory loss in the same digit. The conditions of transverse sensory loss and longitudinal sensory loss in an individual digit are mutually exclusive.\n\n","sortOrder":50},{"sectionNumber":"286","sectionType":"section","heading":"WPI ratings for sensory losses in digits are combined with those for abnormal motion or ankylosis in the same digits.","content":"286     WPI ratings for sensory losses in digits are combined with those for abnormal motion or ankylosis in the same digits.\n\n287     For the thumb and little finger, losses involving the ulnar digital nerve are rated higher than those of the radial digital nerve. For the other fingers, losses involving the radial digital nerve are rated higher than those of the ulnar digital nerve.\n\n","sortOrder":51},{"sectionNumber":"288","sectionType":"section","heading":"If the little finger has been amputated, the ring finger is assessed as if it were the little finger.","content":"288     If the little finger has been amputated, the ring finger is assessed as if it were the little finger.\n\nTable 9.8.2a: Sensory losses in the thumb\n\n- Percentage of digit length %WPI (thumb)\n- 10 1 1 1 1 1 0\n- 20 2 1 1 1 1 1\n- 30 3 2 2 1 1 1\n- 40 4 2 3 1 2 1\n- 50 5 3 3 2 2 1\n- 60 7 3 4 2 3 1\n- 70 8 4 4 2 3 2\n- 80 8 4 5 3 3 2\n- 90 10 5 6 3 4 2\n- 100 11 5 7 3 4 2\n\nTable 9.8.2b: Sensory losses in the index and middle fingers\n\n- Percentage of digit length %WPI (index and middle fingers)\n- 10 1 1 0 0 1 0\n- 20 1 1 1 0 1 1\n- 30 2 1 1 1 1 1\n- 40 2 1 1 1 1 1\n- 50 3 2 1 1 2 1\n- 60 3 2 1 1 2 1\n- 70 4 2 2 1 2 1\n- 80 4 2 2 1 3 1\n- 90 5 3 2 1 3 2\n- 100 5 3 2 1 3 2\n\nTable 9.8.2c: Sensory losses in the little finger\n\n- Percentage of digit length %WPI (little finger)\n- 10 1 0 0 0 0 0\n- 20 1 1 1 0 0 0\n- 30 1 1 1 1 1 0\n- 40 1 1 1 1 1 0\n- 50 2 1 1 1 1 1\n- 60 2 1 1 1 1 1\n- 70 2 1 1 1 1 1\n- 80 2 1 1 1 1 1\n- 90 3 1 2 1 1 1\n- 100 3 2 2 1 1 1\n\nTable 9.8.2d: Sensory losses in the ring finger\n\n- Percentage of digit length %WPI (ring finger)\n- 10 1 0 0 0 0 0\n- 20 1 1 0 0 1 0\n- 30 1 1 1 0 1 1\n- 40 1 1 1 0 1 1\n- 50 2 1 1 1 1 1\n- 60 2 1 1 1 1 1\n- 70 2 1 1 1 1 1\n- 80 2 1 1 1 1 1\n- 90 3 1 1 1 2 1\n- 100 3 2 1 1 2 1\n\n### 9.9        Wrists\n\n","sortOrder":52},{"sectionNumber":"289","sectionType":"section","heading":"The following tables assess impairments to range of motion of the wrists, including ankylosis:","content":"289     The following tables assess impairments to range of motion of the wrists, including ankylosis:\n\na)      [Table 9.9.1a: Wrist flexion/extension](#Table_9_9_1a); and\n\nb)      [Table 9.9.1b: Radial and ulnar deviation of wrist joint](#Table_9_9_1b).\n\n290     Loss of range of motion in each functional plane is measured from the neutral position. The range of motion is expressed as the two achievable limits of active motion in each direction through the normal range of motion. It is possible that the only motion that can be achieved is between two points on one side of the neutral position.\n\n291     The WPI rating for restriction of motion in one direction is assessed according to the active motion than can be achieved in that direction. It is then added to the WPI rating for the active motion in the reverse direction.\n\n292     Add the abnormal motion WPI ratings for each direction of motion for both wrist flexion/extension and radial/ulnar deviation. Where there is ankylosis, including after an arthrodesis procedure, the assessment should be made only under the ankylosis scale.\n\n293     Where an arthroplasty procedure has been undertaken, refer to the AMA5. Assess the upper extremity impairment rating for abnormal motion and the upper extremity impairment rating for arthroplasty in accordance with the AMA5, then convert each of those ratings into WPI ratings using Table 16-3 of the AMA5. Combine those WPI ratings obtained from the AMA5 using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n294     For ankylosis, the optimal position for arthrodesis of the wrist is approximately 15°-20° of dorsiflexion with slight ulnar deviation.\n\n","sortOrder":53},{"sectionNumber":"295","sectionType":"section","heading":"The maximum possible wrist impairment is 35% WPI.","content":"295     The maximum possible wrist impairment is 35% WPI.\n\n296     For the same condition, a WPI rating from [Table 9.9.1a: Wrist flexion/extension](#Table_9_9_1a) or [Table 9.9.1b: Radial and ulnar deviation of wrist joint](#Table_9_9_1b) may not be combined with a WPI rating from [Table 9.14: Upper extremity function](#Table_9_14).\n\nTable 9.9.1a: Wrist flexion/extension\n\n| Extension | %WPI | %WPI | %WPI | Extension |\n| 60° | 25 | 0 | 25 | 60° |\n| 50° | 22 | 1 | 22 | 50° |\n| 40° | 17 | 2 | 15 | 40° |\n| 30° | 16 | 3 | 13 | 30° |\n| 20° | 14 | 4 | 10 | 20° |\n| 10° | 13 | 5 | 8 | 10° |\n| 0° | 13 | 7 | 6 | 0° |\n| 10° | 13 | 8 | 5 | 10° |\n| 20° | 15 | 11 | 4 | 20° |\n| 30° | 17 | 14 | 3 | 30° |\n| 40° | 20 | 18 | 2 | 40° |\n| 50° | 23 | 22 | 1 | 50° |\n| 60° | 25 | 25 | 0 | 60° |\n| Flexion |  |  |  | Flexion |\n\nTable 9.9.1b: Radial and ulnar deviation of wrist joint\n\n| Direction | Ankylosis | Loss of radial deviation | Loss of ulnar deviation | Direction |\n| Radial deviation | %WPI | %WPI | %WPI | Radial deviation |\n| 20° | 11 | 0 | 11 | 20° |\n| 15° | 10 | 1 | 9 | 15° |\n| 10° | 8 | 1 | 7 | 10° |\n| 5° | 7 | 2 | 5 | 5° |\n| 0° | 5 | 2 | 3 | 0° |\n| 5° | 5 | 3 | 2 | 5° |\n| 10° | 5 | 3 | 2 | 10° |\n| 15° | 7 | 5 | 2 | 15° |\n| 20° | 8 | 7 | 1 | 20° |\n| 25° | 10 | 9 | 1 | 25° |\n| 30° | 11 | 11 | 0 | 30° |\n| Ulnar deviation |  |  |  | Ulnar deviation |\n\n### 9.10   Elbows\n\n","sortOrder":54},{"sectionNumber":"297","sectionType":"section","heading":"The following tables assess impairments to range of motion of the elbows, including ankylosis:","content":"297     The following tables assess impairments to range of motion of the elbows, including ankylosis:\n\na)      [Table 9.10.1a: Elbow – flexion/extension](#Table_9_10_1a); and\n\nb)      [Table 9.10.1b: Pronation and supination of forearm](#Table_9_10_1b).\n\n298     Loss of range of motion in each functional plane is measured from the neutral position. The range of motion is expressed as the two achievable limits of active motion in each direction through the normal range of motion. It is possible that the only motion that can be achieved is between two points on one side of the neutral position.\n\n299     The WPI rating for restriction of motion in one direction is assessed according to the active motion than can be achieved in that direction. It is then added to the WPI rating for the active motion in the reverse direction.\n\n300     Add the abnormal motion WPI rating for each direction of motion for both elbow flexion/extension and pronation/ supination. Where there is ankylosis, including after an arthrodesis procedure, the assessment should be made only under the ankylosis scale.\n\n301     Where an arthroplasty procedure has been undertaken, refer to the AMA5. Assess the upper extremity impairment rating for abnormal motion and the upper extremity impairment rating for arthroplasty in accordance with AMA5, then convert each of those ratings into WPI ratings using Table 16-3 of the AMA5. Combine those WPI ratings obtained from the AMA5 using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n","sortOrder":55},{"sectionNumber":"302","sectionType":"section","heading":"For ankylosis, the optimal or functional position is 80° of flexion and 20° of pronation.","content":"302     For ankylosis, the optimal or functional position is 80° of flexion and 20° of pronation.\n\n","sortOrder":56},{"sectionNumber":"303","sectionType":"section","heading":"The maximum possible elbow impairment is 40% WPI.","content":"303     The maximum possible elbow impairment is 40% WPI.\n\n304     For the same condition, a WPI rating from [Table 9.10.1a: Elbow – flexion/extension](#Table_9_10_1a) or [Table 9.10.1b: Pronation and supination of forearm](#Table_9_10_1b) may not be combined with a WPI rating from [Table 9.14: Upper extremity function](#Table_9_14).\n\nTable 9.10.1a: Elbow – flexion/extension\n\n| Flexion | %WPI | %WPI | %WPI | Flexion |\n| 140° | 25 | 25 | 0 | 140° |\n| 130° | 23 | 22 | 1 | 130° |\n| 120° | 20 | 19 | 1 | 120° |\n| 110° | 19 | 16 | 2 | 110° |\n| 100° | 16 | 13 | 4 | 100° |\n| 90° | 15 | 10 | 5 | 90° |\n| 80° | 13 | 7 | 6 | 80° |\n| 70° | 14 | 5 | 9 | 70° |\n| 60° | 15 | 4 | 11 | 60° |\n| 50° | 17 | 3 | 14 | 50° |\n| 40° | 19 | 2 | 16 | 40° |\n| 30° | 20 | 2 | 19 | 30° |\n| 20° | 22 | 1 | 20 | 20° |\n| 10° | 23 | 1 | 22 | 10° |\n| 0° | 25 | 0 | 25 | 0° |\n| Extension |  |  |  | Extension |\n\nTable 9.10.1b: Pronation and supination of forearm\n\n| Direction | Ankylosis | Loss of pronation | Loss of supination | Direction |\n| Supination | %WPI | %WPI | %WPI | Supination |\n| 80° | 17 | 17 | 0 | 80° |\n| 70° | 16 | 16 | 0 | 70° |\n| 60° | 16 | 15 | 1 | 60° |\n| 50° | 15 | 14 | 1 | 50° |\n| 40° | 14 | 13 | 1 | 40° |\n| 30° | 14 | 13 | 1 | 30° |\n| 20° | 13 | 11 | 2 | 20° |\n| 10° | 11 | 9 | 2 | 10° |\n| 0° | 9 | 7 | 2 | 0° |\n| 10° | 7 | 5 | 2 | 10° |\n| 20° | 5 | 2 | 2 | 20° |\n| 30° | 5 | 2 | 4 | 30° |\n| 40° | 7 | 2 | 5 | 40° |\n| 50° | 9 | 1 | 8 | 50° |\n| 60° | 11 | 1 | 11 | 60° |\n| 70° | 14 | 1 | 13 | 70° |\n| 80° | 17 | 0 | 17 | 80° |\n| Pronation |  |  |  | Pronation |\n\n### 9.11   Shoulders\n\n","sortOrder":57},{"sectionNumber":"305","sectionType":"section","heading":"The following tables assess impairments to range of motion of the shoulders, including ankylosis:","content":"305     The following tables assess impairments to range of motion of the shoulders, including ankylosis:\n\na)      [Table 9.11.1a: Shoulder – flexion/extension](#Table_9_11_1a);\n\nb)      [Table 9.11.1b: Shoulder – internal/external rotation](#Table_9_11_1b); and\n\nc)       [Table 9.11.1c: Shoulder – abduction/adduction](#Table_9_11_1c).\n\n306     Loss of range of motion in each functional plane is measured from the neutral position. The range of motion is expressed as the two achievable limits of active motion in each direction through the normal range of motion. It is possible that the only motion that can be achieved is between two points on one side of the neutral position.\n\n307     The WPI rating for restriction of motion in one direction is assessed according to the active motion than can be achieved in that direction. It is then added to the WPI rating for the active motion in the reverse direction.\n\n308     Add the abnormal motion WPI ratings for each direction of motion for shoulder flexion/extension, abduction/adduction and internal/external rotation. Where there is ankylosis, including after an arthrodesis procedure, the assessment should only be made under the ankylosis scale.\n\n309     Where an arthroplasty procedure has been undertaken, refer to the AMA5. Assess the upper extremity impairment rating for abnormal motion and the upper extremity impairment rating for arthroplasty in accordance with the AMA5, then convert each of those ratings into WPI ratings using Table 16-3 of AMA5. Combine those WPI ratings obtained from the AMA5 using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n310     For ankylosis, the optimal or functional position is 20°-40° of flexion, 20°-50° of abduction and 30°-50° of internal rotation. Unless the shoulder has been arthrodesed, an assessment for ankylosis under this table would be rare.\n\n","sortOrder":58},{"sectionNumber":"311","sectionType":"section","heading":"The maximum possible shoulder impairment is 35% WPI.","content":"311     The maximum possible shoulder impairment is 35% WPI.\n\n312     For the same condition, a WPI rating from [Table 9.11.1a: Shoulder – flexion/extension](#Table_9_11_1a), [Table 9.11.1b: Shoulder – internal/external rotation](#Table_9_11_1b) or [Table 9.11.1c: Shoulder – abduction/adduction](#Table_9_11_1c) may not be combined with a WPI rating from [Table 9.14: Upper extremity function](#Table_9_14).\n\nTable 9.11.1a: Shoulder – flexion/extension\n\n| Flexion | %WPI | %WPI | %WPI | Flexion |\n| 180° | 18 | 18 | 0 | 180° |\n| 170° | 18 | 17 | 1 | 170° |\n| 160° | 17 | 17 | 1 | 160° |\n| 150° | 17 | 16 | 1 | 150° |\n| 140° | 17 | 16 | 2 | 140° |\n| 130° | 17 | 15 | 2 | 130° |\n| 120° | 17 | 14 | 2 | 120° |\n| 110° | 17 | 14 | 3 | 110° |\n| 100° | 16 | 13 | 3 | 100° |\n| 90° | 16 | 13 | 4 | 90° |\n| 80° | 15 | 11 | 4 | 80° |\n| 70° | 13 | 9 | 4 | 70° |\n| 60° | 12 | 7 | 5 | 60° |\n| 50° | 10 | 5 | 5 | 50° |\n| 40° | 9 | 3 | 6 | 40° |\n| 30° | 9 | 3 | 6 | 30° |\n| 20° | 9 | 2 | 7 | 20° |\n| 10° | 11 | 2 | 10 | 10° |\n| 0° | 14 | 2 | 13 | 0° |\n| 10° | 15 | 1 | 14 | 10° |\n| 20° | 16 | 1 | 14 | 20° |\n| 30° | 16 | 1 | 16 | 30° |\n| 40° | 17 | 1 | 17 | 40° |\n| 50° | 18 | 0 | 18 | 50° |\n| Extension |  |  |  | Extension |\n\nTable 9.11.1b: Shoulder – internal/external rotation\n\n| Direction | Ankylosis | Loss of external rotation | Loss of internal rotation | Direction |\n| External rotation | %WPI | %WPI | %WPI | External rotation |\n| 90° | 7 | 0 | 7 | 90° |\n| 80° | 7 | 0 | 7 | 80° |\n| 70° | 7 | 0 | 7 | 70° |\n| 60° | 6 | 0 | 6 | 60° |\n| 50° | 6 | 1 | 5 | 50° |\n| 40° | 5 | 1 | 5 | 40° |\n| 30° | 5 | 1 | 5 | 30° |\n| 20° | 5 | 1 | 4 | 20° |\n| 10° | 5 | 1 | 4 | 10° |\n| 0° | 4 | 1 | 3 | 0° |\n| 10° | 4 | 1 | 3 | 10° |\n| 20° | 4 | 1 | 2 | 20° |\n| 30° | 4 | 1 | 2 | 30° |\n| 40° | 4 | 2 | 2 | 40° |\n| 50° | 4 | 2 | 1 | 50° |\n| 60° | 4 | 3 | 1 | 60° |\n| 70° | 5 | 5 | 1 | 70° |\n| 80° | 6 | 6 | 0 | 80° |\n| 90° | 7 | 7 | 0 | 90° |\n| Internal rotation |  |  |  | Internal rotation |\n\nTable 9.11.1c: Shoulder – abduction/adduction\n\n| Direction | Ankylosis | Loss of adduction | Loss of abduction | Direction |\n| Abduction | %WPI | %WPI | %WPI | Abduction |\n| 180° | 11 | 11 | 0 | 180° |\n| 170° | 11 | 11 | 0 | 170° |\n| 160° | 10 | 10 | 1 | 160° |\n| 150° | 10 | 10 | 1 | 150° |\n| 140° | 10 | 9 | 1 | 140° |\n| 130° | 10 | 9 | 1 | 130° |\n| 120° | 10 | 8 | 2 | 120° |\n| 110° | 10 | 8 | 2 | 110° |\n| 100° | 10 | 7 | 2 | 100° |\n| 90° | 10 | 7 | 2 | 90° |\n| 80° | 8 | 5 | 3 | 80° |\n| 70° | 7 | 4 | 3 | 70° |\n| 60° | 7 | 3 | 3 | 60° |\n| 50° | 5 | 2 | 3 | 50° |\n| 40° | 5 | 2 | 3 | 40° |\n| 30° | 5 | 1 | 4 | 30° |\n| 20° | 5 | 1 | 7 | 20° |\n| 10° | 7 | 1 | 6 | 10° |\n| 0° | 8 | 1 | 7 | 0° |\n| 10° | 9 | 1 | 8 | 10° |\n| 20° | 10 | 1 | 9 | 20° |\n| 30° | 10 | 1 | 10 | 30° |\n| 40° | 10 | 0 | 10 | 40° |\n| 50° | 11 | 0 | 11 | 50° |\n| Adduction |  |  |  | Adduction |\n\n### 9.12   Upper extremity amputations\n\n","sortOrder":59},{"sectionNumber":"313","sectionType":"section","heading":"Total loss of hand function is equivalent to amputation of the whole hand and attracts a WPI rating of 54%.","content":"313     Total loss of hand function is equivalent to amputation of the whole hand and attracts a WPI rating of 54%.\n\n314     [Table 9.14: Upper extremity function](#Table_9_14) must not be used for amputations.\n\nTable 9.12.1: Upper extremity amputations\n\n| 54 | Amputation of thumb and all fingers through metacarpals. |\n| 56 | Amputation at wrist or between wrist and distal to bicipital insertion. |\n| 57 | Amputation from distal to deltoid insertion to bicipital insertion. |\n| 60 | Amputation of arm at deltoid insertion and proximally.<br>or<br>Amputation at shoulder. |\n| 70 | Forequarter amputation. |\n\nTable 9.12.2: Amputation of digits\n\n- %WPI Thumb Fingers %WPI\n- Index and middle Ring and little\n- 2 Tip of thumb excluding bone. Tip of finger excluding bone. 1 1\n- 7 Through distal phalanx. Through distal phalanx. 3 2\n- 11 Through IP joint. Through distal IP joint. 5 3\n- 17 Through proximal phalanx. Through middle phalanx. 7 4\n- 22 Through MP joint. Through proximal IP joint. 8\n- Through distal third of 1st metacarpal. Through proximal phalanx. 10 5\n- 23 At or near the CMC joint. Through MP joint or metacarpal. 11\n\n### 9.13   Neurological impairments affecting the upper extremities\n\n315     Sensory impairments due to digital nerve lesions alone are assessed under tables dealing with sensory losses in thumb and fingers:\n\na)      [Table 9.8.2a: Sensory losses in the thumb](#Table_9_8_2a);\n\nb)      [Table 9.8.2b: Sensory losses in the index and middle fingers](#Table_9_8_2b);\n\nc)       [Table 9.8.2c: Sensory losses in the little finger](#Table_9_8_2c); and\n\nd)      [Table 9.8.2d: Sensory losses in the ring finger](#Table_9_8_2d).\n\n316     Care must be taken to avoid duplicating impairment assessments for digital nerve sensory impairment with assessments for peripheral nerve sensory impairment. Assessments for digital nerve sensory impairment are assessed under [Table 9.8.2a](#Table_9_8_2a), Table 9.8.2b, [Table 9.8.2c](#Table_9_8_2c) and [Table 9.8.2d](#Table_9_8_2d). Assessments for peripheral nerve sensory impairment are assessed under [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1), [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a) and [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b).\n\n317     For sensory impairment in the same digit, WPI ratings obtained from [Table 9.13.1](#Table_9_13_1), [Table 9.13.2a](#Table_9_13_2a) and [Table 9.13.2b](#Table_9_13_2b), may not be combined with WPI ratings from [Table 9.8.2a](#Table_9_8_2a), Table 9.8.2b, [Table 9.8.2c](#Table_9_8_2c) and [Table 9.8.2d](#Table_9_8_2d).\n\n318     The grading system set out in [Figure 9-D](#Figure_9_D) is to be used with [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1), [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a) and [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b).\n\nFigure 9-D: Grading system\n\nSee note to Figure 9-D for further information.\n\n| Grading | Sensory deficits or pain Criteria | Motor function Criteria |\n| 0 | No sensation.<br>or<br>Severe pain that prevents all activity. | No contraction. |\n| 1 | No protective sensibility with abnormal sensations.<br>or<br>Severe pain that prevents most activity. | A flicker. |\n| 2 | Decreased protective sensibility with abnormal sensations.<br>or<br>Severe pain that prevents some activity. | Active movement with gravity eliminated. |\n| 3 | Diminished light touch and two-point discrimination with some abnormal sensations.<br>or<br>Slight pain that interferes with some activity. | Active movement against gravity. |\n| 4 | Diminished light touch with or without minimal abnormal sensations.<br>or<br>Pain that is forgotten during activity. | Active movement against gravity and resistance. |\n| 5 | Normal sensation.<br>or<br>No pain. | Normal power. |\n\nNote to Figure 9-D\n\n1. Figure 9-D also appears in [Section 9.6 – Spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities](#_Spinal_nerve_root) as [Figure 9-C: Grading system](#Figure_9_C). It is repeated here for ease of reference.\n\n#### 9.13.1    Cervical nerve root impairment\n\n319     Use the appropriate section of [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1), depending on whether there is involvement of a single spinal nerve, the brachial plexus, or combined nerve root impairment.\n\n320     WPI ratings for sensory impairment may be combined with those for motor impairment, using the combined values chart (see [Appendix 1](#_bookmark300)). [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1) must not be used in conjunction with [Table 9.15: Cervical spine – diagnosis-related estimates](#Table_9_15) where the same nerve is assessed under that table.\n\n","sortOrder":60},{"sectionNumber":"321","sectionType":"section","heading":"The maximum WPI rating for one upper extremity is 60%. A WPI of 60% may be awarded either:","content":"321     The maximum WPI rating for one upper extremity is 60%. A WPI of 60% may be awarded either:\n\na)      for complete brachial plexus sensory loss; or\n\nb)      brachial plexus motor loss;\n\nbut these may not be combined to give a WPI rating greater than 60% for the one upper extremity.\n\nTable 9.13.1: Cervical nerve root impairment\n\n- Single nerve involvement Single nerve involvement\n- Sensory impairment Motor impairment\n- Grading Grading\n- 5 5 4 3 2 1 0 4 3 2 1 0\n- Nerve root %WPI %WPI Nerve root\n- C5 0 0 2 C5 11 15 18 1 1 2 3 3 C5\n- C6 0 0 4 C6 13 18 21 1 2 4 5 5 C6\n- C7 0 0 4 C7 13 18 21 1 1 2 3 3 C7\n- C8 0 0 5 C8 16 23 27 1 1 2 3 3 C8\n- T1 0 0 2 T1 7 10 12 1 1 2 3 3 T1\n\n \n\n- Brachial plexus involvement or combined nerve root impairment\n- Sensory impairment\n- Nerves or nerve roots %WPI\n- Complete brachial plexus (C5 to T1 inclusive) 0 12 24 42 54 60\n- Upper trunk of brachial plexus (C5, C6, Erb-Duchenne) 0 3 6 11 14 15\n- Middle trunk of brachial plexus (C7) 0 1 1 2 3 3\n- Lower trunk of brachial plexus (C8, T1, Déjerine-Klumpke) 0 2 5 8 11 12\n\n \n\n- Brachial plexus involvement or combined nerve root impairment\n- Motor impairment\n- %WPI Nerves or nerve roots\n- 0 12 24 36 51 60 Complete brachial plexus (C5 to T1 inclusive)\n- 0 9 18 27 38 45 Upper trunk of brachial plexus (C5, C6, Erb-Duchenne)\n- 0 4 8 13 18 21 Middle trunk of brachial plexus (C7)\n- 0 8 17 25 36 42 Lower trunk of brachial plexus (C8, T1, Déjerine-Klumpke)\n\n#### 9.13.2    Specific nerve lesions affecting the upper extremities\n\n322     Only employees with an objectively verifiable diagnosis qualify for a WPI rating under [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a) and [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b). The diagnosis is made not only on credible and clinically logical symptoms but, more importantly, on the presence of positive clinical findings and loss of function. The diagnosis should be documented by electromyography as well as sensory and motor nerve conduction studies. As noted under the [Principles of Assessment](#_bookmark9), the assessor should not order additional investigations solely for assessment purposes.\n\n323     It is critical to understand that there is no correlation between the severity of conduction delay on nerve conduction velocity testing, and the severity of either symptoms or the WPI rating.\n\n324     If available, surgical findings of evidence of nerve compression and reactive hyperaemia upon nerve release can be used to confirm the diagnosis.\n\n325     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings obtained for sensory impairment may be combined with WPI ratings for motor impairment.\n\n326     A WPI rating under [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a) and [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b) may be combined (except where the same nerve is assessed) with WPI ratings from [Table 9.15: Cervical spine – diagnosis-related estimates](#Table_9_15).\n\nTable 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment\n\n- Axillary 0 1 1 2 3 3\n- Medial antebrachial cutaneous 0 1 1 2 3 3\n- Medial brachial cutaneous 0 1 1 2 3 3\n- Median nerve (above mid forearm) 0 5 9 16 21 23\n- Median nerve (below mid forearm) 0 5 9 16 21 23\n- Radial palmar digital of thumb 0 1 2 3 4 4\n- Ulnar palmar digital of thumb 0 1 3 5 6 7\n- Radial palmar digital of index finger 0 1 1 2 3 3\n- Ulnar palmar digital of index finger 0 0 1 1 2 2\n- Radial palmar digital of middle finger 0 1 1 2 3 3\n- Ulnar palmar digital of middle finger 0 0 1 1 2 2\n- Radial palmar digital of ring finger 0 0 1 1 2 2\n- Musculocutaneous 0 1 1 2 3 3\n- Radial (including loss of triceps function) 0 1 1 2 3 3\n- Radial (at elbow with sparing of triceps) 0 1 1 2 3 3\n- Suprascapular 0 1 1 2 3 3\n- Ulnar (above mid forearm) 0 1 2 3 4 4\n- Ulnar (below mid forearm) 0 1 2 3 4 4\n- Ulnar palmar digital of ring finger 0 0 0 1 1 1\n- Radial palmar digital of little finger 0 0 0 1 1 1\n- Ulnar palmar digital of little finger 0 0 1 1 2 2\n\nTable 9.13.2b: Specific nerve lesions affecting the upper extremities – motor impairment\n\n- Medial and lateral pectoral 0 1 1 2 3 3\n- Axillary 0 4 8 13 18 21\n- Dorsal scapular 0 1 1 2 3 3\n- Long thoracic 0 2 4 5 8 9\n- Median nerve (above mid forearm) 0 5 10 16 22 26\n- Median nerve (anterior interosseous branch) 0 2 4 5 8 9\n- Median nerve (below mid forearm) 0 1 2 4 5 6\n- Musculocutaneous 0 3 6 9 13 15\n- Radial (including loss of triceps function) 0 5 10 15 21 25\n- Radial (at elbow with sparing of triceps) 0 4 8 13 18 21\n- Subscapulars (upper and lower) 0 1 1 2 3 3\n- Suprascapular (upper and lower) 0 2 4 6 9 10\n- Thoracodorsal 0 1 2 4 5 6\n- Ulnar (above mid forearm) 0 6 11 17 24 28\n- Ulnar (below mid forearm) 0 4 8 13 18 21\n\n#### 9.13.3    Chronic pain conditions\n\n327     This Section applies to the assessment of the degree of permanent impairment of an employee who suffers a chronic pain condition (however described) where no other diagnosis better explains the signs and symptoms of the condition and the condition is an injury.\n\n328     A chronic pain condition affecting the upper extremities should be assessed using the methodology in this Section. A chronic pain condition affecting the lower extremities should be assessed using the same methodology as for the upper extremities substituting, where appropriate, the tables in [Section 9.1 (Feet and toes)](#_Feet_and_toes), [Section 9.2 (Ankles)](#_Ankles), [Section 9.3 (Knees)](#_Knees) and [Section 9.4 (Hips)](#_Hips).\n\n329     If the chronic pain condition affects more than one extremity (whether upper or lower), only one WPI rating obtained under [Table 9.13.3: Chronic pain conditions](#Table_9_13_3) may be used to assess the degree of permanent impairment of the employee.\n\n330     A chronic pain condition that does not affect the upper or lower extremities should be assessed in accordance with the applicable chapters in this Guide. If the condition cannot be assessed in accordance with any other chapters in this Guide (that is, where an assessment of 0% or more is not possible), the degree of permanent impairment of the employee resulting from that injury is 5%.\n\n331     If the employee suffers an injury that results in chronic pain (other than migraine or tension headache) but is not a chronic pain condition, that injury should not be assessed using the methodology in this Section and should be assessed in accordance with the applicable chapters in this Guide.\n\n332     If the employee suffers an injury that results in migraine or tension headache, the assessment of the degree of the permanent impairment of the employee resulting from that injury (to the extent the injury results in migraine or tension headache) is to be made in accordance with Chapter 18 of the AMA5.\n\nSteps in assessing a chronic pain condition\n\n| Step 1 | Assess whether there is objective evidence of impairment and subjective experience of pain in the affected upper extremity. |\n| Step 2 | Assess the sensory deficits and pain in the affected upper extremity according to the grade that best describes the severity of interference with activities as described in [Figure 9-D: Grading system](#Figure_9_D). Use clinical judgment to select the appropriate severity grade from Figure 9-D and explain the reasons for that selection. The maximum value is not automatically applied. |\n| Step 3 | Using the assessments obtained from Step 1 and Step 2, assess the WPI rating for the chronic pain condition using [Table 9.13.3: Chronic pain conditions](#Table_9_13_3). Use clinical judgment to select the appropriate WPI rating from Table 9.13.3 and explain the reasons for that selection. |\n| Step 4 | If the WPI rating obtained from Step 3 is greater than 5%, assess the WPI rating for the affected upper extremity resulting from loss of motion of each affected joint using the tables in [Section 9.8.1 (Abnormal motion of digits)](#_bookmark158), [Section 9.9 (Wrists)](#_bookmark174), [Section 9.10 (Elbows)](#_bookmark179) and [Section 9.11 (Shoulders)](#_bookmark183) as appropriate. (For lower extremity impairment, use the tables in [Section 9.1 (Feet and toes)](#_Feet_and_toes), [Section 9.2 (Ankles)](#_Ankles), [Section 9.3 (Knees)](#_Knees) and [Section 9.4 (Hips)](#_Hips) as appropriate.) |\n| Step 5 | Combine the WPI rating obtained from Step 3 with the WPI rating obtained from Step 4 (if any). The maximum WPI rating for the affected extremity is 60%. |\n\nTable 9.13.3: Chronic pain conditions\n\n| %WPI | Criteria | Grade (see [Figure 9-D](#Figure_9_D)) |\n| 5 | Continuing pain that is disproportionate to any inciting event.<br>and<br>Evidence of at least one of the following:<br>Hyperaesthesiae and/or allodynia; andTemperature asymmetry and/or skin colour changes and/or skin colour asymmetry; and<br>Oedema and/or sweating increase or decrease and/or sweating asymmetry; andDecreased active joint range of motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin). | 5 |\n| 10–15 | Continuing pain that is disproportionate to any inciting event.<br>and<br>Evidence of all of the following:<br>Hyperaesthesiae and/or allodynia; andTemperature asymmetry and/or skin colour changes and/or skin colour asymmetry; andOedema and/or sweating increase or decrease and/or sweating asymmetry; andDecreased active joint range of motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin). | 4 |\n| 16–36 | Same as preceding criteria. | 3 |\n| 37–48 | Same as preceding criteria. | 2 |\n| 49–59 | Same as preceding criteria. | 1 |\n| 60 | Same as preceding criteria. | 0 |\n\n### 9.14   Upper extremity function\n\n333     Before using [Table 9.14: Upper extremity function](#Table_9_14) the assessor should read the instructions preceding the specific joint impairment tables in [Section 9.8 (Hands and fingers)](#_Hands_and_fingers), [Section 9.9 (Wrists)](#_bookmark174), [Section 9.10 (Elbows)](#_bookmark179) and [Section 9.11 (Shoulders)](#_bookmark183) (see [Part II – Introduction](#_PART_II___1)). Table 9.14 is used strictly in accordance with those instructions. In particular, Table 9.14 cannot be used where an assessment can be made under one or more table in Section 9.9, Section 9.10 or Section 9.11 and there is no objectively demonstrated joint instability or arthritis or arthroplasty.\n\n334     [Table 9.14: Upper extremity function](#Table_9_14) is an alternative table, which may be used instead of the specific orthopaedic or neurological table or tables. It is important to note that Table 9.14 assesses the function of the entire upper extremity. Consequently, for the purposes of ascertaining the most beneficial WPI rating for the same upper extremity, any assessment under Table 9.14 for a single upper extremity may be compared only with the total or combined impairment obtained after using other tables in [Part II – The upper extremities](#_PART_II__) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)).\n\n335     For the purposes of ascertaining the most beneficial WPI rating, [Table 9.14: Upper extremity function](#Table_9_14) may not be compared with single impairments under the other tables, unless there are no other impairments affecting the upper extremities.\n\n336     At least one major criterion, and at least two minor criteria (where listed), must be satisfied for a WPI rating to be assigned under [Table 9.14: Upper extremity function](#Table_9_14). Where possible, the major criteria should be assessed on the basis of neurological examination of motor strength, co-ordination and dexterity. Where possible, functional activities should be assessed by observation of the specified activities.\n\n337     [Table 9.14: Upper extremity function](#Table_9_14) should be used only to assess impairment from objectively identified orthopaedic or neurological conditions arising in, and affecting, the upper extremities.\n\n338     While it is true that disuse secondary to pain may produce secondary dysfunction (that is, impairment) of the upper extremities, this must not be assessed using [Table 9.14: Upper extremity function](#Table_9_14) unless this dysfunction is permanent and there are objective clinical findings that cannot be validly assessed using other tables in [Part II – The upper extremities](#_PART_II__) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)).\n\n339     [Table 9.14: Upper extremity function](#Table_9_14) must not be used for assessment of amputations.\n\n340     Where one limb only is affected by the injury, regardless of the number of impairments found in that limb, the limb should be assessed using the relevant tables other than [Table 9.14: Upper extremity function](#Table_9_14) and all impairments combined using the combined values table (see [Appendix 1](#_bookmark300)). The combined impairment rating should then be compared with the rating taken from the relevant (non-dominant or dominant) column in Table 9.14 and the higher rating obtained from the two methods used to assess WPI.\n\n341     Where both limbs are affected by the injury, each limb should be assessed using the tables other than [Table 9.14: Upper extremity function](#Table_9_14) and all impairments in both limbs combined using the combined values table. The combined impairment rating should then be compared with the rating taken from the ‘both extremities’ column in Table 9.14 and the higher rating obtained from the two methods used to assess WPI.\n\n342     [Table 9.14: Upper extremity function](#Table_9_14) may be used to assess upper extremity impairment arising as a result of spinal cord damage. Use the special procedure set out in the introduction to Part III of this Chapter (see [Part III – Introduction](#_bookmark211)). Table 9.14 is not to be used to assess upper extremity impairment arising as a result of nerve root compression, or other neurological sequelae of cervical spinal conditions. These should be assessed under [Table 9.13.1](#Table_9_13_1), [Table 9.13.2a](#Table_9_13_2a) and [Table 9.13.2b](#Table_9_13_2b) (tables dealing with neurological impairments affecting the upper extremities).\n\nTable 9.14: Upper extremity function\n\n- %WPI %WPI %WPI Major criteria(at least one required) Minor criteria(at least two required where listed)\n- Non-dominant extremity Dominant extremity Both extremities\n- 0 0 0 Normal digital dexterity.No limitations in use of extremity for personal care. Writes 2 A4 pages or more at one time.Can lift more than 13 kilograms (males).Can lift more than 9 kilograms (females).Able to lace shoes easily.Joins paper clips without difficulty.\n- 3 5 10 Minor loss of digital dexterity.Minor limitations in use of extremity for personal care. Rests after writing an A4 page.Cannot lift more than 13 kilograms (males).Cannot lift more than 9 kilograms (females).Finds it difficult to do up shoelaces.Fumbles when joining paper clips.\n- 10 10 20 Moderate loss of digital dexterity.Moderate limitations in use of extremity for personal care. Rests after writing half an A4 page.Cannot lift more than 4.5 kilograms.Cannot do up shoelaces.Cannot join paperclips.Dresses slowly unassisted.\n- 15 20 35 Major loss of digital dexterity.Major restrictions in personal care. Rests after writing 50 words or less.Cannot lift more than 1.5 kilograms.Cannot put on a tie or belt.Needs assistance to cut up food.Needs some assistance to dress.\n- 25 30 50 Little useful digital co-ordination.Severely limited use of extremity for personal care. Rests after writing 10 words or less.Cannot lift more than 0.5 kilograms.Constantly drops light objects (for example, cups).Unable to cut up food.Needs extensive assistance to dress.\n- 30 40 60 No co-ordination of digits.Severely limited use of extremity for personal care. Unable to sign name.Constantly needs a splint to write or eat.Unable to lift light objects.Needs food placed in mouth to eat.Unable to dress without assistance.\n- 40 50 70 Minimal extremity movement against gravity.Cannot use extremity for personal care. Cannot use extremity to eat. Cannot bring a pen to paper.Cannot raise extremity to assist dressing.\n- 60 60 84 Unable to use upper extremity at all.\n\n### PART III – THE SPINE\n\n### PART III – INTRODUCTION\n\n","sortOrder":61},{"sectionNumber":"343","sectionType":"section","heading":"The assessor should:","content":"343     The assessor should:\n\na)      obtain a comprehensive, accurate medical history and review all relevant available records;\n\nb)      include in the assessment report a comprehensive description of current symptoms and their relationship to daily activities, detailed findings on physical examination, and all findings of relevant diagnostic and ancillary tests; and\n\nc)       indicate how the impairment assessment was calculated by reference to the relevant tables.\n\n344     For the same condition, WPI ratings from [Table 9.7: Lower extremity function](#_Lower_extremity_function) and/or [Table 9.14: Upper extremity function](#_bookmark206), are not normally combined with WPI ratings from [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__).\n\n345     However, the special procedure set out below applies where there is spinal cord injury with neurological sequelae (that is, corticospinal tract involvement).\n\n| Step 1 | Assess (where applicable):<br>1.1.          Lower limb impairment using [Table 9.7: Lower extremity function](#_Lower_extremity_function);<br>1.2.          Upper limb impairment using [Table 9.14: Upper extremity function](#_bookmark206);<br>1.3.          Bladder/urological dysfunction using [Table 12.7: Neurological impairment of the urinary system](#Table_12_7) (see [Chapter 12 – The neurological system](#_CHAPTER_12__));<br>1.4.          Anorectal dysfunction using [Table 12.8: Neurological impairment of the anorectal system](#Table_12_8) (see [Chapter 12 – The neurological system](#_CHAPTER_12__));<br>1.5.          Sexual dysfunction using [Table 12.9: Neurological impairment affecting sexual function](#Table_12_9) (see [Chapter 12 – The neurological system](#_CHAPTER_12__));<br>1.6.          Respiratory dysfunction (for example, with cervical spinal cord injuries) using [Table 12.6: Neurological impairment of the respiratory system](#Table_12_6) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)). |\n| Step 2 | Combine the relevant impairments from 1-6 in Step 1 above, as applicable. |\n| Step 3 | Then combine the WPI from the above procedure with the relevant WPI from [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__) to obtain the final WPI. |\n\n346     For injuries not involving spinal cord damage but resulting in nerve root involvement/radiculopathy, use [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__), but do not combine with WPI ratings from [Table 9.7: Lower extremity function](#_Lower_extremity_function) or [Table 9.14: Upper extremity function](#_bookmark206).\n\n347     Except where the same nerve is involved, WPI ratings from [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__) (where relevant) may be combined with WPI ratings under the following tables:\n\na)      tables dealing with spinal nerve root impairments and peripheral nerve injuries affecting the lower extremities:\n\ni)        [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1);\n\nii)      [Table 9.6.2a: Sensory impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2a);\n\niii)     [Table 9.6.2b: Motor impairment due to peripheral nerve injuries affecting the lower extremities](#Table_9_6_2b);\n\nb)      tables dealing with neurological impairments affecting the upper extremities:\n\ni)        [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1);\n\nii)      [Table 9.13.2a: Specific nerve lesions affecting the upper extremities – sensory impairment](#Table_9_13_2a);\n\niii)     [Table 9.13.2b: Specific nerve lesions affecting the upper extremities motor impairment](#Table_9_13_2b).\n\n348     Where there is brachial plexus involvement, WPI ratings from [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__) may not be combined with WPI ratings under [Table 9.13.1: Cervical nerve root impairment](#Table_9_13_1).\n\n349     Definitions of clinical findings for diagnosis-related estimates in assessing spinal impairment are used when assessing impairments of the spine under [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) and [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__).\n\n### PART III – DEFINITIONS OF CLINICAL FINDINGS FOR DIAGNOSIS-RELATED ESTIMATES IN ASSESSING SPINAL IMPAIRMENT\n\n350     These definitions, which are taken from the AMA5, apply to corresponding terms appearing in [Part III – The spine](#_bookmark209) of this Chapter.\n\n351     Alteration of motion segment integrity – motion segment alteration can be either loss of motion segment integrity (increased translational or angular motion), or decreased motion secondary to developmental fusion, fracture healing, healed infection, or surgical arthrodesis. An attempt at arthrodesis may not necessarily result in a solid fusion but may significantly limit motion at a motion segment. Motion of the individual spine segments cannot be determined by a physical examination but is evaluated with flexion and extension roentgenograms. When routine x-rays are normal and severe trauma is absent, motion segment alteration is rare, and flexion and extension roentgenograms are indicated only if motion segment alteration is suspected from the individual’s history or routine x-rays.\n\n352     Asymmetry of spinal motion in one of the three principal planes is sometimes caused by muscle spasm or guarding. That is, if an individual attempts to flex the spine, they are unable to do so moving symmetrically: rather, the head or trunk leans to one side. To qualify as true asymmetric motion, the finding must be reproducible and consistent, and the assessor must be convinced that the individual is co-operative and giving full effort.\n\n353     Atrophy is measured with a tape measure at identical levels on both limbs. For reasons of reproducibility, the difference in circumference should be 2cm or greater in the thigh, and 1cm or greater in the arm, forearm, or leg.\n\n354     Cauda equina syndrome is manifested by bowel or bladder dysfunction, saddle anaesthesia and variable loss of motor and sensory function in the lower extremities. Individuals with cauda equina syndrome usually have loss of sphincter tone on rectal examination and diminished or absent bladder, bowel, and lower limb reflexes.\n\n355     Electrodiagnostic verification of radiculopathy – unequivocal electrodiagnostic evidence of acute nerve root pathology includes the presence of multiple positive sharp waves or fibrillation potentials in muscles innervated by one nerve root. However, the quality of the person performing and interpreting the study is critical. Electromyography should be performed only by a physician qualified through education, training, and experience in these procedures. Electromyography does not detect all compressive radiculopathies and cannot determine the cause of the nerve root pathology. On the other hand, electromyography can detect non-compressive radiculopathies which are not identified by imaging studies.\n\n356     Loss of motion segment integrity is defined as an anteroposterior motion of one vertebra over another that is greater than 3.5mm in the cervical spine, greater than 2.5mm in the thoracic spine, and greater than 4.5mm in the lumbar spine. Alternatively, it is defined as a difference in the angular motion of two adjacent motion segments greater than 15° at L1-2, L2-3 and L3-4, greater than 20° at L4-5 and greater than 25° at L5-S1. In the cervical spine, it is also defined as motion at one level that is more than 11° greater than at either adjacent level.\n\n357     Muscle guarding is a contraction of muscle to minimise motion or agitation of the injured or diseased tissue. It is not true muscle spasm because the contraction can be relaxed. In the lumbar spine, the contraction frequently results in loss of the normal lumbar lordosis, and it may be associated with reproducible loss of spinal motion.\n\n358     Muscle spasm is a sudden, involuntary contraction of a muscle or group of muscles. Paravertebral muscle spasm is common after acute spinal injury but is rare in chronic back pain. It is occasionally visible as a contracted paraspinal muscle but is more often diagnosed by palpation (a hard muscle).\n\n359     To differentiate true muscle spasm from voluntary muscle contraction, the individual should not be able to relax the contractions. The spasm should be present standing, as well as in the supine position, and frequently causes a scoliosis. The physician can sometimes differentiate spasm from voluntary contraction by asking the individual to place all their weight first on one foot, and then the other, while the physician gently palpates the paraspinous muscles. With this manoeuvre, the individual normally relaxes the paraspinal muscles on the weight-bearing side. If the assessor witnesses this relaxation, it usually means that true muscle spasm is not present.\n\n360     Non-verifiable radicular root pain is pain that is in the distribution of a nerve root but has no identifiable origin (that is, there are no objective physical, imaging, or electromyographic abnormal findings).\n\n361     Radiculopathy is significant alteration in the function of a nerve root or nerve roots, and is usually caused by pressure on one or several nerve roots. The diagnosis requires a dermatomal distribution of pain, numbness, and/ or paraesthesia. A root tension sign is usually positive. A diagnosis of herniated disc must be substantiated by an appropriate finding on an imaging study. The presence of findings on an imaging study is insufficient to make the diagnosis of radiculopathy. There must also be clinical evidence as described above.\n\n362     Reflexes may be normal, increased, reduced, or absent. For reflex abnormalities to be considered valid, the involved and normal limb(s) should show marked asymmetry between arms or legs on repeated testing. Once lost because of previous radiculopathy, a reflex rarely returns. Abnormal reflexes such as Babinski signs or clonus may be signs of corticospinal tract involvement.\n\n363     Urodynamic tests – cystometrograms are useful in individuals where a cauda equina syndrome is possible but not certain. A normal cystometrogram makes the presence of a nerve-related bladder dysfunction unlikely. Occasionally, more extensive urodynamic testing is necessary.\n\n364     Weakness and loss of sensation – to be valid, the sensory findings must be in a strict anatomical distribution (that is, follow dermatomal patterns). Motor findings should also be consistent with the affected nerve structure(s). Significant, long-standing weakness is usually accompanied by atrophy.\n\n### PART III – MULTI-LEVEL FRACTURES INVOLVING THE SPINAL CANAL\n\n365     For multiple fractures involving the spinal canal on more than one level, as distinct from the spinous processes or facet joints, the assessment made under [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__) is to be adjusted as follows:\n\na)      where there are multi-level fractures but no associated neurological compromise: increase the assessment under Table 9.15, Table 9.16 or Table 9.17 by one level;\n\nb)      where there are multi-level fractures with neurological compromise: increase the assessment under Table 9.15, Table 9.16 or Table 9.17 by two levels.\n\n","sortOrder":62},{"sectionNumber":"366","sectionType":"section","heading":"The adjustment, by one or two levels, as applicable, may be made only once under each table.","content":"366     The adjustment, by one or two levels, as applicable, may be made only once under each table.\n\n","sortOrder":63},{"sectionNumber":"367","sectionType":"section","heading":"The adjusted WPI assessment may not exceed the maximum WPI rating available in each individual table.","content":"367     The adjusted WPI assessment may not exceed the maximum WPI rating available in each individual table.\n\n### 9.15   Cervical spine – diagnosis-related estimates\n\nTable 9.15: Cervical spine – diagnosis-related estimates\n\nSee note to Table 9.15 for further information.\n\n| 0 | No significant clinical findings, no muscular guarding, no documented neurological impairment, no significant loss of motion segment integrity, no other indication of impairment related to injury.<br>or<br>No fractures. |\n| 8 | Clinical history and examination findings compatible with specific injury. Findings may include: muscle guarding or spasm; asymmetric loss of range of motion or non-verifiable radicular complaints defined as complaints of radicular pain without objective findings.<br>and<br>No alteration of structural integrity.<br>or<br>Clinically significant radiculopathy and objectively demonstrated disc herniation consistent with the radiculopathy (improved following non-operative treatment).<br>or<br>Fractures:<br>Compression fracture of one vertebral body of less than 25%; orPosterior element fracture without dislocation – healed without loss of structural integrity or radiculopathy; orSpinous or transverse process fracture with displacement. |\n| 10–18 | Significant signs of radiculopathy, such as pain and/or sensory loss in a dermatomal distribution, loss or alteration of relevant reflex(es), loss of muscle strength, or unilateral atrophy compared with the unaffected side, measured at the same distance above or below the elbow. The neurological impairment may be verified by electrodiagnostic findings.<br>or<br>Clinically significant radiculopathy and objectively verified disc herniation consistent with the radiculopathy, or with improved radiculopathy following surgery.<br>or<br>Fractures:<br>Compression fracture of one vertebral body of 25% to 50% – healed without loss of structural integrity, with or without radiculopathy; orPosterior element fracture with displacement disrupting the spinal canal – healed without loss of structural integrity, with or without radiculopathy.<br>Note: In the case of fractures, differentiation from a congenital or developmental condition should be accomplished, if possible, by examining pre-injury roentgenograms, if available, or by a bone scan performed after the onset of the condition. |\n| 28 | Alteration of motion segment integrity (at least 3.5mm of translation of one vertebra on another or angular motion of more than 11° greater than at each adjacent level).<br>or<br>Bilateral or multilevel radiculopathy with objectively verified disc herniation consistent with the radiculopathy.<br>or<br>Loss of motion of a motion segment due to a developmental fusion or successful or unsuccessful attempt at surgical arthrodesis.<br>or<br>Compression fracture of one vertebral body of more than 50% without residual neural compromise. |\n| 38 | Significant upper extremity impairment requiring the use of upper extremity external functional or adaptive device(s). There may be total neurological loss at a single level or severe, multilevel neurological dysfunction.<br>or<br>Structural compromise of the spinal canal with severe upper extremity motor and sensory deficits but without lower extremity involvement. |\n\nNote to Table 9.15\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n### 9.16   Thoracic spine – diagnosis-related estimates\n\nTable 9.16: Thoracic spine – diagnosis-related estimates\n\nSee note to Table 9.16 for further information.\n\n| 0 | No significant clinical findings, no muscular guarding, no documented neurological impairment, no significant loss of motion segment integrity, no other indication of impairment related to injury.<br>or<br>No fractures. |\n| 8 | History and examination findings compatible with a specific injury. Findings may include: significant muscle guarding or spasm; asymmetric loss of range of motion (dysmetria); or non-verifiable radicular complaints, defined as complaints of radicular pain without objective findings.<br>and<br>No alteration of motion segment integrity.<br>or<br>Herniated disc at the level and on the side that would be expected from objective clinical findings, but without radicular signs following conservative treatment.<br>or<br>Fractures:<br>Compression fracture of one vertebral body of less than 25%; orPosterior element fracture without dislocation – healed without alteration of motion segment integrity or radiculopathy; orSpinous or transverse process fracture with displacement, but without a vertebral body fracture. |\n| 10–18 | Ongoing neurological impairment of the lower extremity related to a thoracolumbar injury, documented by alteration of motor and sensory functions, altered reflexes, or findings of unilateral atrophy above or below the knee related to no other condition (may be verified by electrodiagnostic testing).<br>or<br>Clinically significant radiculopathy and objectively verified disc herniation consistent with the radiculopathy, or with improved radiculopathy following surgery.<br>or<br>Fractures:<br>Compression fracture of one vertebral body of 25% to 50% – healed without alteration of structural integrity; orPosterior element fracture with mild displacement disrupting the canal – healed without alteration of structural integrity.<br>Note: Differentiation from a congenital or developmental condition should be accomplished, if possible, by examining pre-injury roentgenograms, if available, or by a bone scan performed after the onset of the condition. |\n| 23 | Alteration of motion segment integrity (more than 2.5mm translation of one vertebra on another).<br>or<br>Bilateral or multilevel radiculopathy with objectively verified disc herniation consistent with the radiculopathy.<br>or<br>Compression fracture of one vertebral body of more than 50% without residual neural compromise. |\n| 28 | Significant signs of radiculopathy, such as dermatomal pain and/or in a dermatomal distribution, sensory loss, loss of relevant reflex(es), loss of muscle strength or measured unilateral atrophy above or below the knee compared to measurements on the contralateral side at the same location (may be verified by electrodiagnostic findings).<br>and<br>Alteration of motion segment integrity (more than 2.5mm translation of one vertebra on another).<br>or<br>Compression fracture of one vertebral body by more than 50% with neural motor compromise, but not bilateral involvement. In that instance, refer notes concerning corticospinal tract impairment evaluation<br>([Part III – Introduction](#_bookmark211)). |\n\nNote to Table 9.16\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n### 9.17   Lumbar spine – diagnosis-related estimates\n\nTable 9.17: Lumbar spine – diagnosis-related estimates\n\nSee note to Table 9.17 for further information.\n\n| 0 | No significant clinical findings, no observed muscle guarding or spasm, no documented neurological impairment, no documented alteration in structural integrity, and no other indication of impairment related to injury.<br>or<br>No fractures. |\n| 8 | Clinical history and examination findings compatible with a specific injury. Findings may include: significant muscle guarding or spasm; asymmetric loss of range of motion; or non-verifiable radicular complaints, defined as complaints of radicular pain without objective findings.<br>and<br>No alteration of the structural integrity and no significant radiculopathy.<br>or<br>Prior clinically significant radiculopathy and objectively demonstrated disc herniation, consistent with the radiculopathy, but radiculopathy no longer present following conservative treatment.<br>or<br>Fractures:<br>Compression fracture of one vertebral body of less than 25%; orPosterior element fracture without dislocation (not developmental spondylolysis) that has healed without alteration of motion segment integrity; orSpinous or transverse process fracture with displacement without a vertebral body fracture, with no disruption of the spinal canal. |\n| 10–13 | Significant signs of radiculopathy, such as dermatomal pain and/or in a dermatomal distribution, sensory loss, alteration of relevant reflex(es), loss of muscle strength or measured unilateral atrophy above or below the knee compared to measurements on the contralateral side at the same location (may be verified by electrodiagnostic findings).<br>or<br>History of a herniated disc at the level and on the side consistent with objective clinical findings, associated with radiculopathy, or now asymptomatic following surgery for radiculopathy.<br>or<br>Fractures:<br>Compression fracture of one vertebral body of 25% to 50% – healed without alteration of structural integrity; orPosterior element fracture with displacement disrupting the spinal canal – healed without alteration of structural integrity. |\n| 23 | Loss of motion segment integrity (at least 4.5mm of translation of one vertebra on another, or angular motion greater than 15° at L1-2, L2-3, and L3-4, greater than 20° at L4-5, and greater than 25° at L5-S1). May have complete, or near complete, loss of motion of a motion segment due to developmental fusion, or successful or unsuccessful attempt at surgical arthrodesis.<br>or<br>Compression fracture of one vertebral body of more than 50%, without residual neurological compromise. |\n| 28 | Both radiculopathy and loss of motion segment integrity are present, with significant lower extremity impairment indicated by atrophy or loss of reflex(es), pain, and/or sensory changes within an anatomic distribution (dermatomal), verified by electrodiagnostic findings.<br>and<br>Loss of motion segment integrity (at least 4.5mm of translation of one vertebra on another or angular motion greater than 15° at L1-2, L2-3, and L3-4, greater than 20° at L4-5, and greater than 25° at L5-S1).<br>or<br>Compression fracture of one vertebral body of more than 50%, with unilateral neurological compromise. |\n\nNote to Table 9.17\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n### 9.18   Fractures of the pelvis\n\n368     A WPI rating from [Table 9.18: Fractures of the pelvis](#Table_9_18) may be combined with WPI ratings from [Table 9.15: Cervical spine – diagnosis-related estimates](#_Cervical_spine__), [Table 9.16: Thoracic spine – diagnosis-related estimates](#_Thoracic_spine__) or [Table 9.17: Lumbar spine – diagnosis-related estimates](#_Lumbar_spine__).\n\nTable 9.18: Fractures of the pelvis\n\n| 0 | Healed fracture:<br>without displacement or residual signsof one or both rami with displacement but without residual signsof ischium or ilium with displacement but without residual signsof coccyx with displacement but without residual signsof one pubic ramus with displacement, deformity and residual signs. |\n| 2 | Healed fracture of ilium with displacement, deformity and residual signs. |\n| 5 | Healed fracture of:<br>sacrum with displacement but without residual signssymphysis pubis without separation and without residual signsboth pubic rami with displacement, deformity and residual signs.<br>Non-union of coccyx fracture.<br>Excision of coccyx. |\n| 10 | Healed fracture of:<br>ischium with displacement of 2.5cm or more, deformity and residual signssacrum involving sacro-iliac joint. |\n| 15 | Healed fracture of symphysis pubis with separation or displacement. |\n| Evaluate in accordance with [Table 9.4: Hips](#Table_9_4) | Fracture involving acetabulum. |\n\n## CHAPTER 10 – THE URINARY SYSTEM\n\n### 10.0   Introduction\n\n369     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n370     Impairments assessed under [Chapter 10 – The urinary system](#_bookmark222) include those resulting from an endocrine system condition. An impairment assessed under [Chapter 3 – The endocrine system](#_CHAPTER_3__) may be combined with those assessed under Chapter 10.\n\n### 10.1   The upper urinary tract\n\n","sortOrder":64},{"sectionNumber":"371","sectionType":"section","heading":"The upper urinary tract comprises the kidney and ureters.","content":"371     The upper urinary tract comprises the kidney and ureters.\n\n","sortOrder":65},{"sectionNumber":"372","sectionType":"section","heading":"Upper urinary tract dysfunction may be indicated by symptoms and signs including:","content":"372     Upper urinary tract dysfunction may be indicated by symptoms and signs including:\n\na)      changes in urination;\n\nb)      oedema;\n\nc)       decreased physical stamina;\n\nd)      appetite and weight loss;\n\ne)      anaemia;\n\nf)        uraemia;\n\ng)      loin, abdominal or costovertebral angle pain;\n\nh)      haematuria;\n\ni)        rigours / chills and fever;\n\nj)        hypertension or its complications;\n\nk)      abnormalities in the appearance of the urine or its sediment;\n\nl)        biochemical blood changes.\n\n373     Especially in its early stages, renal disease may only become evident with laboratory findings.\n\n374     Continuous medical treatment includes drug or dietary therapy.\n\n375     Renal replacement therapy includes peritoneal or haemodialysis and renal transplantation.\n\nTable 10.1: The upper urinary tract\n\n- Criteria (criteria in both Category A and Category B must be satisfied if present)\n- Category A Category B\n- Nerve root Creatinine clearance Other symptom(s)\n- 0 >62ml/min and intermittent symptoms and signs of upper urinary tract dysfunction are present but do not require continuous treatment or surveillance.\n- 5 52-62ml/min and intermittent symptoms and signs of upper urinary tract dysfunction are present but do not require continuous treatment or surveillance.\n- 10 not applicable Loss of one kidney or one kidney not functioning.\n- 15 >62ml/min and intermittent symptoms and signs of upper urinary tract dysfunction are present and require continuous surveillance and frequent treatment.\n- 20 52-62ml/min and symptoms and signs of upper urinary tract dysfunction are present and require continuous surveillance and frequent treatment.\n- 25 not applicable Successful renal transplantation results in marked renal function improvement (regardless of creatinine clearance level).\n- 30 43-52ml/min and symptoms and signs of upper urinary tract dysfunction are present and require continuous surveillance and frequent treatment.\n- 40 28-42ml/min Not applicable\n- 50 43-52ml/min and symptoms and signs of upper urinary tract dysfunction are present and are not completely controlled by surgical or continuous medical treatment.\n- 60 <28ml/min Not applicable\n- 70 28-42ml/min and symptoms and signs of upper urinary tract dysfunction are present and are not controlled by surgical or continuous treatment.\n- 80 <28ml/min and symptoms and signs of upper urinary tract dysfunction are present and are not controlled by surgical or continuous treatment.\n- 90 <14ml/min and renal replacement therapy.\n- 95 <14ml/min and metabolic coma from renal failure.\n\n### 10.2   Urinary diversion\n\n376     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings derived from [Table 10.2: Urinary diversion](#Table_10_2) may be combined with WPI ratings derived from [Table 10.1: The upper urinary tract](#Table_10_1).\n\nTable 10.2: Urinary diversion\n\n| %WPI | Type of diversion |\n| 10 | Ureterointestinal.<br>or<br>Cutaneous ureterostomy. |\n| 15 | Nephrostomy. |\n\n### 10.3   Lower urinary tract\n\n","sortOrder":66},{"sectionNumber":"377","sectionType":"section","heading":"The lower urinary tract comprises the bladder and urethra.","content":"377     The lower urinary tract comprises the bladder and urethra.\n\n378     Using the combined values chart (see [Appendix 1](#_bookmark300)), WPI ratings derived from [Table 10.3: Lower urinary tract](#Table_10_3) may be combined with WPI ratings from [Table 10.1: The upper urinary tract](#Table_10_1), and with WPI ratings from [Table 10.2: Urinary diversion](#Table_10_2).\n\n379     Impairment in the lower urinary tract due to neurological causes, as opposed to local lower urinary tract pathology, should be assessed under [Table 12.7: Neurological impairment of the urinary system](#Table_12_7) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n380     If:\n\na)      several impairments of the urinary system are present; and\n\nb)      there is an impairment of bladder function due to neurological causes\n\nthen:\n\nc)       a WPI rating from [Table 10.3: Lower urinary tract](#Table_10_3) (except for bladder function) may be combined with a WPI rating from [Chapter 12 – The neurological system](#_CHAPTER_12__).\n\n","sortOrder":67},{"sectionNumber":"381","sectionType":"section","heading":"Symptoms and signs of bladder disorder include:","content":"381     Symptoms and signs of bladder disorder include:\n\na)      urinary frequency;\n\nb)      dysuria;\n\nc)       strangury;\n\nd)      urinary incontinence;\n\ne)      urine retention;\n\nf)        haematuria;\n\ng)      pyuria;\n\nh)      passage of urinary calculi;\n\ni)        a suprapubic mass.\n\n","sortOrder":68},{"sectionNumber":"382","sectionType":"section","heading":"Signs and symptoms of urethra function impairment include:","content":"382     Signs and symptoms of urethra function impairment include:\n\na)      dysuria;\n\nb)      diminished urinary stream;\n\nc)       urinary retention;\n\nd)      incontinence;\n\ne)      extraneous or ectopic urinary openings;\n\nf)        periurethral masses;\n\ng)      diminished urethral calibre.\n\nTable 10.3: Lower urinary tract\n\n| 0 | Symptoms and signs of bladder or urethral disorder occurring 1-3 times a year and requiring intermittent treatment – between episodes lower urinary tract function is normal. |\n| 5 | Symptoms and signs of bladder or urethral disorder occurring 4-6 times a year and requiring intermittent treatment – between episodes lower urinary tract function is normal.<br>or<br>Urethral stricture requiring dilation up to six times a year – between dilations there is normal urethral function. |\n| 10 | Symptoms and signs of bladder disorder occurring 7-12 times a year and requiring intermittent treatment – between episodes bladder function is normal.<br>or<br>Urethral stricture requiring dilation more than six times a year – between dilations there are significant periods of normal urethral function. |\n| 15 | Symptoms and signs of bladder disorder occurring more than 12 times a year and requiring intermittent treatment – between episodes bladder function is normal.<br>or<br>Urethral fistula. |\n| 20 | Symptoms and signs of bladder disorder requiring continuous treatment.<br>or<br>Good bladder reflex activity (that is, storage of urine) but no voluntary control over the reflex activity.<br>or<br>Urethral stricture requiring dilation more than six times a year – between dilations there are no significant periods of normal urethral function. |\n| 30 | Poor reflex bladder activity (that is, intermittent dribbling incontinence, stress incontinence or urge incontinence) and no voluntary control over the incontinence.<br>or<br>Urethral dysfunction resulting in intermittent urine dribbling and loss of voluntary urinary control. |\n| 40 | No reflex or voluntary control of bladder (that is, continuous dribbling incontinence).<br>or<br>Urinary diversion with cystectomy. |\n\n## CHAPTER 11 – THE REPRODUCTIVE SYSTEM\n\n### 11.0   Introduction\n\n383     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n### 11.1   Male reproductive system\n\n384     WPI ratings from tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system) may be combined, provided the total WPI rating for all conditions affecting ability to father children does not exceed 20%.\n\n385     The WPI ratings in the tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system) are applicable to 40–65 year old men.\n\n","sortOrder":69},{"sectionNumber":"386","sectionType":"section","heading":"Where the employee is outside this age group, the following calculation should be made:","content":"386     Where the employee is outside this age group, the following calculation should be made:\n\na)      for men 39 years of age or younger, the combined WPI rating (from the tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system)) is increased by 50%;\n\nb)      men 66 years of age or older, the combined WPI rating (from the tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system)) is decreased by 50%.\n\n387     For example, a 29 year old man with a combined maximum WPI of 20% of the male reproductive system would be rated as suffering a 30% WPI: 20% WPI + (0.5 x 20% WPI) = 30% WPI.\n\n388     The tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system) are not to be used with respect to sexual dysfunction arising as a result of neurological impairments rather than local reproductive pathology. Where sexual dysfunction is the result of spinal cord injury, use [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)). Where sexual dysfunction is the result of neurological disorder other than spinal nerve root impairment, use [Table 12.9: Neurological impairment affecting sexual function](#Table_12_9) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n389     The tables in [Section 11.1 (Male reproductive system)](#_Male_reproductive_system) are intended for use only to assess impairment resulting from neurological impairment, or local lesions of:\n\na)      penis;\n\nb)      scrotum;\n\nc)       testes;\n\nd)      epididymes;\n\ne)      spermatic cords; and\n\nf)        prostate and/or seminal vesicles.\n\n390     These tables can be used to assess impairment where obstruction of the vascular supply of the penis and other male organs occurs.\n\n391     These tables are not intended for use where sexual function is impaired for any other reason (for example, pain or depression).\n\n#### 11.1.1     Male reproductive organs – penis\n\nTable 11.1.1: Male reproductive organs – penis\n\n| 0 | Occasional interference with sexual function. |\n| 10 | Sexual function possible but always with a degree of difficulty with erection, ejaculation and/or sensation. |\n| 15 | Sexual function possible in that there is sufficient erection but sensation and/or ejaculation is absent. |\n| 20 | No sexual function is possible. |\n\n#### 11.1.2     Male reproductive organs – scrotum\n\n392     Skin disorders such as dermatitis, or tinea, affecting the scrotal skin are assessed under [Table 4.1: Skin disorders](#Table_4_1) (see [Chapter 4 – Disfigurement and skin disorders](#_CHAPTER_4__)). [Table 11.1.2: Male reproductive organs – scrotum](#Table_11_1_2) is not used to assess these conditions.\n\nTable 11.1.2: Male reproductive organs – scrotum\n\n| 0 | Symptoms and/or signs of scrotal loss or disease with no evidence of testicular malfunction, malposition or loss of mobility. |\n| 5 | Symptoms and/or signs of scrotal loss or disease with no evidence of testicular malfunction but with testicular malposition or loss of mobility. |\n| 10 | Total loss of scrotum.<br>or<br>Symptoms and signs of scrotal loss or disease with necessity for testes to be implanted elsewhere to preserve testicular function. |\n| 15 | Symptoms and signs of scrotal loss or disease with necessity for testes to be implanted elsewhere to preserve testicular function.<br>and<br>Scrotal pain or discomfort present with physical activity. |\n| 20 | Symptoms and signs of scrotal loss or disease unable to be controlled by treatment.<br>and<br>Scrotal pain severely limits physical activity. |\n\n#### 11.1.3     Male reproductive organs – testes, epididymes and spermatic cords\n\nTable 11.1.3: Male reproductive organs – testes, epididymes and spermatic cords\n\n| 0 | Symptoms and signs of testicular, epididymal and/or spermatic cord dysfunction are present and there is anatomical alteration.<br>and<br>Continuous treatment is not required and there are no seminal or hormonal abnormalities. |\n| 5 | Loss of one testis. |\n| 10 | Symptoms and signs of testicular, epididymal and/or spermatic cord dysfunction are present and there is anatomical alteration.<br>and<br>Continuous or frequent treatment is required, or treatment is not possible.<br>and<br>There are no seminal or hormonal abnormalities. |\n| 15 | Symptoms and signs of testicular, epididymal and/or spermatic cord dysfunction are present and there is anatomical alteration.<br>and<br>Continuous or frequent treatment is required, or treatment is not possible.<br>and<br>There is no detectable seminal or hormonal function. |\n| 20 | Loss of both testes. |\n\n#### 11.1.4     Male reproductive organs – prostate and seminal vesicles\n\nTable 11.1.4: Male reproductive organs – prostate and seminal vesicles\n\n| 0 | Symptoms and signs of prostate and/or seminal vesicle disease or dysfunction are present.<br>and<br>There is anatomical alteration.<br>and<br>Continuous or very frequent treatment not required. |\n| 10 | Frequent and severe symptoms of prostate and/or seminal vesicle disease or dysfunction are present.<br>and<br>there is anatomical alteration.<br>and<br>Continuous or very frequent treatment not required. |\n| 15 | Prostatectomy. |\n\n### 11.2   Female reproductive system\n\n393     WPI ratings from the tables in [Section 11.2 (Female reproductive system)](#_Female_reproductive_system) may be combined. However, the total WPI rating for all conditions affecting ability to conceive and be delivered of children may not exceed 30%.\n\n394     The tables in [Section 11.2 (Female reproductive system)](#_Female_reproductive_system) are not to be used with respect to sexual dysfunction arising as a result of neurological impairments rather than local reproductive pathology. Where sexual dysfunction is the result of spinal cord injury, use [Table 9.6.1: Spinal nerve root impairment affecting the lower extremity](#Table_9_6_1) (see [Chapter 9 – The musculoskeletal system](#_bookmark123)). Where sexual dysfunction is the result of neurological disorder other than spinal nerve root impairment, use [Table 12.9: Neurological impairment affecting sexual function](#Table_12_9) (see [Chapter 12 – The neurological system](#_CHAPTER_12__)).\n\n#### 11.2.1     Female reproductive organs – vulva and vagina\n\nTable 11.2.1: Female reproductive organs – vulva and vagina\n\nSee note to Table 11.2.1 for further information.\n\n| 0 | Symptoms and signs of disease or deformity of the vulva and/or vagina are present.<br>and<br>Continuous treatment is not required.<br>and<br>Sexual intercourse is possible.<br>and<br>The vagina is adequate for childbirth. | Symptoms and signs of disease or deformity of the vulva and/or vagina are present.<br>and<br>Continuous treatment is not required.<br>and<br>Sexual intercourse is possible with or without considerable difficulty. |\n| 10–15 | Symptoms and signs of disease or deformity of the vulva and/or vagina are present.<br>and<br>Continuous treatment is required.<br>and<br>Sexual intercourse is possible only with difficulty.<br>and<br>Limited potential for vaginal delivery. | Symptoms and signs of disease or deformity of the vulva and/or vagina are present.<br>and<br>Continuous treatment is required and may not control symptoms.<br>and<br>Sexual intercourse is not possible. |\n| 25 | Symptoms and signs of disease or deformity of the vulva and/or vagina are present.<br>and<br>Continuous treatment does not control symptoms.<br>and<br>Sexual intercourse is not possible.<br>and<br>Vaginal delivery is not possible. |  |\n\nNote to Table 11.2.1\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n#### 11.2.2     Female reproductive organs – cervix and uterus\n\nTable 11.2.2: Female reproductive organs – cervix and uterus\n\nSee notes to Table 11.2.2 for further information.\n\n| 0 | Symptoms or signs of disease or deformity of cervix and/or uterus present.<br>and<br>Continuous treatment not required.<br>or<br>Cervical stenosis not requiring treatment. | Cervical stenosis.<br>or<br>Anatomical loss of cervix and/or uterus. |\n| 5 |  | Symptoms and signs of disease or deformity of cervix and/or uterus present.<br>and<br>Continuous treatment required. |\n| 10 | Symptoms and signs of disease or deformity of cervix and/or uterus present.<br>and<br>Continuous treatment required. | Symptoms and signs of disease or deformity of the cervix and/or uterus present.<br>and<br>Treatment does not give control. |\n| 15 | Cervical stenosis requiring periodic treatment. |  |\n| 25 | Symptoms and signs of disease or deformity of cervix and/or uterus present.<br>and<br>Treatment does not control symptoms.<br>or<br>Complete cervical stenosis. |  |\n| 30 | Total hysterectomy.<br>and/or<br>Amputation of cervix. |  |\n\nNotes to Table 11.2.2\n\n1. Hormone replacement therapy is not considered continuous treatment for the purposes of Table 11.2.2.\n2. Oral contraception may be considered continuous treatment if pregnancy is contraindicated because of the cervical or uterine lesion.\n\n#### 11.2.3     Female reproductive organs – fallopian tubes and ovaries\n\nTable 11.2.3: Female reproductive organs – fallopian tubes and ovaries\n\n| 0 | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment not required.<br>and<br>No difficulties with conception or loss of one ovary. | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment not required.<br>or<br>Unilateral or bilateral loss of one or both fallopian tubes and/or one or both ovaries. |\n| 5 | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment not required.<br>and<br>Conception possible with medical intervention.<br>or<br>Loss of one fallopian tube. | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment required. |\n| 10 | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment required.<br>and<br>Conception is possible although medical intervention may be required. | Symptoms or signs of disease or deformity of the fallopian tubes or ovaries present.<br>and<br>Continuous treatment does not give control. |\n| 20 | Bilateral loss of both fallopian tubes.<br>or<br>Irreparable loss of patency of both fallopian tubes. |  |\n| 30 | Loss of both ovaries.<br>or<br>Failure to produce ova despite treatment. |  |\n\n## CHAPTER 12 – THE NEUROLOGICAL SYSTEM\n\n### 12.0   Introduction\n\n395     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n","sortOrder":70},{"sectionNumber":"396","sectionType":"section","heading":"The four categories of cerebral impairment are:","content":"396     The four categories of cerebral impairment are:\n\na)      disturbances of levels of consciousness or awareness:\n\ni)        [Table 12.1.1: Permanent disturbances of levels of consciousness and awareness](#Table_12_1_1);\n\nii)      [Table 12.1.2: Epilepsy, seizures and convulsive disorders](#Table_12_1_2);\n\niii)     [Table 12.1.3: Sleep and arousal disorders](#Table_12_1_3);\n\nb)      impairment of memory, learning, abstract reasoning and problem solving ability:\n\ni)        [Table 12.2: Impairment of memory, learning, abstract reasoning and problem solving ability](#Table_12_2);\n\nc)       communication impairments:\n\ni)        [Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#Table_12_3); and\n\nd)      emotional or behavioural impairments:\n\ni)        [Table 12.4: Emotional or behavioural impairments](#Table_12_4).\n\n397     WPI ratings from these four categories of cerebral impairment may not be combined with each other. The highest WPI rating from these four categories is to be used. Unless otherwise indicated, the highest WPI rating may then be combined with:\n\na)      a WPI rating from any other table or tables in [Chapter 12 – The neurological system](#_CHAPTER_12__) other than tables covering the first four categories; and\n\nb)      WPI ratings from tables in other chapters.\n\n","sortOrder":71},{"sectionNumber":"398","sectionType":"section","heading":"The following procedure should be used in assessing cerebral function.","content":"398     The following procedure should be used in assessing cerebral function.\n\n| Step 1 | Assess whether disturbance is present in the level of consciousness or awareness ([Table 12.1.1: Permanent disturbances of levels of consciousness and awareness](#Table_12_1_1), [Table 12.1.2: Epilepsy, seizures and convulsive disorders](#Table_12_1_2) and [Table 12.1.3: Sleep and arousal disorders](#Table_12_1_3)). This may be a permanent alteration or an intermittent alteration in consciousness, awareness or arousal. Use the most applicable of Table 12.1.1, Table 12.1.2 or Table 12.1.3. |\n| Step 2 | Evaluate mental status and highest integrative functioning ([Table 12.2: Impairment of memory, learning, abstract reasoning and problem solving ability](#Table_12_2)). |\n| Step 3 | Identify any difficulty with comprehension and the use of language ([Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#Table_12_3)) Use the higher of the WPI ratings from these two tables. |\n| Step 4 | Evaluate any emotional or behavioural disturbances, such as depression, that can modify cerebral function ([Table 12.4: Emotional or behavioural impairments](#Table_12_4)). |\n| Step 5 | Identify the most severe cerebral impairment from steps 1 to 4 above. Combine the most severe WPI rating with WPI ratings from any tables in [Chapter 12 – The neurological system](#_CHAPTER_12__) including and following [Table 12.5.1: The olfactory nerve (I)](#Table_12_5_1), or with WPI ratings from other chapters. |\n\n399     For the purposes of [Chapter 12 – The neurological system](#_CHAPTER_12__), activities of daily living are those in [Figure 12-A](#Figure_12_A).\n\nFigure 12-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\nNotes regarding station, gait and movement disorders\n\n1. Station, gait and movement disorders:\n\n(i)        station and gait disorders affecting the lower extremities are to be assessed under [Table 9.7: Lower extremity function](#Table_9_7) (see [Chapter 9 – Musculoskeletal system](#_bookmark123));\n\n(ii)      movement disorders affecting the upper extremities are to be assessed under [Table 9.14: Upper extremity function](#Table_9_14) (see [Chapter 9 – Musculoskeletal system](#_bookmark123)); and\n\n(iii)     except as provided for in the case of injury involving spinal cord damage (see notes to [Table 9.15: Cervical spine – diagnosis-related estimates](#Table_9_15), [Table 9.16: Thoracic spine – diagnosis-related estimates](#Table_9_16) and [Table 9.17:](#Table_9_17) [Lumbar spine – diagnosis-related estimates](#_bookmark219), [Chapter 9 – Musculoskeletal system](#_bookmark123)), station, gait and movement disorders may not be combined with any other WPI ratings from Chapter 9 for the same condition, but may be combined with other WPI ratings under [Chapter 12 – The neurological system](#_CHAPTER_12__).\n\n### 12.1   Disturbances of levels of consciousness and awareness\n\n#### 12.1.1     Permanent disturbances of levels of consciousness and awareness\n\n400     [Table 12.1.1: Permanent disturbances of levels of consciousness and awareness](#Table_12_1_1) applies to stupor, coma, and permanent vegetative state. These conditions are assessed based on clinical findings on neurological examination and relevant ancillary testing such as CT scan, MRI, SPECT, EEG, evoked potentials and vestibular testing.\n\nTable 12.1.1: Permanent disturbances of levels of consciousness and awareness\n\nSee note to Table 12.1.1 for further information.\n\n| 10–15 | Mild persistent alteration of state of consciousness limiting ability to perform some activities requiring alertness but not interfering with self care. |\n| 30 | Moderate persistent alteration of state of consciousness limiting ability to perform most activities of daily living including self care. |\n| 70 | Semi-comatose state with complete dependence on others for self care and subsistence. |\n| 95 | Persistent vegetative state or coma requiring total medical support in a specialised care facility. |\n\nNote to Table 12.1.1\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n#### 12.1.2     Epilepsy, seizures and convulsive disorders\n\n401     [Table 12.1.2: Epilepsy, seizures and convulsive disorders](#Table_12_1_2) is used for episodic neurological disorders of consciousness and awareness.\n\nTable 12.1.2: Epilepsy, seizures and convulsive disorders\n\n| 10 | Paroxysmal disorder with predictable characteristics but unpredictable occurrence and frequency and severity of attacks which place some restrictions on activities of daily living and may constitute a risk to the employee or others. |\n| 20 | Paroxysmal disorder with predictable characteristics but unpredictable occurrence and frequency and severity of attacks which place many restrictions on activities of daily living and constitutes a risk to the employee or others. |\n| 40 | Severe paroxysmal disorder of such frequency and severity that it limits activities of daily living to those that are supervised or protected. |\n| 70 | Severe, uncontrollable paroxysmal disorder of such severity that it totally restricts the employee’s daily activities – full time care and supervision are required. |\n\n#### 12.1.3     Sleep and arousal disorders\n\n","sortOrder":72},{"sectionNumber":"402","sectionType":"section","heading":"Arousal and sleep disorders include disorders related to:","content":"402     Arousal and sleep disorders include disorders related to:\n\na)      initiating and maintaining sleep, or inability to sleep;\n\nb)      excessive somnolence, including sleep-induced respiratory impairment; and\n\nc)       sleep-wake schedules.\n\n403     Central sleep apnoea should be assessed using [Table 12.1.3: Sleep and arousal disorders](#Table_12_1_3). Obstructive sleep apnoea should be assessed using [Table 2.4: WPI derived from obstructive sleep apnoea score](#Table_2_4) (see [Chapter 2 – The respiratory system](#_CHAPTER_2__)).\n\nTable 12.1.3: Sleep and arousal disorders\n\nSee notes to Table 12.1.3 for further information.\n\n| 10 | Reduced daytime alertness placing some restrictions on activities of daily living, performance of which might constitute a risk to the employee. |\n| 20 | Reduced daytime alertness placing many restrictions on activities of daily living and constituting a risk to the employee. |\n| 40 | Reduced daytime alertness of such severity that it limits activities of daily living to those that are supervised or protected. |\n| 60 | Severe reduction in daytime alertness which totally restricts the employee’s daily activities.<br>Full time care and supervision are required. |\n\nNotes to Table 12.1.3\n\n1. ‘Supervision’ means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.\n\n### 12.2   Impairment of memory, learning, abstract reasoning and problem solving ability\n\n404     WPI ratings in [Table 12.2: Impairment of memory, learning, abstract reasoning and problem-solving ability](#Table_12_2) reflect increasing levels of severity. To satisfy particular WPI rating requirements, the majority of criteria for each WPI rating should be present, as described in [Figure 12-B: Clinical dementia rating (CDR)](#Figure_12_B).\n\n405     The WPI ratings are incremental. In order to satisfy the criteria for a particular degree of impairment, the employee must have a greater degree of impairment than that described for the preceding levels.\n\n406     The clinical dementia rating (CDR) test for memory, abstract reasoning and problem solving ([Figure 12-B](#Figure_12_B)) should be administered by a professional competent in the area.\n\n407     The employee’s cognitive function for each category (memory, orientation, judgement and problem solving, community affairs, home and hobbies, personal care) is scored independently. For the purposes of assessing impairment, memory is considered the primary category. The other categories are secondary.\n\n","sortOrder":73},{"sectionNumber":"408","sectionType":"section","heading":"The following rules apply to scoring:","content":"408     The following rules apply to scoring:\n\na)      if at least three secondary categories are given the same numeric score as memory, then the clinical dementia rating equals the memory score (CDR=M);\n\nb)      if three or more of the secondary categories are given a score greater than or less than that for memory, then CDR is increased or decreased from M by one level as applicable;\n\nc)       however, if three secondary categories are scored one side of M, and two are scored on the other side of M, then CDR=M.\n\n409     Find the row in [Table 12.2: Impairment of memory, learning, abstract reasoning and problem-solving ability](#Table_12_2) that exactly matches the respective scores for CDR and memory. The WPI rating is shown in the first column of that row.\n\nTable 12.2: Impairment of memory, learning, abstract reasoning and problem solving ability\n\n| %WPI | CDR Score | Memory Score |\n| 0 | 0 | 0 |\n| 3 | 0.5 | 0 |\n| 7 | 0.5 | 0.5 |\n| 10 | 0.5 | 1.0 |\n| 15 | 1.0 | 0.5 |\n| 20 | 1.0 | 1.0 |\n| 25 | 1.0 | 2.0 |\n| 30 | 2.0 | 1.0 |\n| 40 | 2.0 | 2.0 |\n| 45 | 2.0 | 3.0 |\n| 55 | 3.0 | 2.0 |\n| 70 | 3.0 | 3.0 |\n\nFigure 12-B: Clinical dementia rating (CDR)\n\nFrom the AMA5.\n\n- Impairment level and CDR score(most of the criteria for a particular WPI rating should be present)\n- Category None 0 Questionable 0.5 Mild 1.0 Moderate 2.0 Severe 3.0\n- Memory (M) No memory loss or slight inconsistent forgetfulness. Consistent slight forgetfulness; partial recollection of events; ‘benign’ forgetfulness. Moderate memory loss; more marked for recent events; defect interferes with everyday activities. Severe memory loss; only highly learned material retained; new material rapidly lost. Severe memory loss; only fragments remain.\n- Orientation (O) Fully oriented. Fully oriented, except for slight difficulty with time relationships. Moderate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhere. Severe difficulty with time relationships; usually disoriented to time, often to place. Oriented to person only.\n- Judgement and problem solving (JPS) Solves everyday problems and handles business and financial affairs well; judgement good in relation to past performance. Slight impairment in solving problems, similarities and differences. Moderate difficulty in handling problems, similarities and differences; social judgement usually maintained. Severely impaired in handling problems, similarities and differences; social judgement usually impaired. Unable to make judgements or solve problems.\n- Community affairs(CA) Independent function at usual level in job, shopping, volunteer and social groups. Slight impairment in these activities. Unable to function independently at these activities although may still be engaged in some; appears normal to casual inspection. No pretence of independent function outside home; appears well enough to be taken to functions outside a family home. No pretence of independent function outside home; appears too ill to be taken to functions outside the employee’s family home.\n- Home and hobbies(HH) Life at home, hobbies and intellectual interests well maintained. Life at home, hobbies and intellectual interests slightly impaired. Mild but definite impairment of function at home; more difficult chores abandoned; more complicated hobbies and interests abandoned. Only simple chores preserved; very restricted interests, poorly maintained. No significant function in home.\n- Personal care (PC) Fully capable of self care. Fully capable of self care. Needs prompting. Requires assistance in dressing, hygiene, keeping of personal effects. Requires much help with personal care; frequent incontinence.\n\nSource: Morris JC, 1993, ‘The Clinical Dementia Rating (CDR): current version and scoring rules’, Neurology, 43(11): 2412-2414.\n\n### 12.3   Communication impairments – dysphasia and aphasia\n\n410     Communication involves comprehension, understanding, language, and effective interaction between and among individuals. Aphasia is a condition in which language function is defective or absent. It includes a lack of comprehension with deficits in vision, hearing, and language (both spoken and written), and also the inability to implement discernible and appropriate language symbols by voice, action, writing or pantomime. Dysphasia is a language impairment that is less severe that aphasia (which literally means ‘no speech’) but still is associated with a lesion in the dominant parietal lobe. It presents as a communication problem due to receptive or expressive dysphasia or a combination of the two. Inability to have a meaningful conversation because no nouns are used is an example of dysphasia. Other common errors include errors of grammatical structure, word-finding difficulties, and word substitution. Dysphasia and aphasia are different from dysarthria, which is imperfect articulation of speech due to disordered muscle control. Dysphonia is an impairment of sound production that causes difficulty speaking and understanding. Speech and communication impairments due to non neurological primary problems are discussed in [Chapter 7 – Ear, nose and throat disorders](#_bookmark96).\n\n411     Dysphasia is the most common diagnosis, since most individuals usually retain some ability to communicate. An inability to understand language has a poorer prognosis than an inability to express language. Speech therapy is of little value in the absence of comprehension; therefore, compensatory techniques may not be learned when a receptive aphasia or dysphasia exists. Tests for dysphasia should be conducted after it is established how confused or disoriented the individual is and which side of the brain is dominant for speech. Cognition should also be evaluated after dysphasia mechanisms have been excluded.\n\n","sortOrder":74},{"sectionNumber":"412","sectionType":"section","heading":"Aphasia and dysphasia test batteries are frequently devised by the clinician and cover the following simple tasks:","content":"412     Aphasia and dysphasia test batteries are frequently devised by the clinician and cover the following simple tasks:\n\na)      listening to spontaneous speech or responses to simple questions;\n\nb)      pointing commands and questions that can be answered ‘yes’ or ‘no’ to test comprehension;\n\nc)       repeating words and phrases;\n\nd)      naming objects that have high-and-low frequency use;\n\ne)      reading comprehension and reading aloud (reading is related to educational achievement, which must be known before interpreting reading comprehension and reading aloud results); and\n\nf)        writing and spelling.\n\n413     If comprehension is relatively intact, the aphasia screening battery may be adequate to place an individual in class 1 or 2. However, individuals with dysphasia may score poorly on aphasia and dysphasia test batteries while they demonstrate communicative competency for activities of daily living. This communicative competency may be measured by means of the communicative abilities in daily living (CADL), in which non verbal communication is assessed. [Table 12.3: Criteria for rating impairment due to aphasia or dysphasia](#Table_12_3) describes the criteria for rating impairment due to aphasia or dysphasia.\n\nTable 12.3: Criteria for rating impairment due to aphasia or dysphasia\n\n| 5 | Minimal disturbance in comprehension and production of language symbols of daily living. |\n| 10 | Moderate impairment in comprehension and production of language symbols of daily living. |\n| 32 | Able to comprehend non verbal communication; production of unintelligible or inappropriate language for daily activities. |\n| 50 | Complete inability to communicate or comprehend language symbols. |\n\n### 12.4   Emotional or behavioural impairments\n\n414     Emotional or behavioural disorders resulting from verifiable neurological impairments (for example, stroke or head injury) are assessed under [Table 12.4: Emotional or behavioural impairments](#Table_12_4).\n\n415     Psychiatric impairments without documented neurological origin are assessed under [Chapter 5 – Psychiatric conditions](#_CHAPTER_5__). They are not assessed under [Table 12.4: Emotional or behavioural impairments](#Table_12_4).\n\n","sortOrder":75},{"sectionNumber":"416","sectionType":"section","heading":"Neurological conditions associated with changes in emotion and affect include:","content":"416     Neurological conditions associated with changes in emotion and affect include:\n\na)      right hemisphere infarct and inappropriate jocularity;\n\nb)      left hemisphere infarct and deep dejection, and dysphasia;\n\nc)       left-sided temporolimbic seizure foci and ideational disorders; and\n\nd)      right-sided temporolimbic seizure foci and mood disturbances.\n\n417     The neuropsychiatric inventory (NPI) may be used to assess ‘no cognitive’ behavioural symptoms such as apathy, delusions, dysphoria, agitation/aggression, euphoria, hallucinations, irritability/lability, and aberrant motor behaviour (Cummings et al, 1994).\n\nTable 12.4: Emotional or behavioural impairments\n\nSee notes to Table 12.4 for further information.\n\n| %WPI | Criteria (all required) |\n| 0 | No limitation of activities of daily living and daily social and interpersonal functioning. |\n| 5 | Minor limitation of activities of daily living and daily social and interpersonal functioning attributable to the normal variation in the general population. |\n| 10 | Mild limitation of activities of daily living and daily social and interpersonal functioning. Impairment levels are compatible with most usual functioning.<br>Able to live independently, looks after self adequately, with occasional lapses in grooming and observing nutritional requirements.<br>Existing relationships strained. |\n| 30 | Moderate limitation of some activities of daily living and some daily social and interpersonal functioning. Cannot live independently without regular support.<br>Needs supervision and/or prompting to perform activities of self-care and personal hygiene.<br>Previously established relationships severely strained. |\n| 50 | Severe limitation in performing most activities of daily living.<br>Impairment significantly impedes useful functioning in most daily social and interpersonal functioning. |\n| 65 | Severe limitation in performing most activities of daily living.<br>Impairment significantly impedes useful functioning in most daily social and interpersonal functioning. Needs supervised residential care.<br>Unable to form or sustain long-term relationships. |\n| 80 | Completely unable to perform any daily activities, requiring total dependence on another person. Impairment levels preclude all useful functioning.<br>Unable to function within society. |\n\nNotes to Table 12.4\n\n1. ‘Supervision’ means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.\n2. ‘Suitable’ person means a person capable of responsibly caring for the employee in an appropriate way.\n\n### 12.5   Cranial nerves\n\n418     Unless otherwise indicated, only the highest WPI rating from the preceding four categories (that is all tables in [Section 12.1 (Disturbances of levels of consciousness and awareness)](#_Disturbances_of_levels), [Section 12.2 (Impairment of memory, learning, abstract reasoning and problem solving ability)](#_Impairment_of_memory_), [Section 12.3 (Communication impairments – dysphasia and aphasia)](#_Communication_impairments__) and [Section 12.4 (Emotional or behavioural impairments)](#_Emotional_or_behavioural)) may be combined with a WPI rating from one or more tables in the remainder of [Chapter 12 – The neurological system](#_CHAPTER_12__), and with WPI ratings from other chapters. (For further information about deriving WPI ratings from an assessment of cerebral function, see Steps 1 to 5 in the introduction to Chapter 12).\n\n#### 12.5.1     The olfactory nerve (I)\n\n419     The WPI ratings in [Table 12.5.1: The olfactory nerve (I)](#Table_12_5_1) reflect bilateral partial loss of function and total loss of function (anosmia).\n\n420     A WPI rating made under [Table 12.5.1: The olfactory nerve (I)](#Table_12_5_1) may not be combined with a WPI rating for the same condition made under [Table 7.3: Olfaction and taste](#Table_7_3) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)).\n\nTable 12.5.1: The olfactory nerve (I)\n\n| 2 | Bilateral partial loss of function. |\n| 5 | Bilateral total loss of function. |\n\n#### 12.5.2     The optic nerve, the oculomotor and trochlear nerves and the abducens (II, III, IV and VI)\n\n421     Dysfunction of these cranial nerves causes impairment of the visual system and is to be assessed under [Chapter 6 – The visual system](#_CHAPTER_6__).\n\n#### 12.5.3     The trigeminal nerve (V)\n\n422     This is a mixed nerve having sensory fibres to the face, cornea, anterior scalp, nasal and oral cavities, tongue and supratentorial dura mater. It also transmits motor impulses to the muscles of mastication.\n\n423     Where sensory loss affects more than one division of the nerve with differing severity, the respective values for each affected division may be combined using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n424     If paralysis of the motor fibres of the nerve causes interference with speech, this impairment should be evaluated in accordance with the criteria in [Chapter 7 – Ear, nose and throat disorders](#_bookmark96).\n\n425     Impairment due to chewing and swallowing difficulties is assessed under [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6). For the same condition, WPI ratings derived from Table 12.5.6 may not be combined with WPI ratings from [Table 7.7: Chewing and swallowing](#Table_7_7) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)).\n\nTable 12.5.3: The trigeminal nerve (V)\n\n| 0 | No loss of sensory function. |\n| 3 | Partial loss of sensory function of any one division of the nerve. |\n| 6 | Partial loss of sensory function of any two divisions of the nerve. |\n| 7 | Complete loss of sensory function of any one division of the nerve.<br>and/or<br>Mild uncontrolled facial neuralgic pain that may interfere with activities of daily living. |\n| 10 | Partial loss of sensory function of all three divisions of the nerve. |\n| 14 | Complete loss of sensory function of any two divisions of the nerve.<br>and/or<br>Moderately severe, uncontrolled facial neuralgic pain that interferes with activities of daily living. |\n| 20 | Complete loss of sensory function of all three divisions of the nerve.<br>and/or<br>Severe, uncontrolled, unilateral or bilateral facial neuralgic pain preventing performance of activities of daily living. |\n\n#### 12.5.4     The facial nerve (VII)\n\n426     This is a mixed nerve. The motor part innervates the facial muscles of expression and the accessory muscles for chewing and swallowing. The sensory fibres carry tactile sensations from the ear, soft palate and adjacent pharynx, and transmit taste from the anterior two thirds of the tongue.\n\n427     Impairment due to chewing and swallowing difficulties is assessed under [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6). For the same condition, WPI ratings derived from Table 12.5.6 may not be combined with WPI ratings from [Table 7.7: Chewing and swallowing](#Table_7_7) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)).\n\n428     Facial nerve injury, complicated by visual changes, such as occur with corneal desiccation and scarring, should rate as a significant impairment. This should be assessed under [Chapter 6 – The visual system](#_bookmark75), and may be combined with a WPI rating from [Table 12.5.4: The facial nerve (VII)](#Table_12_5_4).\n\n429     For the same condition, a WPI rating from [Table 12.5.4: The facial nerve (VII)](#Table_12_5_4) may not be combined with a WPI rating from [Table 7.3: Olfaction and taste](#Table_7_3) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)).\n\nTable 12.5.4: The facial nerve (VII)\n\nSee note to Table 12.5.4 for further information.\n\n| 3 | Complete loss of taste over anterior two thirds of tongue.<br>or<br>Mild unilateral facial weakness. |\n| 10–12 | Mild bilateral facial weakness.<br>or<br>Severe unilateral facial paralysis with 75% or greater facial involvement and inability to control eyelid closure. |\n| 30 | Severe bilateral facial paralysis with 75% or greater facial involvement and inability to control eyelid closure. |\n\nNote to Table 12.5.4\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n#### 12.5.5     The auditory nerve (VIII)\n\n","sortOrder":76},{"sectionNumber":"430","sectionType":"section","heading":"The auditory nerve has two portions:","content":"430     The auditory nerve has two portions:\n\na)      the cochlear portion concerned with hearing; and\n\nb)      the vestibular portion concerned with balance and spatial orientation.\n\n431     Impairment of hearing due to a lesion of the cochlear portion of the nerve should be evaluated under [Chapter 7 – Ear, nose and throat disorders](#_bookmark96). A WPI rating derived from Chapter 7 may be combined with a WPI rating from [Table 12.5.5: The auditory nerve (VIII)](#Table_12_5_5).\n\n","sortOrder":77},{"sectionNumber":"432","sectionType":"section","heading":"Lesions of the vestibular portion of the nerve result in vertigo with or without nausea and vomiting.","content":"432     Lesions of the vestibular portion of the nerve result in vertigo with or without nausea and vomiting.\n\n433     [Table 12.5.5: The auditory nerve (VIII)](#Table_12_5_5) is used where symptoms are continuous.\n\n434     To obtain the final WPI rating in the case of episodic disturbances of equilibrium (such as Menière’s disease), apply the modifier from [Figure 12-C: %WPI modifiers for episodic conditions](#Figure_12_C) to the WPI rating from [Table 12.5.5: The auditory nerve (VIII)](#Table_12_5_5).\n\nTable 12.5.5: The auditory nerve (VIII)\n\nSee notes to Table 12.5.5 for further information.\n\n| 0 | Symptoms of vestibular dysequilibrium present without supporting objective findings, and activities of daily living can be performed without assistance. |\n| 5 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and most activities of daily living can be performed without assistance. |\n| 10 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and most activities of daily living, except those of a complex nature (for example, riding a bicycle), or hazardous nature (for example, walking on a roof, girders or scaffolding), can be performed without assistance. |\n| 20 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and assistance is required with most activities of daily living, except self care, walking, and riding in a motor vehicle as a passenger. |\n| 30 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and assistance is required with all activities of daily living, except self care. |\n| 45 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and assistance is required with all activities of daily living, including self care not requiring ambulation. |\n| 60 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and activities of daily living cannot be performed without assistance, including self care. |\n| 80 | Symptoms of vestibular dysequilibrium present with supporting objective findings, and activities of daily living cannot be performed without assistance, including self care, and home confinement is necessary |\n\nNotes to Table 12.5.5\n\n1. ‘Assistance’ means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.\n\nFigure 12-C: %WPI modifiers for episodic conditions\n\n| Signs and symptoms | Modifier |\n| Absent. | 0.0 |\n| Intermittent. | 0.2 |\n| Present on a daily basis for periods aggregating 3 or more months per year but less than 6 months per year. | 0.4 |\n| Present on a daily basis for periods aggregating 6 or more months per year but less than 8 months per year. | 0.6 |\n| Present on a daily basis for periods aggregating 8 months or more per year but less than 10 months per year. | 0.8 |\n| Present on a daily basis for period aggregating 10 months per year or more. | 1.0 |\n\n#### 12.5.6     The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)\n\n435     The spinal accessory nerve assists the vagus nerve in supplying some of the muscles of the larynx, and innervates the cervical portions of the sternocleidomastoid and trapezius muscles.\n\n436     Disorders of these nerves affecting musculoskeletal function should be assessed in accordance with criteria contained in [Chapter 9 – Musculoskeletal system](#_bookmark123).\n\n437     The glossopharyngeal nerve and the vagus nerve are mixed nerves supplying sensory fibres to the posterior third of the tongue, larynx and trachea. Sensory impairment may contribute to difficulties swallowing, breathing and speaking.\n\n","sortOrder":78},{"sectionNumber":"438","sectionType":"section","heading":"The hypoglossal nerve is a motor nerve that innervates the musculature of the tongue.","content":"438     The hypoglossal nerve is a motor nerve that innervates the musculature of the tongue.\n\n439     Dysarthia is a situation where the articulation of the voice mechanism is at fault. Pronunciation is unclear, although the linguistic content and meaning are normal.\n\n440     Dysphagia is a condition in which the action of swallowing is difficult to perform, painful, or in which swallowed material is delayed in its passage to the stomach. Speech is slowed or slurred and may be completely unintelligible or non- functional. All other causes of difficulty with chewing or swallowing should be assessed using [Table 7.7: Chewing and swallowing](#Table_7_7) (see [Chapter 7 – Ear, nose and throat disorders](#_bookmark96)). For the same condition, WPI ratings from Table 7.7 may not be combined with WPI ratings from [Table 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)](#Table_12_5_6).\n\nTable 12.5.6: The glossopharyngeal, vagus, spinal accessory and hypoglossal nerves (IX, X, XI and XII)\n\n| 10 | Mild dysarthria (speech slow or slurred especially when tired).<br>Dystonia (only neurological).<br>Mild dysphagia (coughing on liquids or semi-solid foods).<br>Diet limited to semi-solid or soft foods.<br>Spasmodic torticollis (only neurological). |\n| 25 | Moderately severe dysarthia (speech is laboured, imprecise, and often unintelligible).<br>Speaker is required to repeat often and may need augmentative device to help convey message. Moderately severe dysphagia with nasal regurgitation and aspiration of liquids and semisolid foods.<br>Diet limited to liquid foods. |\n| 50 | Severe dysarthia – speech may be completely unintelligible or non-functional, or intelligible only to familiar people, and only with the aid of an augmentative communication device.<br>Severe dysphagia (inability to swallow food, liquids or manage oral secretions).<br>Regular suctioning required.<br>Ingestion of food requires tube feeding or gastrotomy. |\n\n### 12.6   Neurological impairment of the respiratory system\n\n441     Where the ability to breathe is impaired because of a neurological impairment, [Table 12.6: Neurological impairment of the respiratory system](#Table_12_6) may be used. Impairments of the respiratory system not of documented neurological origin are assessed under [Chapter 2 – The respiratory system](#_CHAPTER_2__). They are not assessed under Table 12.6.\n\nTable 12.6: Neurological impairment of the respiratory system\n\n| 10 | Able to breathe spontaneously but has difficulty performing activities of daily living that require moderate exertion. |\n| 25 | Able to breathe spontaneously but is restricted to sitting, standing or limited walking. |\n| 60 | Able to breathe spontaneously but to such a limited degree that the employee is confined to bed. |\n| 90 | No capacity for spontaneous respiration. |\n\n### 12.7   Neurological impairment of the urinary system\n\n442     Where there is loss of bladder control due to a neurological impairment, [Table 12.7: Neurological impairment of the urinary system](#Table_12_7) may be used.\n\n443     Impairments of the urinary system not of documented neurological origin are assessed under [Chapter 10 – Urinary system](#_bookmark222). They are not assessed under [Table 12.7: Neurological impairment of the urinary system](#Table_12_7).\n\n","sortOrder":79},{"sectionNumber":"444","sectionType":"section","heading":"Documentation by cystometric and other relevant urologic tests may be necessary.","content":"444     Documentation by cystometric and other relevant urologic tests may be necessary.\n\n445     The status of the upper urinary tract must also be considered. Except for an impairment of bladder function, if several impairments of the urinary system are present, a WPI rating from [Table 12.7: Neurological impairment of the urinary system](#Table_12_7) may be combined with a WPI rating from [Chapter 10 – Urinary system](#_bookmark222).\n\nTable 12.7: Neurological impairment of the urinary system\n\nSee note to Table 12.7 for further information.\n\n| 5 | Some degree of voluntary control but impaired by urgency or intermittent incontinence. |\n| 10–15 | Good bladder reflex activity, limited capacity, and intermittent emptying without voluntary control. |\n| 30 | Poor bladder reflex activity, intermittent dribbling, and no voluntary control. |\n| 50 | No reflex or voluntary control of the bladder. |\n\nNote to Table 12.7\n\n1. Assessors should refer to the [Principles of Assessment](#_bookmark9) for guidance on awarding an impairment value within a range.\n\n### 12.8   Neurological impairment of the anorectal system\n\n446     Where there is loss of ability to control emptying because of a neurological impairment, [Table 12.8: Neurological impairment of the anorectal system](#Table_12_8) may be used. Impairments of the anorectal system not of documented neurological origin are assessed under [Chapter 8 – The digestive system](#_CHAPTER_8__). They are not assessed under Table 12.8.\n\nTable 12.8: Neurological impairment of the anorectal system\n\n| 10 | Reflex regulation but only limited voluntary control. |\n| 20 | Reflex regulation but no voluntary control. |\n| 40 | No reflex regulation or voluntary control. |\n\n### 12.9   Neurological impairment affecting sexual function\n\n447     Where there is loss of awareness and the capability of having an orgasm because of a neurological impairment, [Table 12.9: Neurological impairment affecting sexual function](#Table_12_9) may be used. Impairments of sexual function not of documented neurological origin are not assessed under Table 12.9. They are assessed under [Chapter 11 – The reproductive system](#_CHAPTER_11__).\n\n","sortOrder":80},{"sectionNumber":"448","sectionType":"section","heading":"The employee’s previous sexual functioning should be considered.","content":"448     The employee’s previous sexual functioning should be considered.\n\n449     Impairment of the peripheral nervous system is assessed using the methodology for assessing the lower and upper extremities described in [Chapter 9 – Musculoskeletal system](#_bookmark123).\n\nTable 12.9: Neurological impairment affecting sexual function\n\n| 10 | Sexual functioning is possible, but with difficulty of erection or ejaculation in men, or lack of awareness, excitement or lubrication in either sex. |\n| 15 | Reflex sexual functioning is possible, but there is no awareness. |\n| 20 | No sexual functioning. |\n\n## CHAPTER 13 – THE HAEMATOPOIETIC SYSTEM\n\n### 13.0   Introduction\n\n450     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n### 13.1   Anaemia\n\n451     Iron deficiency anaemia and megaloblastic anaemia are generally manageable with proper treatment and should not cause permanent impairment. Some haemolytic anaemias are reversible with appropriate therapy, such as steroids or splenectomy, and also should result in negligible impairment.\n\n452     The impairment resulting from persistent refractory anaemia, whether haemolytic or aplastic, is assessed using [Table 13.1: Anaemia](#Table_13_1).\n\nTable 13.1: Anaemia\n\nSee note to Table 13.1 for further information.\n\n| %WPI | Haemoglobin level | Transfusion requirements |\n| 0 | 100-120g/L | None |\n| 10 | 80-100g/L | None |\n| 20 | 80-100g/L | 2 units every 6 weeks |\n| 40 | <80g/L | 2-3 units every 4 to 6 weeks |\n| 60 | <80g/L | 2-3 units every 2-3 weeks |\n\nNote to Table 13.1.\n\n1. The haemoglobin levels referred to in Table 13.1 are the levels prior to transfusion.\n\n### 13.2   Leukocyte abnormalities or disease\n\n453     Chronic low white cell counts (for example, neutropenia) are usually associated with substantially increased risk of infection. Impairment is measured in terms of the infection.\n\n454     Neoplastic disorders of leukocytes include leukaemias, lymphomas, multiple myeloma, and macroglobulinaemia. Some of these disorders (chronic lymphatic leukaemia, hairy cell leukaemia, and some lymphomas) may cause no impairment for many years.\n\n455     Similarly, multiple myeloma and macroglobulinaemia may be initially asymptomatic, and cause no gastrointestinal haemorrhage, bone pain, or need for chemotherapy or radiation.\n\n","sortOrder":81},{"sectionNumber":"456","sectionType":"section","heading":"The impairment should be assessed by reference to the appropriate chapters of this guide.","content":"456     The impairment should be assessed by reference to the appropriate chapters of this guide.\n\n457     As the early stages of HIV infection are not likely to manifest in impaired organ systems, [Table 13.2: Leukocyte abnormalities or disease](#Table_13_2) alone should be used to assess any impairment. Where organ systems are impaired as the disease progresses, impairment should be assessed using those chapters of the guide which assess impairment of the principal organ systems affected by the disease: including, but not limited to, [Chapter 2 – The respiratory system](#_CHAPTER_2__), [Chapter 8 – The digestive system](#_CHAPTER_8__), [Chapter 10 – The urinary system](#_bookmark222), and [Chapter 12 – The neurological system](#_CHAPTER_12__). If several systems are involved, the WPI ratings derived for each system are combined using the combined values chart (see [Appendix 1](#_bookmark300)).\n\n458     The combined impairment should then be compared with the WPI rating from [Table 13.2: Leukocyte abnormalities or disease](#Table_13_2) in order to ascertain the more beneficial WPI rating.\n\n","sortOrder":82},{"sectionNumber":"459","sectionType":"section","heading":"The contribution of side effects of drug treatment to overall impairment should also be considered.","content":"459     The contribution of side effects of drug treatment to overall impairment should also be considered.\n\n460     The same principle applies to other conditions of the haematopoietic system where organ systems are impaired by the disease process and impairment can be assessed using other chapters of the guide.\n\n461     For the purposes of [Table 13.2: Leukocyte abnormalities or disease](#Table_13_2), activities of daily living are those in [Figure 13-A](#Figure_13_A).\n\nFigure 13-A: Activities of daily living\n\n| Physical activity | Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising. |\n\nTable 13.2: Leukocyte abnormalities or disease\n\nSee notes to Table 13.2 for further information.\n\n| %WPI | Criteria (all required) |\n| 0 | Signs of leukocyte abnormality but no symptoms.<br>No or infrequent treatment needed.<br>All the activities of daily living can be performed. |\n| 10 | Signs and symptoms of leukocyte abnormality.<br>Infrequent treatment needed.<br>Almost all the activities of daily living can be performed. |\n| 20 | Signs and symptoms of leukocyte abnormality.<br>Continuous or regular treatment needed.<br>Most of the activities of daily living can be performed. |\n| 30 | Signs and symptoms of leukocyte abnormality.<br>Continuous or regular treatment needed.<br>Interference with the performance of the activities of daily living to the extent that some assistance from others is required. |\n| 50 | Signs and symptoms of leukocyte abnormality.<br>Continuous or regular treatment needed.<br>Interference with the performance of the activities of daily living to the extent that considerable assistance from others is required. |\n| 70 | Signs and symptoms of leukocyte abnormality.<br>Continuous or regular treatment needed.<br>Interference with the performance of the activities of daily living to the extent that continuous assistance from others is required. |\n| 80 | Signs and symptoms of leukocyte abnormality.<br>Continuous or regular treatment needed.<br>Totally dependent on others for performance of all activities of daily living. |\n\nNotes to Table 13.2\n\n1. ‘Assistance’ means the immediate presence of a suitable person, responsible in whole or in part for the care of the employee.\n\n### 13.3   Haemorrhagic disorders and platelet disorders\n\n462     Thrombocytopenia does not constitute an impairment unless severe and not reversible by steroids, splenectomy, or other therapy.\n\n463     A bleeding disorder that causes problems only after trauma or surgery does not constitute a permanent bleeding impairment.\n\n464     Where an injury is made more severe by the presence of an underlying bleeding disorder, a combined WPI rating is allowed, incorporating values for bleeding sites or organ damage. A WPI rating obtained from tables in other chapters may be combined with a WPI rating obtained from [Table 13.3: Haemorrhagic disorders and platelet disorders](#Table_13_3).\n\n465     Other complications of bleeding disorders, including gastrointestinal, mucosal or intramuscular haemorrhage, should also be assessed according to the site of the blood loss under other Chapters of the guide, including [Chapter 8 – The](#_CHAPTER_8__) [digestive system](#_bookmark108) and/or [Table 13.1: Anaemia](#Table_13_1).\n\n466     A WPI rating obtained from other tables in this Guide may be combined with a WPI rating obtained from [Table 13.3: Haemorrhagic disorders and platelet disorders](#Table_13_3).\n\nTable 13.3: Haemorrhagic disorders and platelet disorders\n\n| 0 | Splenectomy.<br>or<br>Easy bruising. |\n| 10 | Continuous or regular medication is required. |\n| 25 | Refractory thrombocytopenia <20,000/µL. |\n\n### 13.4   Thrombotic disorders\n\n","sortOrder":83},{"sectionNumber":"467","sectionType":"section","heading":"Long-term prophylaxis means prophylaxis continuing for at least two years.","content":"467     Long-term prophylaxis means prophylaxis continuing for at least two years.\n\n468     Employees who have permanent respiratory or cardiac limitations secondary to massive pulmonary embolism should be assessed as appropriate under [Chapter 1 – The cardiovascular system](#_CHAPTER_1__) and [Chapter 2 – The respiratory system](#_CHAPTER_2__).\n\n469     For specific levels of impairment for post-thrombotic syndrome, use [Table 1.4: Peripheral vascular disease of the lower extremities](#Table_1_4) or [Table 1.5: Peripheral vascular disease of the upper extremities](#Table_1_5) (see [Chapter 1 – The cardiovascular system](#_CHAPTER_1__)). These tables may be used as an alternative. WPI ratings from Tables 1.4 or 1.5, and [Table 13.4: Thrombotic disorders](#_bookmark280), may not be combined.\n\n470     [Table 1.4: Peripheral vascular disease of the lower extremities](#Table_1_4) and [Table 1.5: Peripheral vascular disease of the upper extremities](#Table_1_5) should be used as the primary guide for assessing peripheral complications of thrombosis.\n\nTable 13.4: Thrombotic disorders\n\n| 0 | Superficial thrombosis or thrombophlebitis. |\n| 10 | Deep venous or other thrombosis requiring long-term prophylaxis with warfarin. |\n| 30 | Post-phlebitic syndrome. |\n\n# DIVISION 2 – ASSESSMENT OF THE DEGREE OF NON-ECONOMIC LOSS SUFFERED BY AN EMPLOYEE AS A RESULT OF AN INJURY OR IMPAIRMENT\n\n### Introduction\n\n471     In conducting an assessment, the assessor must have regard to the [Principles of Assessment](#_bookmark9) and the definitions contained in the [Glossary](#_bookmark16).\n\n","sortOrder":84},{"sectionNumber":"472","sectionType":"section","heading":"The degree of non-economic loss is to be assessed in accordance with [Division 2](#_bookmark282).","content":"472     The degree of non-economic loss is to be assessed in accordance with [Division 2](#_bookmark282).\n\n","sortOrder":85},{"sectionNumber":"473","sectionType":"section","heading":"The compensation payable for non-economic loss is divided into two equal amounts.","content":"473     The compensation payable for non-economic loss is divided into two equal amounts.\n\n474     [Table B6: Worksheet – calculation of non-economic loss](#Table_B6) uses the following formula to calculate the total payable in an individual case:\n\n![Start formula A plus B equals total in dollars end formula ](image.012.png)\n\nWHERE “A” = the percentage assessment of total permanent impairment, multiplied by the first half of the maximum\n\nAND “B” = a reasonable percentage of the second half of the maximum having regard to the non-economic loss suffered.\n\n","sortOrder":86},{"sectionNumber":"475","sectionType":"section","heading":"Listed below are the tables in [Division 2](#_bookmark282) used to calculate a reasonable percentage.","content":"475     Listed below are the tables in [Division 2](#_bookmark282) used to calculate a reasonable percentage.\n\na)      Pain:\n\ni)        [Table B1: Pain](#Table_B1).\n\nb)      Suffering:\n\ni)        [Table B2: Suffering](#Table_B2).\n\nc)       Loss of amenities:\n\ni)        [Table B3.1: Mobility](#Table_B3_1);\n\nii)      [Table B3.2: Social relationships](#Table_B3_2); and\n\niii)     [Table B3.3: Recreation and leisure activities](#Table_B3_3).\n\nd)      Other loss:\n\ni)        [Table B4: Other loss](#Table_B4).\n\ne)      Loss of expectation of life:\n\ni)        [Table B5: Loss of expectation of life](#Table_B5).\n\n476     Scores derived from these tables are then transferred to [Table B6: Worksheet – calculation of non-economic loss](#Table_B6).\n\n### B1 Pain\n\n","sortOrder":87},{"sectionNumber":"477","sectionType":"section","heading":"Using [Table B1: Pain](#Table_B1), a score out of five is assessed for pain.","content":"477     Using [Table B1: Pain](#Table_B1), a score out of five is assessed for pain.\n\n478     Using [Table B6: Worksheet – calculation of non-economic loss](#Table_B6), the score for pain is combined with the scores derived from [Table B2: Suffering](#Table_B2), [Table B3.1: Mobility](#Table_B3_1), [Table B3.2: Social relationships](#Table_B3_2), [Table B3.3: Recreation and leisure activities](#Table_B3_3), [Table B4: Other loss](#Table_B4) and [Table B5: Loss of expectation of life](#Table_B5).\n\n","sortOrder":88},{"sectionNumber":"479","sectionType":"section","heading":"The term ‘pain’ is defined in the [Glossary](#_bookmark16).","content":"479     The term ‘pain’ is defined in the [Glossary](#_bookmark16).\n\n","sortOrder":89},{"sectionNumber":"480","sectionType":"section","heading":"Only ongoing pain of a continuing or episodic nature is to be considered.","content":"480     Only ongoing pain of a continuing or episodic nature is to be considered.\n\n481     [Table B1: Pain](#Table_B1) does not include:\n\na)      temporary pain; or\n\nb)      speculation of future pain that has not yet manifested itself.\n\n482     In [Table B1: Pain](#Table_B1), VAPS means ‘visual analogue pain scale’, with 0 being no pain, and 10 being the worst pain ever experienced.\n\nTable B1: Pain\n\n| 0 | No pain experienced.<br>VAPS = 0 |\n| 1 | Intermittent attacks of pain of nuisance value only.<br>Can be ignored when activity commences.<br>VAPS = 1-2 |\n| 2 | Intermittent attacks of pain.<br>Not easily tolerated, but short-lived.<br>Pain responds fairly readily to treatment (for example, analgesics, anti-inflammatory medications).<br>VAPS = 3-4 |\n| 3 | Episodes of pain more persistent.<br>Not easily tolerated.<br>Treatment, if available, of limited benefit.<br>VAPS = 5-6 |\n| 4 | Pain occurring most of the time.<br>Restrictions on activity.<br>Resistant to treatment.<br>VAPS = 7-8 |\n| 5 | Pain continuous and severe.<br>Preventing activity.<br>Uncontrolled by medication.<br>VAPS = 9-10 |\n\n### B2 Suffering\n\n","sortOrder":90},{"sectionNumber":"483","sectionType":"section","heading":"Using [Table B2: Suffering](#Table_B2), a score out of five is assessed for suffering.","content":"483     Using [Table B2: Suffering](#Table_B2), a score out of five is assessed for suffering.\n\n484     Using [Table B6: Worksheet – calculation of non-economic loss](#Table_B6), the score for suffering is combined with the scores derived from [Table B1: Pain](#Table_B1), [Table B3.1: Mobility](#Table_B3_1), [Table B3.2: Social relationships](#Table_B3_2), [Table B3.3: Recreation and leisure activities](#Table_B3_3), [Table B4: Other loss](#Table_B4) and [Table B5: Loss of expectation of life](#Table_B5).\n\n","sortOrder":91},{"sectionNumber":"485","sectionType":"section","heading":"The term ‘suffering’ is defined in the [Glossary](#_bookmark16).","content":"485     The term ‘suffering’ is defined in the [Glossary](#_bookmark16).\n\n486     Suffering includes emotional symptoms which are within the normal range of human responses to distressing events such as grief, anguish, fear, frustration, humiliation, embarrassment.\n\n","sortOrder":92},{"sectionNumber":"487","sectionType":"section","heading":"Only ongoing suffering of a continuing or episodic nature is considered.","content":"487     Only ongoing suffering of a continuing or episodic nature is considered.\n\n488     [Table B2: Suffering](#Table_B2) does not include:\n\na)      temporary suffering; or\n\nb)      speculation about future suffering that has not yet manifested itself.\n\nTable B2: Suffering\n\n| 0 | No symptoms of mental distress experienced. |\n| 1 | Symptoms of mental distress minimal or ill defined.<br>Symptoms occur intermittently.<br>No interference with activity. |\n| 2 | Distinct symptoms of mental distress which are episodic in nature.<br>Activities reduced during such episodes.<br>Recovers quickly after episodes. |\n| 3 | Symptoms of mental distress are distinct and varied.<br>Episodes of mental distress occur regularly.<br>Ability to cope or perform activity effectively reduced during episodes.<br>Needs time to recover between episodes.<br>Treatment – medication such as anti-depressants, counselling or other therapy by a psychologist or<br>psychiatrist, or other supportive therapy – is of benefit in controlling or relieving symptoms. |\n| 4 | Symptoms of mental distress are wide ranging and tend to dominate thinking.<br>Rarely free of symptoms of mental distress.<br>Difficulty coping or performing activity.<br>Treatment necessary either to control or relieve symptoms. |\n| 5 | Symptoms of mental distress arising from accepted condition interferes with normal thought processes. Activities severely restricted.<br>Treatment of no real benefit in controlling or relieving symptoms. |\n\n### B3 Loss of amenities\n\n489     The term ‘loss of amenities’ is defined in the [Glossary](#_bookmark16). Loss of amenities is also known as ‘loss of enjoyment of life’.\n\n","sortOrder":93},{"sectionNumber":"490","sectionType":"section","heading":"A score out of five is assessed for each of the following:","content":"490     A score out of five is assessed for each of the following:\n\na)      Mobility (using [Table B3.1: Mobility](#_bookmark288)). ‘Mobility’ refers to the employee’s ongoing ability to move around in their environment. This includes walking, driving, being a passenger, using public transport\n\nb)      Social relationships (using [Table B3.2: Social relationships](#_bookmark289)). ‘Social relationships’ refers to the employee’s ongoing capacity to engage in usual social and personal relationships\n\nc)       Recreation and leisure activities (using [Table B3.3: Recreation and leisure activities](#_bookmark290)). ‘Recreation and leisure activities’ refers to the employee’s ongoing ability to maintain customary recreational and leisure pursuits.\n\n491     Using [Table B6: Worksheet – calculation of non-economic loss](#_bookmark295), these scores are then combined with the scores derived from [Table B1: Pain](#Table_B1), [Table B2: Suffering](#Table_B2), [Table B4: Other loss](#_bookmark292) and [Table B5: Loss of expectation of life](#_bookmark293).\n\nTable B3.1: Mobility\n\n| 0 | No or minimal restrictions on mobility. |\n| 1 | Periodic effects on mobility, resulting in the need for some assistance<br>or<br>effects continuing but mild (such as slowing of pace or the need for a walking stick). |\n| 2 | Mobility reduced, but remains independent of others both within and outside the home.<br>Can travel but may require rest breaks, special seating, or other special treatment. |\n| 3 | Mobility markedly reduced.<br>Needs some assistance from others.<br>Unable to use most forms of transport. |\n| 4 | Restricted to home and vicinity.<br>Can only travel outside home with door to door transport and the assistance of others. |\n| 5 | Severely restricted mobility (for example, bed, chair, room).<br>Dependent on others for assistance.<br>Mechanical devices or appliances used for mobility within the home (for example, wheelchair, hoist). |\n\nTable B3.2: Social relationships\n\n| Score | Description of effect (all required) |\n| 0 | Usual relationships unaffected. |\n| 1 | Minor interference with personal relationships, causing some reduction in social activities and contacts. |\n| 2 | Relationships confined to immediate and extended family and close friends, but unable to relate to casual acquaintances. |\n| 3 | Difficulty in maintaining relationships with close friends and the extended family. |\n| 4 | Social contacts confined to immediate family. |\n| 5 | Difficulties relating socially to anyone. |\n\nTable B3.3: Recreation and leisure activities\n\n| Score | Description of effect (all required) |\n| 0 | Able to follow usual recreation and leisure activities |\n| 1 | Intermittent interference with activities.<br>In between episodes able to pursue usual activities. |\n| 2 | Interference to activities reduces frequency of activity, but is able to continue.<br>Is able to follow alternatives. |\n| 3 | Unable to continue with pre-injury level of activity.<br>Alternative activity possible. |\n| 4 | Range of pre-injury activities greatly reduced.<br>Needs some assistance to participate in pre-injury recreation and leisure activities. |\n| 5 | Unable to undertake any pre-injury recreation and leisure activities. |\n\n### B4 Other loss\n\n492     [Table B4: Other loss](#_bookmark292) is used to assess losses of a non-economic nature that are not adequately covered by [Table B1: Pain](#Table_B1), [Table B2: Suffering](#Table_B2), [Table B3.1: Mobility](#_bookmark288), [Table B3.2: Social relationships](#_bookmark289), [Table B3.3: Recreation and leisure activities](#Table_B3_3) or [Table B5: Loss of expectation of life](#_bookmark293).\n\n","sortOrder":94},{"sectionNumber":"493","sectionType":"section","heading":"A score out of three is assessed.","content":"493     A score out of three is assessed.\n\n494     Using [Table B6: Worksheet – calculation of non-economic loss](#_bookmark295), this score is then combined with the scores derived from [Table B1: Pain](#Table_B1), [Table B2: Suffering](#Table_B2), [Table B3.1: Mobility](#_bookmark288), [Table B3.2: Social relationships](#_bookmark289), [Table B3.3: Recreation and leisure activities](#Table_B3_3) and [Table B5: Loss of expectation of life](#_bookmark293).\n\nTable B4: Other loss\n\n| Score | Description of effect |\n| 0 | Nil or minimal disadvantages. |\n| 1 | Moderate disadvantages. For example, dependence upon a specialised diet; detrimental effects of climatic features including temperature, humidity, ultra-violet rays, light, noise, dust. |\n| 2 | Marked disadvantages. For example, requirement to move to specially modified premises. |\n| 3 | Severe disadvantages. For example, dependence upon external life saving or supporting machines including aspirator, respirator, dialysis machine, or any form of electro-mechanical device for the sustenance or extension of activities. |\n\n### B5 Loss of expectation of life\n\n","sortOrder":95},{"sectionNumber":"495","sectionType":"section","heading":"A score out of three is assessed.","content":"495     A score out of three is assessed.\n\n496     Using [Table B6: Worksheet – calculation of non-economic loss](#_bookmark295), this score is then combined with the scores derived from [Table B1: Pain](#Table_B1), [Table B2: Suffering](#Table_B2), [Table B3.1: Mobility](#_bookmark288), [Table B3.2: Social relationships](#_bookmark289), [Table B3.3: Recreation and leisure activities](#Table_B3_3) and [Table B4: Other loss](#_bookmark292).\n\n497     Loss of expectation of life is restricted to a maximum of three points because of the value placed on it by the courts in damages cases.\n\nTable B5: Loss of expectation of life\n\n| Score | Description of effect |\n| 0 | Loss of life expectancy of less than one year. |\n| 1 | Loss of life expectancy of one year to less than 10 years. |\n| 2 | Loss of life expectancy of 10 years to less than 20 years. |\n| 3 | Loss of life expectancy of 20 years or greater. |\n\n### B6 Calculation of non-economic loss\n\n498     [Table B6: Worksheet – calculation of non-economic loss](#_bookmark295) allows for the calculation of the percentage of non-economic loss suffered by the employee for the purposes of section 27 of the Seafarers Act.\n\nTable B6: Worksheet – calculation of non-economic loss\n\nSTEP 1 – Calculation of total score from Division 2 tables\n\n- Table Score Factor Final score\n- Table B1: Pain x 0.5 =\n- Table B2: Suffering x 0.5 =\n- B3: Amenities of life\n- B3.1: Mobility score x 0.6 =\n- B3.2: Social relationships x 0.6 =\n- B3.3: Recreation and leisure activities x 0.6 =\n- Table B4: Other loss x 1.0 =\n- Table B5: Loss of expectation of life x 1.0 =\n- Total of scores =\n\nSTEP 2 – Conversion of total of scores to a percentage\n\n| Choose either Step 2.1 or Step 2.2 |\n| --- |\n| Step 2.1<br>If the total of scores from Step 1 above:<br>    equals 15; or    is greater than 15<br>then the percentage of non-economic loss suffered by the employee is 100% (%NEL). |\n| Or |\n| Step 2.2<br>If the total of scores from Step 1 above is less than 15, complete the following calculation to find the percentage non-economic loss suffered by the employee:<br>![Start formula start fraction open round bracket total of scores from step one close round bracket over 15 end fraction times 100 equals percentage non-economic loss end formula](image.013.png) |\n\n# DIVISION 3 – CALCULATION OF THE TOTAL ENTITLEMENT TO COMPENSATION FOR PERMANENT IMPAIRMENT AND NON-ECONOMIC LOSS\n\n","sortOrder":96},{"sectionNumber":"499","sectionType":"section","heading":"Use [Table C1: Worksheet – calculation of total entitlement](#_bookmark298) to derive the total entitlement.","content":"499     Use [Table C1: Worksheet – calculation of total entitlement](#_bookmark298) to derive the total entitlement.\n\nTable C1: Worksheet – calculation of total entitlement\n\nCurrent statutory maximum amounts for permanent impairment and non-economic loss compensation are available on the Authority’s website: [comcare.gov.au/claims/statutory-rates](https://www.seacare.gov.au/claims-rehabilitation/statutory-rates-for-compensation). They are indexed annually on 1 July in accordance with movements in the Consumer Price Index.\n\n- Calculate total whole person impairment entitlement\n- Step 1 Obtain the current indexed maximum amount for permanent impairment under subsection 39(9) of the Seafarers Act (maximum s 39(9) amount) and complete the following calculation:Start formula percentage whole person impairment times the current indexed maximum amount for permanent impairment equals under subsection 9 of section 39 of the Seafarers Rehabilitation and Compensation Act 1992 equals end formula $\n- Step 2 Obtain the current indexed maximum amount for non-economic loss under subsection 41(2) “A” of the Seafarers Act (maximum s 41(2) “A” amount) and complete the following calculation:Start formula percentage whole person impairment times the current indexed maximum amount for non-economic loss A under subsection 2 of section 41 of the Seafarers Rehabilitation and Compensation Act 1992 equals end formula $\n- Step 3 Obtain the current indexed maximum amount for non-economic loss under subsection 41(2) “B” of the Seafarers Act (maximum s 41(2) “B” amount) and complete the following calculation:Start formula percentage whole person impairment times the current indexed maximum amount for non-economic loss B under subsection 2 of section 41 of the Seafarers Rehabilitation and Compensation Act 1992 equals end formula $\n- Step 4 Add the amounts calculated in Steps 1, 2 and 3 to calculate the total entitlement under sections 39 and 41 of the Seafarers Act: $\n\n \n\n# APPENDIX 1 – COMBINED VALUES CHART\n\n","sortOrder":97},{"sectionNumber":"500","sectionType":"section","heading":"The values are derived from the formula:","content":"500     The values are derived from the formula:\n\n![Start formula B times open round bracket one minus A close round bracket plus A equals combined value of A and B end formula](image.017.png)\n\nWHERE “A” and “B” are the decimal equivalents of the WPI ratings.\n\n501     In the chart all values are expressed as percentages. To combine any two impairment values, locate the larger of the values on the side of the chart and read along that row until you come to the column indicated by the smaller value at the bottom of the chart. At the intersection of the row and the column is the combined value.\n\n502     For example, to combine 35% and 20%, read down the side of the chart until you come to the larger value, 35%. Then read across the 35% row until you come to the column indicated by 20% at the bottom of the chart. At the intersection of the row and column is the number 48. Therefore, 35% combined with 20% is 48%. Because of the construction of this chart, the larger impairment value must be identified at the side of the chart.\n\n503     If three or more impairment values are to be combined, sort the impairment values from highest to lowest, select the highest and find their combined values as above. The use that combined value and the third highest impairment value to locate the combined value of all.\n\n504     This process can be repeated indefinitely, the final value in each instance being the combination of all the previous values. In each step of this process the larger impairment value must be identified at the side of the chart.\n\nCombined values chart\n\nSource: The AMA5 (pages 604-5).\n\n![A numerical matrix with percentage impairments on the X axis and the Y axis and corresponding combined whole person impairment ratings established using the formula described in paragraph 502](image.018.png)\n\nCombined values chart (continued)\n\n![The first continuation of a numerical matrix with percentage impairments on the X axis and the Y axis and corresponding combined whole person impairment ratings established using the formula described in paragraph 502](image.019.png)\n\nCombined values chart (continued)\n\n![The last continuation of a numerical matrix with percentage impairments on the X axis and the Y axis and corresponding combined whole person impairment ratings established using the formula described in paragraph 502](image.020.png)\n","sortOrder":98}],"analysis":{"kimi_summary":{"_metrics":{"completionTokens":673},"content_quality":"ok","complexity_score":9,"scope_assessment":{"changed":false,"description":"This is Edition 3.0 of an established assessment guide, replacing Edition 2.1. The scope remains consistent with the original legislative intent under section 42 of the Seafarers Rehabilitation and Compensation Act 1992 — to provide criteria and methods for assessing permanent impairment and non-economic loss. The update appears to be a routine revision rather than expansion beyond the original purpose."},"complexity_factors":["Extensive cross-referencing between 13 body system chapters and multiple tables within each","Numerous defined terms in the Glossary (18+ specialised definitions)","Complex mathematical combining of impairment values using Appendix 1 formula","Conditional application rules determining which edition applies based on claim dates","Multiple assessment pathways for same conditions (e.g., spinal cord damage vs nerve root compression)","Detailed exclusion rules preventing double-counting of impairments","Age-based adjustments for reproductive system assessments","Extensive use of medical abbreviations and technical measurements (METS, LogMar, spirometry values)","Nested conditional logic in tables requiring multiple criteria to be satisfied","Special procedures for pre-existing conditions, aggravation, and subsequent injuries","Conversion formulas between AMA5 ratings and WPI percentages","Modifier calculations for episodic conditions"],"plain_english_summary":"This is a **comprehensive medical assessment guide** used to calculate compensation for seafarers (sailors, ship workers) who suffer **permanent injuries** from workplace accidents or diseases.\n\n**What it does:**\n- Provides detailed tables and methods to assess **how badly** a worker is permanently impaired — expressed as a percentage of \"whole person impairment\" (WPI)\n- Covers **every body system**: heart, lungs, hormones, skin, mental health, eyes, ears, digestion, muscles and bones, urinary system, reproductive organs, brain/nerves, and blood disorders\n- Includes a separate assessment for **\"non-economic loss\"** — the impact on quality of life (pain, suffering, loss of enjoyment, reduced life expectancy)\n- Explains how to **combine multiple impairments** when injuries affect several body parts\n\n**Who it affects:**\n- **Seafarers** (employees covered by the Seafarers Rehabilitation and Compensation Act 1992)\n- **Employers and insurers** who must assess claims\n- **Medical assessors** who evaluate injured workers\n- **The Administrative Appeals Tribunal** reviewing disputed assessments\n\n**Why it matters:**\nThis guide determines **how much lump-sum compensation** an injured seafarer receives for permanent damage. It replaces an older version (Edition 2.1) and applies to claims received on or after **1 April 2023**. The system is complex because it must fairly quantify very different injuries — from a lost finger to brain damage — using consistent medical criteria.\n\n**Key features:**\n- **Threshold rule**: Most injuries need at least 10% WPI to qualify for compensation (with exceptions for fingers, toes, taste and smell)\n- **Two-part payment**: One amount for physical impairment, another for quality-of-life impact\n- **Strict methodology**: Assessors must follow specific tables and cannot simply guess — they must use clinical evidence and defined tests"},"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":true,"description":"This instrument approves Edition 3.0 of the Guide, replacing Edition 2.1. It applies to new permanent impairment claims and reassessments received on or after 1 April 2023, with transitional provisions for earlier claims and reviews."},"complexity_factors":["Contains numerous detailed medical tables with specific impairment percentages and diagnostic criteria","Requires cross-referencing between multiple body system chapters and the combined values chart","Incorporates complex assessment methodologies (e.g., whole person impairment, non-economic loss scoring)","Includes extensive definitions, principles of assessment, and transitional application rules"],"plain_english_summary":"This instrument adopts Edition 3.0 of the Guide for assessing permanent impairment of seafarers, replacing Edition 2.1, and applies to claims or reassessments received by an employer on or after 1 April 2023. It prescribes percentage-based whole person impairment ratings (usually payable from 10% WPI), criteria across body systems, and a separate assessment of non-economic loss. It affects seafarers, employers, insurers, medical assessors and the AAT’s reviews."},"flash_summary":{"complexity_score":9,"scope_assessment":{"changed":false,"description":"This Edition 3.0 is an update to the previously approved Guide (Edition 2.1) that standardises and refines assessment methodology rather than expanding who is covered by the Seafarers Act. The instrument (sections 5–7 and Schedule 1) replaces the prior approved Guide, clarifies temporal application (which claims and reassessments the new Guide applies to), aligns methods with AMA4/AMA5 where directed, and adds updated, more detailed medical and procedural guidance. Those are methodological and procedural changes: they alter how impairments are measured, how evidence must be produced, and the administrative burden of assessment, but they do not broaden the statutory class of eligible persons or change statutory entitlements under the Seafarers Act. The principal substantive change in operation is temporal (which claims/reassessments fall under the new Guide) and methodological (updated tables and measurement rules), not scope of eligibility."},"complexity_factors":["Lengthy, technical Guide incorporated as Schedule 1 (many hundreds of numbered paragraphs across Divisions 1–3 and Appendix 1).","Large number of defined terms and cross‑references (definitions in the instrument and the Guide’s Glossary; cross‑references to the Seafarers Act, AMA4 and AMA5).","Extensive system‑by‑system impairment tables (cardiovascular, respiratory, neurological, musculoskeletal, etc.) with many fixed percentage entries and range entries (numerous tables and subtables).","Complex conditional application and transitional rules in section 6 (multiple subsections governing when the Guide applies to new claims, reassessments, and AAT review).","Detailed combination rules and a numeric combined‑values chart (Appendix 1) requiring iterative combination logic.  ","Nested exceptions and alternative assessment routes (e.g. where Guide cannot apply use AMA5; specific exceptions for vision/hearing/psychiatric conditions) (paras 54–56).","Multiple measurement standards and accreditation requirements (spirometry, sleep studies, EMG, ophthalmology protocols) with specific laboratory standards and repeat testing requirements. ","Numerical thresholds and non‑linear mapping rules (WPI thresholds for payment, visual system conversions, asthma scoring, sleep apnoea scoring, etc.).","Multiple decision‑makers and procedural pathways (assessor, employer determinations, Administrative Appeals Tribunal review, and the Authority having discretion where multiple tables apply) increasing administrative complexity (paras 48, 5, 6)."],"plain_english_summary":"**What this instrument does (mechanics)**\n\n- Approves and brings into force (from 1 April 2023) the Seafarers Rehabilitation and Compensation Act 1992 – Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0 (the Guide) as the legally required method for assessing permanent impairment and non‑economic loss under the Seafarers Rehabilitation and Compensation Act 1992 (the Seafarers Act) (see sections 2, 3, 5 and Schedule 1). \n- Repeals the prior approved Guide (Edition 2.1) so assessments to which the new Guide applies must use Edition 3.0 (section 7). \n- Rules when and to which claims the new Guide applies (claims and reassessments received on or after the commencement date, with specific transitional rules for earlier claims where reassessment is requested after commencement) and confirms Administrative Appeals Tribunal (AAT) review jurisdiction over assessments made under the new Guide (section 6). \n\n**Who this affects**\n\n- Employees (seafarers) who make claims for lump‑sum compensation for permanent impairment or for additional non‑economic loss under sections 39–41 of the Seafarers Act. The Guide defines how the degree of whole person impairment (WPI) and non‑economic loss (NEL) are measured and converted into compensation (Schedule 1, Divisions 1–3).  \n- Employers who are statutorily responsible for determining (and, where payable, paying) impairment compensation and for arranging assessments; employers must use the approved Guide when they assess or reassess an employee’s permanent impairment (see section 5 note and section 6).  \n- Medical assessors (registered medical practitioners and audiologists) and the AAT, because the Guide prescribes the assessment methods, tests and evidence the assessor or decision‑maker must apply or consider (Schedule 1, Principles of Assessment and specific chapters).\n\n**Why it matters (substance, not politics)**\n\n- The Guide standardises how permanent impairment and associated non‑economic losses are quantified and expressed as percentages (whole person impairment, WPI) and how those percentages map to statutory maximum payments (Division 1, Division 2, Division 3, Appendix 1). This creates legally binding assessment rules that determine whether a claimant meets the statutory thresholds for payment (for example, generally WPI must be 10% or more for a s39 lump sum, except certain losses such as loss of a finger/toe/taste/smell where lower thresholds apply) (see paragraphs 13–14). \n- The Guide is highly detailed and prescriptive: it contains system‑by‑system chapters (cardiovascular, respiratory, neurological, musculoskeletal, etc.), measurement protocols (for example, spirometry, visual testing, EMG), tables of fixed percentage values and ranges, rules for combining multiple impairments (Appendix 1), and rules for how to treat pre‑existing conditions, aggravation and reassessments (Principles of Assessment, paragraphs 24–39, 49–56). \n\n**How decisions are made and who pays**\n\n- Assessments are performed or certified by an *assessor* (registered medical practitioner or audiologist, or the employer, or a member of the AAT in certain review contexts) as defined in the Guide (Glossary). The employer is the primary decision‑maker for initial determinations under the Seafarers Act and the AAT reviews those assessments on appeal (section 5 note; section 6(5)).  \n- Payments of statutory lump sums are calculated by applying the WPI/NEL percentages to the statutory maxima (indexed amounts) and are payable under the Seafarers Act by the liable party (the employer or as provided by the Act) in accordance with the calculation worksheets in Division 3 (see Table C1 and explanatory paragraphs 17, 499).  \n\n**Key measurement and procedural effects that change behaviour or impose costs**\n\n- Employers and claimants must rely on the Guide’s prescribed tests and evidence (for example, accredited respiratory labs, sleep studies, EMG, ophthalmology assessments) to obtain WPI and NEL ratings. That creates real compliance and diagnostic costs (Schedule 1, Chapters 2, 6, 9, 12).  \n- The Guide requires assessors to follow specific tables and combination rules. Where multiple tables could apply, the instrument instructs that the authority will select the table(s) that are most favourable to the employee (para 48). That rule creates an incentive for claimants to have assessors document alternative applicable tables; it also creates a procedural cost for employers/insurers who must evaluate multiple assessments.  \n- The Guide tightens how pre‑existing conditions and aggravation are handled (paras 33–39). It limits compensable impairment to the permanent increase attributable to the compensable injury (so pre‑existing symptomatic conditions may reduce recoverable impairment) — this alters the allocation of benefits between employees and employers/insurers, and requires medical record comparison.  \n\n**Implementation and operational trade‑offs, risks and frictions to expect**\n\n- Implementation burden and specialist scarcity: many assessment items require specialist testing (ophthalmology, audiology, polysomnography, EMG) and specialist reports. That can delay final determinations and increase costs for employers and employees (see many chapter‑specific measurement requirements).  \n- Clinical discretion vs. fixed values: numerous tables set fixed percentages (no middle ground) while others allow ranges requiring assessor justification (para 46–47). This mixture increases litigation risk and administrative review when parties disagree about placing a claimant within a range.  \n- Cross‑reference complexity: the Guide cross‑references AMA4 and AMA5, other chapters, and multiple diagnostic pathways (see paras 40–56, Glossary). Interpreting which table applies to a given clinical presentation can be non‑trivial and can increase AAT review likelihood.  \n- Concentrated benefits, diffuse costs: benefits (lump sums) are concentrated to claimants who obtain higher WPI/NEL ratings; compliance and assessment costs fall on employers and the insurance/administration system. The Guide’s procedural requirements therefore shift administrative and clinical costs onto employers/insurers and increase demand for specialist medical services.  \n\n**Operational notes and important rules to watch**\n\n- Thresholds: generally no payment for s39 impairment determinations under 10% WPI except for certain listed losses (para 13–14).  \n- Reassessment windows: the new Guide applies to claims received on or after commencement and to reassessments requested after commencement even if the original claim was received earlier (s6(1)–(3)). However, routine reconsideration or AAT review of a determination is not the same as a reassessment request for Guide‑application purposes (s6(3)).  \n- When the Guide cannot assess an impairment, assessors must use AMA5 or clinical judgment per the Guide’s exceptions rules (paras 54–56).  \n\nSources and statutory hooks: sections 2–7 of the instrument (name, commencement, authority, definitions, approval, application and repeal) and Schedule 1 (the Guide and its chapters) set out the rules and methods summarised above."}},"importantCases":[],"_links":{"self":"/api/acts/f2023l00223","history":"/api/acts/f2023l00223/history","analysis":"/api/acts/f2023l00223/analysis","conflicts":"/api/acts/f2023l00223/conflicts","importantCases":"/api/acts/f2023l00223/important-cases","documents":"/api/acts/f2023l00223/documents"}}