SCHEDULE A

SCHEDULE OF PERMANENT IMPAIRMENTS

Table of Contents

DIVISION 1:  MUSCULO-SKELETAL SYSTEM

Subdivision 1:  Upper limb

Subdivision 2:  Lower limb

Subdivision 3:  Spine

DIVISION 2: CENTRAL AND PERIPHERAL NERVOUS SYSTEM

Subdivision 1:  Skull, Brain and Carotid Vessels

Subdivision 2:  Spinal Cord

Subdivision 3:  Cranial Nerves

Subdivision 4:  Peripheral Nervous System

DIVISION 3: MAXILLOFACIAL SYSTEM

Subdivision 1:  TMJ Joints

Subdivision 2:  Fronto-Orbito-Nasal Area

Subdivision 3:  Throat and Related Structures

DIVISION 4:  VISION

DIVISION 5:  UROGENITAL SYSTEM AND FETUS

DIVISION 6:  RESPIRATORY SYSTEM

DIVISION 7:  DIGESTIVE TRACT

DIVISION 8:  CARDIOVASCULAR SYSTEM

DIVISION 9:  ENDOCRINE SYSTEM

Subdivision 1:  Hypothalamus, Pituitary, Thyroid And Parathyroid Glands

Subdivision 2:  Pancreas (Endocrine Function)

Subdivision 3:  Adrenal Glands

DIVISION 10:  HEMATOPOIETIC SYSTEM

DIVISION 11:  COGNITIVE FUNCTION

DIVISION 12:  VESTIBULOCOCHLEAR APPARATUS

DIVISION 13:  THE SKIN

Subdivision 1:  Facial Disfigurement

Subdivision 2:  Disfigurement of Other Parts Of The Body

Subdivision 3:  Disfigurement From Partial or Total Amputation

DIVISION I: THE MUSCULOSKELETAL SYSTEM

Subdivision 1:  The Upper Limb

0.1  Definition

In this Division, "non-specified abnormal healing" means an anatomic abnormality at the end of the expected healing process, which is not specified elsewhere in the Schedule, such as the change in angulation of the fracture fragment, rotational abnormalities or shortening.

1.  Shoulder and arm

1.1 Amputations

1.2 Fractures

(b) humeral fracture:

1.3 Non-bony disruption

(a) as a general rule:

If the disruption is associated with range of motion loss of an adjacent joint, then an additional range of motion loss impairment may be rated in section 1.5 of this subdivision.

(b) exceptions to the general rule in clause (a):

(i) rotator cuff tear:

(A) imaging positive, full thickness:

(ii) biceps tendon rupture (distal or proximal):

1.4  Ligamentous and other soft tissue disruptions

(a) acromioclavicular and sternoclavicular joint injuries:

(b) glenohumeral instability – traumatic gleno-humeral dislocation (confirmed by plane radiography):

(i) no recurrence of dislocation within one year of motor vehicle collision:

(ii) recurrence of dislocation within one year of motor vehicle collision:

1.5  Range of motion loss of the shoulder joint complex

(a) flexion-extension (motion in the scapular plane):

Combined range of motion in degrees:  Normal total range of motion for this plane is 230 degrees.

(b) abduction-adduction (motion in the coronal plane):

Combined range of motion in degrees: Normal total range of motion for this plane is 230 degrees.

(c) internal rotation – external rotation:

Combined gleno-humeral range of motion in degrees: Normal total range of motion for this plane is 180 degrees.

2.  Elbow and forearm

2.1 Amputations

2.2  Fractures

(b) fracture of the radius:

(c) fracture of the ulna:

2.3 Non-bony disruptions

2.4  Ligamentous and other soft tissue disruptions

(a) ulnar and radial collateral injuries:

2.5  Range of motion loss at the elbow

(a) flexion-extension:

Combined range of motion:  Normal total range of motion for this plane is 140 degrees.

(b) pronation-supination:

Combined range of motion:  Normal total range of motion for this plane is 160 degrees.

3.  Wrist and hand

3.1  Amputations

(b) transmetacarpal or MCP disarticulation:

If multiple metacarpals are affected, the impairment ratings are combined, not added.

(c) trans-digital (proximal phalanx) or PIP disarticulation:

If multiple digits are affected, the impairment ratings are combined, and not added.

(d) trans-digital (middle or distal phalanx) or DIP disarticulation:

If multiple digits are affected, the impairment ratings are combined, and not added.

3.2  Fractures

If any of the above are associated with range of motion loss, apply sections 3.5a and 3.5b for further impairment rating.

3.3 Non-bony disruptions

If the disruption is associated with range of motion loss of an adjacent joint, then an additional range of motion loss impairment may be rated under section 3.5a or 3.5b.

3.4  Soft tissue and ligamentous disruptions

(a) carpal instability:  To be rated by report of a health care practitioner.  The radiological appearance, including carpal height, carpal translation and degree of joint arthrosis must be used to determine mild, moderate and severe impairment.

(c) carpal tunnel syndrome:  Rate according to the neurologic impairment guidelines (see Division 2 Subdivision 4).

3.5a Range of motion loss of the wrist

(a) flexion-extension:

Combined range of motion in degrees:  Normal total range of motion for this plane is 120 degrees.

(b) radial deviation – ulnar deviation:

Combined range of motion in degrees:  Normal total range of motion for this plane is 50 degrees.

3.5b Range of motion loss of the hand

(a) thumb IP flexion-extension:

Combined range of motion:  Normal total range of motion for this plane is 80 degrees.

(b) thumb MCP flexion-extension:

Combined range of motion:  Normal total range of motion for this plane is 60 degrees.

(c) thumb adduction:

This motion is evaluated by measuring the distance in centimeters from the flexor crease of the IP joint of the thumb to the distal palmar crease overlying the MCP joint of the small finger.

(d) thumb radial abduction:

Combined range of motion:  Normal total range of motion for this plane is 50 degrees.

(e) thumb opposition:

This motion is evaluated by measuring the distance in centimeteres from the flexor crease of the IP joint of the thumb to the distal palmar crease overlying the MCP joint of the middle finger.

(f) finger DIP flexion-extension:

Combined range of motion: Normal total range of motion for this plane is 70 degrees.

(g) finger PIP flexion-extension:

Combined range of motion: Normal total range of motion for this plane is 130 degrees.

(h) finger MCP flexion-extension:

Combined Range of Motion: Normal total range of motion for this plane is 110 degrees.

Subdivision 2: Lower Limb

1.  Pelvis

1.1  Amputation

1.2  Fractures

(c) fracture involving the acetabulum (to be rated under section 2.4 – Range of motion loss at the hip)

1.3  Pelvic range of motion loss

Clinical tests to identify range of motion loss of the sacroiliac joint lack sufficient inter-rater reliability to be considered reliable.  Therefore, impairments for pelvic range of motion loss are not rated.

2.  Hip and thigh

2.1  Amputation

(b) above knee amputation:

2.2  Fractures

(b) [repealed] M.R. 61/2015

Fracture complications:

(d) femoral shaft fractures with angulation:

(e) femoral shaft fractures with mal-rotation:

(f) resulting in avascular necrosis:

(i) leading to hip arthroplasty (see clause (b) of this section)

(ii) without arthroplasty (to be rated according to range of motion loss in 2.4)

2.3 Non-bony disruptions

If a disruption referred to in clause (a) or (b) is associated with range of motion loss of an adjacent joint, then an additional range of motion loss impairment may be rated under section 2.4 (Range of motion loss at the hip).

(c) [repealed] M.R. 61/2015

2.4  Range of motion loss at the hip

(a) hip joint ankylosis:

(b) range of motion restriction:

(i) flexion-extension:

Combined range of motion in degrees: Normal total range of motion for this plane is 150 degrees.

(ii) internal-external rotation:

Combined range of motion in degrees: Normal total range of motion for this plane is 90 degrees.

(iii) abduction-adduction:

Combined range of motion in degrees: Normal total range of motion for this plane is 60 degrees.

2.5  Thigh muscular atrophy

3.  Knee and leg

3.1  Amputations

3.2  Fractures

Fracture complications:

(d) leg (tibial or fibular) fractures resulting in single or multi-planar angulation:

(e) leg (tibial or fibular) fractures resulting in mal-rotation:

These awards include any limb shortening or weakness.

3.3 Non-bony disruptions

If a disruption under clause (a) or (b) is associated with range of motion loss of an adjacent joint, then an additional range of motion loss impairment may be rated under section 3.5 (Range of motion loss at the knee).

(c) [repealed] M.R. 61/2015

3.4  Ligamentous and other soft tissue disruptions

In general, the higher the grade of ligament injury, the greater the impairment and the corresponding impairment rating.  Most grade I and II knee joint ligament injuries heal without functional sequelae, and therefore do not warrant an impairment rating.

(a) cruciate or collateral ligament injuries associated with:

3.5  Range of motion loss at the knee

(a) ankylosis:

(b) flexion:

Active range of motion in degrees:

(c) flexion contracture:

Active range of motion in degrees away from the neutral position (knee straight position):

3.6 Leg muscular atrophy

4.  Ankle and foot

4.1  Amputations

4.2  Fractures

Fracture complications:

(a) fracture of the tibia or fibula:

4.3 Non-bony disruptions

If a disruption referred to in clause (a) or (b) is associated with range of motion loss of an adjacent joint, then an additional range of motion loss impairment may be rated under section 4.5 (Range of motion loss at the foot or ankle).

4.4  Ligamentous and other soft tissue disruptions

4.5  Range of motion loss at the foot or ankle

(a) ankylosis of the ankle or foot:

(vi) metatarsophalangeal:

(vii) interphalangeal:

(b) range of motion restriction:

(i) tibiotalar plantar flexion in degrees

(ii) tibiotalar dorsiflexion in degrees:

(v) toe

Subdivision 3: The Spine

In the following sections 1 to 4, a reference to fusion denoted by "*" includes bony fusion using an internal fixation device or bone graft material.

1.  Cervical spine

(c) non-union of the odontoid process following a fracture:

(iii) accompanied by myelopathy (see Division 2 Subdivision 3).

(e) instability of the atlanto-axial joint (C1 and C2), following a fracture or ligamentous injury, as documented by evidence of excessive motion on flexion extension views:

(iii) accompanied by myelopathy: (see Division 2 Subdivision 3)

(h) vertebral body fracture (non-compression):

(iii) with associated myelopathy (see Division 2 Subdivision 3).

(i) vertebral body compression fracture with radiographic instability on flexion extension views (as per Table 1.1):

(j) vertebral body compression fracture without radiographic instability on flexion extension views (as per Table 1.1), including any range of motion restriction:

2.  Thoracic spine

(a) vertebral body compression fracture with radiographic instability on flexion extension views (as per Table 1.1):

(b) vertebral body compression fracture without radiographic instability on flexion extension views (as per Table 1.1), including any range of motion restriction:

(d) vertebral body fracture (non-compression):

(iii) with associated myelopathy: (see Division 2 Subdivision 3)

3.  Lumbar spine

(a) vertebral body compression fracture with radiographic instability (as per Table 1.1):

(b) vertebral body compression fracture without radiographic instability (as per Table 1.1), including any range of motion restriction:

(d) vertebral body fracture (non-compression):

(iii) with associated myelopathy: (see Division 2 Subdivision 3)

4.  Other spinal impairments

(a) post-traumatic alteration of an intervertebral disc (e.g. disc herniation, internal disc disruption, disc space infection, discectomy) including any range of motion restriction or radiographic instability, per spinal segment:

(i) with associated myelopathy: (see Division 2 Subdivision 3)

(ii) with associated radiculopathy: (see Division 2 Subdivision 4)

Table 1.1

DIVISION 2:  CENTRAL AND PERIPHERAL NERVOUS SYSTEM

1.  Definitions:

In this Division,

"autonomic dysreflexia" means an alteration of autonomic reflexes associated with quadriplegia or paraplegia above the T6 level that can result in sudden and sustained elevation of blood pressure; (« dysréflexie autonome »)

"paraplegia" means a neurological injury affecting the trunk and lower limbs (but sparing the upper limbs and head) that manifests with alterations in motor power and control and sensory loss below the level of injury.  This condition is associated with certain types of spinal cord injuries.  It may be complete or incomplete; (« paraplégie »)

"quadriplegia" means a neurological injury affecting both upper and lower limbs, that manifests with alterations in motor power and control and sensory loss below the level of injury.  This condition is associated with certain types of spinal cord injuries. It may be complete or in````complete. (« quadriplégie »)

Subdivision 1:  Skull, Brain And Carotid Vessels

1.  Alteration of brain tissue

1.1  Cerebral concussion or contusion

(d) post concussion syndrome: (see sections 4.6, 4.7 and 4.9 of this subdivision)

1.2  Post-traumatic alteration of tissue

2.  Alteration of the skull

2.1  Post-traumatic bony alteration

2.2  Bony deformity following a depressed fracture of the calvarium

(a) without dural laceration:

(b) with dural laceration:

(i) with associated hemorrhage: (see section 2.1 of this subdivision)

(ii) with associated vascular injury: (see section 3.1 of this subdivision)

3.  Alteration of cerebrovascular supply

3.1  Internal carotid artery occlusion

(b) associated with hemiplegia: (see subdivision 2)

3.2  Internal carotid artery stenosis

(d) associated with hemiplegia: (see subdivision 2)

3.3  Hydrocephalus

4.  Functional alteration of the brain

4.1 Upper limb function

4.2  Station and gait assessment

4.3  Bladder function

(a) incontinence or urinary retention:

(d) Class 1, 2 or 3 renal functional impairment (See Division 5 — section 2).

4.4  Anorectal Function

4.5  Sexual dysfunction

4.6  Communication disorders (dysphasia, aphasia, alexia, agraphia, acalculia and other communication

disorders)

4.7  Alterations of consciousness (posttraumatic epilepsy, syncope, cataplexy, narcolepsy, and other neurological disorders and alterations of consciousness)

4.8  Disturbances of vision

To be rated according to Division 4.

4.9  Alterations of the higher cognitive or integrative mental functions (organic cerebral syndrome, dementia and neurologic deficiencies)

4.10  Endocrine dysfunction

To be rated according to Division 9.

Subdivision 2: Spinal Cord

Spinal cord injuries must be classified according to the American Spinal Injury Association (ASIA) scale as follows:

(a) ASIA Grade A = Complete: No sensory or motor function is preserved below the neurological level of the lesion (including the sacral segments).

(b) ASIA Grade B = Sensory Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 (light touch, pin prick at S4-S5: or deep anal pressure (DAP), AND no motor function is preserved more than three levels below the motor level on either side of the body.

(c) ASIA Grade C = Incomplete: There is preservation of some motor function below the neurological level of the lesion, and the majority of key muscles below the neurological level have a muscle grade less than 3.

(d) ASIA Grade D = Incomplete: There is preservation of some motor function below the neurological level of the lesion, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3.

(e) ASIA Grade E = Normal:  Motor and sensory function is normal.

The motor index score provides a numerical scoring system to document changes in motor function. Each of the key muscles is graded according to the motor grading scale (grade 1 to 5).  A normal score is as follows:

Total Score = 100 (Maximum Score Possible)

The following information is required in order to determine the impairment rating for a spinal cord injury:

(a) spinal level of injury (e.g. the site of fracture or dislocation if any);

(b) neurological level of injury (the motor and sensory level of injury as determined by physical exam for both the right and left side of the body);

(c) whether the lesion is complete or incomplete;

(d) the ASIA Grade; and

(e) the motor index score.

1.  Complete quadriplegia or paraplegia (ASIA Grade A)

1.1  Quadriplegia, including all anatomical and physiological deficits inherent in this condition as well as any vertebrospinal impairments and grafting, if applicable:

1.2  Paraplegia, including all anatomical and physiological deficits inherent in this condition as well as any vertebrospinal impairments and grafting, if applicable:

2.  Incomplete Quadriplegia Or Paraplegia with Complete or Partial Preservation of Sensation Only and No Motor Preservation (ASIA Grade B)

2.1  Quadriplegia, including all anatomical and physiological deficits inherent in this condition as well as any vertebrospinal impairments and grafting, if applicable:

2.2  Paraplegia, including all anatomical and physiological deficits inherent in this condition as well as any vertebrospinal impairments and grafting, if applicable:

3.  Incomplete quadriplegia or paraplegia with partial preservation of motor power, with or without sensory preservation (ASIA Grades C and D)

3.1  Upper limb function

3.2  Station and gait assessment

3.3  Bladder function

(a) incontinence or urinary retention:

(d) Class 1, 2 or 3 renal functional impairment (See Division 5 — section 2).

3.4  Anorectal Function

3.5  Sexual dysfunction

3.6  Autonomic dysreflexia:

3.7  Class 1, 2, 3 or 4 respiratory functional impairment (See Division 6 — section 2).

Subdivision 3: Cranial Nerves

1.  Olfactory nerves (Right and Left)

(b) distortion of smell (if present add to above %):

2.  Optic nerve and visual pathways: (see Division 3 Subdivision 5)

3.  Occulomotor (left and right) and eye parasympathetic input

(a) ptosis:

(v) if uncorrectable with surgery/bracing, rate as if blind.

(b) pupil dilation:

(c) diplopia:

4.  Trochlear, and Abducens

(a) diplopia: See Division 4 (Vision)

NOTE: Combinations of dysfunction of these three nerves (regarding diplopia) are not additive, even if bilateral (the impairment is the inability to maintain conjugate gaze).

5.  Trigeminal

Add impairment ratings to arrive at a total.  If bilateral, add impairment ratings for each side to arrive at a total impairment rating.

(a) motor (unilateral or bilateral):

(vi) dystonic or other involuntary movement of jaw:

(b) sensory - rate according to the following table:

(c) with associated pain (Painful dysesthesia or typical neuralgia):

6.  Facial Nerve

(a) motor:

(i) stapedius weakness:

(ii) facial weakness:

(add 2% if weakness results in difficulty eating)

(add 2% if weakness results in difficulty speaking)

Where facial weakness is associated with alteration in form and symmetry, (see Division 13 – The Skin).

(b) sensory:

(c) lacrimation:

(d) salivation:

(e) taste:

(iii) distortion: (if present add to impairment rating determined under (i) or (ii)

7.  Auditory Nerve:

(a) acoustic (cochlear division): hearing loss and tinnitus (see Division 12 - Vestibulocochlear Apparatus);

(i) hearing loss (see Division 12 – Vestibulocochlear Apparatus);

(ii) tinnitus:

For a Class 2 or Class 3 rating, tinnitus must be present on a constant basis for more than 3 consecutive months.

(b) Vestibular division (see Division 12 – Vestibulocochlear Apparatus).

8.  Glossopharyngeal, Vagal, and Hypoglossal

(a) dysphagia (swallowing difficulty) (see Division 3 – Maxillofacial System, Throat and Related Structures);

(b) dysphonia, dysarthria (abnormal speech) (see Division 3 – Maxillofacial System, Throat and Related Structures);

(c) neuralgia:

(d) spasmodic dysphonia: rate according to degree of dysphonia described above.

9.  Spinal accessory

(b) cervical dystonia (spasmodic torticollis):

(i) with neck and head deviation:

Subdivision 4:  Peripheral Nervous System

Motor impairment or sensory impairment is determined under Tables 2.1, 2.2 and 2.3 and the following grading systems:

Motor impairment:

(a) grade 5:  no loss of motor function and absence of weakness;

(b) grade 4:  weakness against strong resistance, including any muscular atrophy;

(c) grade 3:  weakness against minor resistance, with full range of motion against gravity, including any muscular atrophy;

(d) grade 2:  weakness with full range of motion with gravity eliminated, including any muscular atrophy;

(e) grade 1: weakness with less than full range of motion, even with gravity eliminated, including muscular atrophy;

(f) grade 0: complete paralysis, including muscular atrophy.

Sensory impairment:

(a) grade 1:  no sensory impairment;

(b) grade 2:  hypesthesia including dysesthesia, paresthesia and hyperesthesia (altered sensation);

(c) grade 3:  anesthesia including pain (loss of sensation).

1.  Brachial plexus

NOTE:  Maximum for upper limb neurological impairment is 60%.

2.  Lumbosacral plexus

3.  Sensory Loss

Permanent, post-traumatic alteration of the skin sensation in the region of post-traumatic skin impairment, such as a scar or abrasion. (see Table 3.1)

Table 2.1: Nerve Roots

Table 2.2: Peripheral Nerves – Head, Neck and Upper Limbs

Table 2.3:  Peripheral Nerves – Lower Limbs

Table 3.1:  Sensory Loss

DIVISION 3:  MAXILLOFACIAL SYSTEM

Subdivision 1

1.  Temporomandibular joints (TMJ)

1.1  Range of motion loss

(a) bilateral TMJ ankylosis:

(b) jaw excursion (as measured between the free edge of the upper and lower incisors):

(c) reduction of laterotrusion:

(d) reduction of protrusion:

1.2  Miscellaneous dysfunction

2.  Maxilla

2.3  Loss of soft palate

(a) with rhinolalia:

2.4  Loss of dental arch

2.5  Malalignment of the palate and dental arch

3.  Mandible

3.1  Body or ramus

(b) mal-union:

3.2  Loss of dental arch

3.3 Neck of condyle (See subsection 1.1 above).

4.  Alteration or loss of teeth

4.1  Previously healthy teeth

4.2  Previously damaged teeth

Subdivision 2 – Fronto-Orbito-Nasal Area

1.  

The Orbit

1.1  Impairment of orbital walls causing displacement of the eye

(a) unilateral:

(b) bilateral:

Orbital problem may lead to secondary visual impairment (see Division 4).

1.2  Disruption of medial or lateral canthus

(a) unilateral:

(b) bilateral:

1.3  Disruption of lacrimal apparatus

1.4.1 [Repealed] M.R. 61/2015

1.4.2 [Repealed] M.R. 61/2015

2.  Nasal impairment

2.1  Airflow obstruction

2.2  Mucosal dysfunction causing bleeding, crusting and patient discomfort

2.3  Septal perforation

2.4  Olfactory disruption (see Division 2, Subdivision 3 - Cranial Nerves).

2.5  Alteration in form and symmetry (see Division 13, Subdivision 1 - Facial Disfigurement, Table 13.1)

3.  Paranasal Sinuses

4.  Salivary glands

4.1  Hyposalivation:  disruption of salivation significant enough to cause problems with

Subdivision 3:  Throat and Related Structures

Multiple deficits

In the event of multiple deficits in this subdivision, multiply the total of the impairment ratings for the applicable classes by 0.7.

Example: (Respiration Impairment  +  Deglutition Impairment  +  Speech Impairment)  ×  .7

(20%  +  10%  +  25%)  ×  .7  =  38.5%

1.  Respiration

Apply the permanent impairment rating for the applicable class of upper airway dysfunction set out in Table 3.1 below. Table 3.1 applies only to respiratory difficulty attributed to upper airway dysfunction.  For lower respiratory tract functional impairment, see Division 6 (The Respiratory System).

Table 3.1:  Classes of air passage deficits

* Patients with successful permanent tracheostomy or stoma should be rated at 25% impairment of the whole person.

** Prophylactic restriction of activity, such as strenuous competitive sport, does not exclude patient from Class 1.

2.  Mastication and Deglutition

2.1  Dietary restriction

3.  Taste

4.  Speech Impairment (see Table 3.2)

Table 3.2: Speech Impairment

DIVISION 4:  VISION

1.  Impairment ratings for vision loss

1.2  Alteration of vision

1.8  Other impairments to vision

The maximum impairment award for injury to a single eye is 30% (equivalent to unilateral loss of vision). Other impairments to vision are evaluated in accordance with the following evaluation process:

"aphakia" means absence of the lens of an eye, occurring congenitally or as a result of trauma or surgery; (« aphakie »)

"pseudophakia" means replacement of the natural lens with an artificial lens. (« pseudophakie »)

2.  Process for evaluating vision

2.1  Criteria for evaluating vision

A deficit of the visual system occurs where there is a deviation from normal in one or more functions of the eye.

Visual integrity requires:

(a) integrity of corrected visual acuity for distance and close up;

(b) integrity of the field of vision; and

(c) ocular motility without diplopia.

The evaluation of these three functions is necessary in determining the visual deficit and their coordinated action is essential to optimal sight.

Other ocular functions or problems that affect the coordinated functions of the eye are awarded percentages of deficit in accordance with the scale prescribed for those functions.

2.2  Methods for evaluating vision

(a) Determination of central visual acuity

Visual acuity test charts:  For distance vision tests, the Snellen test chart with non-serif block letters or numbers, the illiterate E chart, or Landolt's broken-ring chart are acceptable.  For near vision, charts with print similar to that of the Snellen chart, with Revised Jaeger Standard print, or with American point-type notation for use at 35cm (14 inches) are acceptable.

The far test distance should simulate infinity at 6m (20 feet) or no less than 4m (13 feet 1 inch).  The near test distance should be fixed at 35cm (14 inches), in keeping with the Revised Jaeger Standard.  Adequate and comfortable illumination must be diffused onto the test card at a level about three times greater than that of the usual rule of illumination.

Acuity should be measured for near and far, both without correction and with the best spectacle correction, or with contact lens correction if usually worn.  If, however, contacts are not usually worn, it is not necessary to fit them to determine the best acuity.  Note that certain ocular conditions, particularly corneal disorders, may be better corrected with contact lenses.

Table 4.1 – Loss (in %) of central vision in a single eye

In Table 4.1 the upper number shows the percentage loss of central vision without allowance for the monocular pseudophakia.  The lower number shows the percentage loss of central vision with allowance for monocular aphakia or monocular pseudophakia.

Using Table 4.1, the examiner identifies the Snellen rating for near vision along the top row, and Snellen rating for distance along the first column.  Reading down from the former and across from the latter, the examiner locates two impairment values for the loss of central vision where the column and row cross.

Monocular aphakia or monocular pseudophakia is considered to be an additional central vision impairment.  If either are present, the remaining central vision is decreased by 50%, as shown in Table 4.1.

(b) Determination of extent of visual fields

The extent of the visual field is determined by the use of standard perimetry using the values shown in Table 4.2.

Table 4.2:  Stimuli equivalent to the Goldmann Kinetic Stimulus

The results may be transferred to the chart shown below.

The extent of the normal visual fields for the eight principal meridians are shown in Table 4.3.

Table 4.3: Normal Visual Fields for Eight Principal Meridians

Any scotomata within the field should be subtracted from the maximum number of degrees for that meridian.  An additional 5% should be included for an inferior quadrantic loss, and 10% for an inferior hemianopic loss, as loss of inferior field is of greater functional consequence.

The Esterman 120 binocular field test should be used for any binocular field.

The extent of the field can be defined on the field chart by drawing a line outside the location of the furthest 10 decimal point in each meridian.  Assume that if any stimuli 10 decibels or greater are seen within the 20 or 30 degree field, that there will be no field remaining beyond this.  But if the 10-decibel stimulus is seen out of the edge of the 30-degree field, then the extent of loss cannot be known unless a larger field is tested.

If an automated central field is normal, it may be accepted the entire field is normal unless the ocular exam or history suggests otherwise, in which case a full field should be tested.

Table 4.4: Deficit of visual field

* or more

When the central visual field is impaired, the percentage of deficit is that of the concomitant loss of visual acuity.  If the visual acuity is normal, the percentage of deficit is calculated on the basis of the degrees lost.

(c) Determination of ocular motility

Abnormal ocular motility and binocular diplopia — Unless a patient has diplopia with 30º of the center of fixation, the diplopia rarely causes significant visual impairment.  An exception is diplopia on looking downward.  The extent of diplopia in the various directions of gaze is determined on an arc perimeter at 33cm or with a bowl perimeter.  A tangent screen also is acceptable for evaluating the central 30º.  Examination is made in each of the eight major meridians by using a small test light or the projected light of approximately Goldmann III-4e without adding coloured lenses or correcting prisms.  Diplopia within the central 20º is estimated to be a 100% impairment of ocular motility.  This is applied to the injured eye only.

To determine the impairment of ocular motility, the patient is seated with both eyes open and the chin resting in the chin rest and centered so that the eyes are equidistant from the sides of the central fixation target.

The presence of diplopia is then plotted along the eight meridians of a suitable visual field chart.  The impairment percentage for loss of ocular motility due to diplopia in the meridian of maximum impairment can be determined according to the following chart.  When there is diplopia of the same eye along multiple meridians, the corresponding impairment percentages are combined.

(d) Determination of the visual efficiency of an eye

The methods described in clause (a), (b) and (c) above are used to evaluate:

(i) visual acuity,

(ii) the field of vision, and

(iii) ocular motility.

The percentage of visual efficiency of each eye is determined by the following formula:

A × B × C = E

In this formula:

Ais the percentage of visual acuity retained;

Bis the percentage of visual field retained;

Cis the percentage of ocular motility retained; and

Eis the percentage of visual efficiency of the eye.

(e) Determination of efficiency of entire visual system

The percentage of efficiency of binocular vision is determined by the following formula

3A/4 + B/4 = E

In this formula:

Ais the percentage of visual efficiency of the better eye;

Bis the percentage of visual efficiency of the other eye;

Eis the percentage of visual efficiency of binocular vision.

The percentage of deficit for the entire visual system is the difference between the percentage of visual efficiency of binocular vision (the percentage determined for E in the above formula) and 100%.

DIVISION 5:  UROGENITAL SYSTEM AND FETUS

1.  Urinary tract tissue disruption

1.1  Kidney impairment

(c) reduction or loss of renal function (See section 2 – Renal Functional impairment);

(d) with associated anemia (See Division 10 – The Hematopoietic System).

1.2  Ureteric impairment:

(b) with associated reduction or loss of renal function (See section 2 – Renal Functional impairment)

1.3  Bladder impairment:

(b) incontinence or urinary retention:

1.4  Urethral impairment

2.  Renal functional impairment

(a) Class 1:

creatinine clearance of 30 to 80 mL/min

OR

intermittent symptoms and signs of upper urinary tract dysfunction are present that do not require continuous treatment or surveillance

(b) Class 2:

creatinine clearance of 10 to 30 mL/min

OR

creatinine clearance is greater than 30 mL/min, but symptoms and signs of upper urinary tract dysfunction are incompletely controlled by continuous treatment or surveillance

(c) Class 3

creatinine clearance is less than 10 mL/min

OR

creatinine clearance is greater than 10 mL/min, but symptoms and signs of upper urinary tract dysfunction persists despite continuous medical or surgical treatment

3.  Reproductive organ tissue disruption

3.1  Male genitalia

(c) loss of both testicles (including epididymides and spermatic cords):

(g) with associated urinary incontinence from any of above (See 1.3 – Bladder impairment).

3.2  Female genitalia

3.2.1  Internal genitalia:

(a) loss of both ovaries (including fallopian tubes):

(c) loss of the uterus (including cervix):

*Necessitated by the MVA.

3.2.2  External genitalia:

4.  Sexual dysfunction

DIVISION 6: RESPIRATORY SYSTEM

1.  Respiratory system tissue disruption

1.3  Alteration of tissue following

(a) with associated alteration of pulmonary function (see section 2 – Respiratory functional impairment).

1.5  Tracheal stenosis

(According to Table 3.1 – Classes of Air Passage Deficits – in Division 3)

1.6  Alteration of tissue following a tracheotomy or penetrating throat wound:

2.  Respiratory functional impairment

2.1 Interpretation – In section 2.2,

"D_CO" means diffusion capacity of carbon monoxide, being a measure of the efficiency of gas transfer across the lung; (« DL_CO »)

"FEV₁" means forced expiratory volume in 1 second, being the volume of air exhaled in the first second of a forced expiratory maneuver; (« VEMS »)

"FVC" means forced vital capacity, being the volume of air one can exhale with a forced expiratory maneuver. (« CVF »)

2.2  Impairment ratings

Both FVC and FEV1 are greater than 80% of predicted

AND

FEV₁ /FVC is greater than 70% of predicted;

AND

D_CO is greater than 70% of predicted

Either FVC or FEV₁ is between 60% and 80% of predicted;

OR

D_CO is between 60% and 80% of predicted.

FVC is between 50% and 59% of predicted;

OR

FEV₁ is between 40% and 59% of predicted

OR

D_CO is between 40% and 59% of predicted.

FVC is less than 50% of predicted;

OR

FEV₁ is less than 40% of predicted

OR

D_CO is less than 40% of predicted.

DIVISION 7:  THE DIGESTIVE TRACT

In this division, the different impairment rating classes consider both tissue disruption and functional loss together.

1.  

Impairment rating criteria for the upper GI tract

Either

(i) symptoms or signs of upper digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and continuous treatment is not required, and weight can be maintained at a desirable level.

Either

(i) symptoms and signs of upper digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and dietary or medical treatments are required for control of symptoms/signs, and weight loss does not exceed 10% below desirable body weight.

Either

(i) symptoms and signs of upper digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and

(iii) dietary or medical treatments do not completely control symptoms/signs, or

(iv) weight loss is 10% to 20% below desirable body weight.

Either

(i) symptoms and signs of upper digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and

(iii) dietary or medical treatments do not completely control symptoms/signs, or

(iv) weight loss is more than 20% below desirable body weight.

2.  Impairment rating criteria for the lower GI tract

2.1  Colon and rectum

Either

(i) symptoms or signs of lower digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and continuous treatment is not required, and weight can be maintained at a desirable level.

Either

(i) symptoms and signs of lower digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and dietary or medical treatments are required for control of symptoms/signs, and weight loss does not exceed 10% below desirable body weight.

Either

(i) symptoms and signs of lower digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and

(iii) dietary or medical treatments do not completely control symptoms/signs, or

(iv) weight loss is 10% to 20% below desirable body weight.

Either

(i) symptoms and signs of lower digestive tract disease are present, or

(ii) there is anatomic loss or alteration of tissue,

and

(iii) dietary or medical treatments do not completely control symptoms/signs, or

(iv) weight loss is more than 20% below desirable body weight.

2.2  Anal Impairment

There is either

(i) evidence of anatomic loss or alteration of tissue, or

(ii) mild incontinence of stool,

and symptoms can be controlled by treatment.

There is evidence of anatomic loss or alteration of tissue and either

(i) there is moderate incontinence of stool, requiring continual treatment, or

(ii) symptoms are incompletely controlled by treatment.

There is evidence of anatomic loss or alteration of tissue, and either

(i) complete fecal incontinence is present, or

(ii) symptoms are unresponsive to treatment.

3.  Impairment rating criteria for the liver and biliary tract

3.1  Liver tissue disruption

Residual hepatic functional impairment:

There is objective evidence of persistent liver disease, there are no symptoms or signs of ascites, jaundice, or other significant hepatic complications, and biochemical studies indicate minimal disturbance in hepatic function.

There is objective evidence of chronic liver disease, there are no symptoms, or signs of ascites, jaundice, or esophageal bleeding, and biochemical studies indicate severe disturbance in hepatic function.

There is

(i) objective evidence of progressive chronic liver disease, or

(ii) history of jaundice, ascites, or bleeding of upper gastrointestinal varices, or

(iii) intermittent hepatic encathalopathy.

There is

(i) objective evidence of progressive chronic liver disease, or

(ii) persistent jaundice or bleeding, esophageal varices,

and there are central nervous system manifestations of hepatic insufficiency.

3.2  Biliary tract

There is occasional biliary tract dysfunction with documented biliary tract disease.

There is recurrent biliary tract dysfunction despite ongoing treatment.

There is obstruction of the bile tract with recurrent cholangitis.

There is persistent jaundice and progressive liver disease due to obstruction of the common bile duct.

4.  Impairment rating criteria for the abdominal wall, inguinal and femoral regions

4.1  Hernia-related impairments

Palpable defect in supporting structures of abdominal wall and slight protrusion at site of defect with increased abdominal pressure where the defect is readily reducible.

Palpable defect in the supporting structures of abdominal wall where frequent or persistent protrusion at site of defect may increase with intra-abdominal pressure and is manually reducible.

Palpable defect in supporting structures of abdominal wall where persistent, irreducible, or irreparable protrusion at the site of the defect has occurred causing limitation in normal activities.

4.2  Post-operative abdominal wall-related impairments

DIVISION 8:  CARDIOVASCULAR SYSTEM

1.  Cardiac lesions:  According to Table 8.1

2.  Thoracic arterial lesions

(c) functional limitations (See Table 8.1).

3.  Peripheral arterial lesions

(e) functional limitations (See Tables 8.2 and 8.3).

4.  Venous and lymphatic lesions

(a) post-traumatic venous insufficiency or lymphatic insufficiency:

Table 8.1  Functional limitations following cardiovascular injury

Table 8.2  Functional Limitations Following A Lower Limb Vascular Lesion

Table 8.3  Functional Limitations Following An Upper Limb Vascular Lesion

DIVISION 9:  ENDOCRINE SYSTEM

Subdivision 1: Hypothalamus, Pituitary, Thyroid And Parathyroid Glands

2.  Partial hypopituitarism, excluding diabetes insipidus, requiring replacement of

Subdivision 2: Pancreas (Endocrine Function)

For exocrine pancreatic impairments, refer to Section 1 of Division 7:  The Gastrointestinal Tract

1. *Diabetes mellitus

*Diabetes may occur following MVA-related trauma by one of several mechanisms. If the pancreas is traumatised, there may be sufficient tissue injury to impair insulin production resulting in tertiary diabetes.  Certain drugs, e.g. Prednisone, can induce secondary diabetes by altering the hormonal balance.  If this drug (or similar drug) is used to treat an MVA-related condition, then the diabetic complication is also considered accident related.  Finally a claimant with pre-existing Type 1 or 2 diabetes, or a claimant with borderline diabetes, may have their metabolism altered by prolonged inactivity (e.g. bedrest) associated with the treatment of their MVA-related condition.  This alteration in their diabetic status is usually temporary.

Subdivision 3:  Adrenal Glands

DIVISION 10:  THE HEMATOPOIETIC SYSTEM

1.  Tissue Disruption

1.1  Spleen

(d) injury causing some loss of splenic function (see section 2 – Functional Impairment of the Hematopoietic System).

1.2  Thymus

(d) injury causing some loss of splenic function (see section 2 – Functional Impairment of the Hematopoietic System).

2.  Functional Impairment of the Hematopoietic System

2.1 Red blood cells

2.2  White blood cells (WBC)

(a) conditions leading to a decreased WBC count

2.3  Platelet and clotting factors

DIVISION 11:  PSYCHIATRIC CONDITION, SYNDROME OR PHENOMENON

DIVISION 12:  VESTIBULOCOCHLEAR APPARATUS

Impairment rating procedure

In this Division, the whole-person impairment rating is determined by combining the separate impairment ratings for hearing loss, vestibular (labyrinthine) function and tinnitus in accordance with the following formula:

(H  ×  0.8)  +  (V  ×  0.9)  +  (T  ×  0.8)  =  1

In this formula:

His the impairment rating for hearing loss determined determined under section 3;

Vis the impairment rating for vestibular function determined under section 4;

Tis the impairment rating for tinnitus determined under section 5; and

Iis the whole-person impairment rating.

1.  Ear or pinna

See Table 13.1 – Evaluation of facial disfigurement, in Division 13 – The Skin.

2.  External canal injury (e.g. stenosis)

3.  Hearing

Permanent hearing impairment may be classified as wither unilateral or bilateral.

Unaided:

(a) profound bilateral sensory neural hearing loss

(b) unilateral sensory neural hearing loss profound

(c) reduction in hearing other than above

(see Table 12.1).

Table 12.1  Impairment rating for hearing loss

* According to the average obtained by a valid audiogram on frequencies of 500, 1000 and 2,000 cycles.

Addendum to Table 12.1

Reduction in speech discrimination score below 80% in affected ear multiplies hearing impairment by a factor of 2.  For example, a hearing loss of over 35 to 40 ISO in the most impaired ear = 2% whole-person impairment.  However, if the affected ear speech discrimination is < 80%, the final rating is multiplied by 2 resulting in a 4% whole-person impairment.  The maximum award for this category is 30% equivalent to the maximum award for profound bilateral hearing loss.

4.  Vestibular function

4.1  Loss of labyrinth (as determined by clinical examination and/or electronystagmography):

4.2  Functional criteria of vestibular impairment

Vestibular injury may be compensated over time and should be rated at both 6 and 12 months after injury to establish whether it has become static.

5.  Tinnitus, unilateral or bilateral

DIVISION 13:  THE SKIN

1.  Definitions

In this Division,

"alteration in form and symmetry" means a skin or surface disfigurement that results in a change in tissue bulk, consistency, length or texture.  It does not refer to the presence of a scar; (« modification de la forme et de la symétrie »)

"conspicuous" means a skin disfigurement that is readily discernable with the unaided eye; (« apparent »)

"faulty scar" means a scar that is misaligned, irregular, depressed, deeply adhering, pigmented, scaly, retractile, keloidal or hypertrophic; (« cicatrice vicieuse »)

"flat scar" means a scar that is almost linear, at the same level as the adjoining tissue and almost the same colour, causing no contraction or distortion of neighboring structures; (« cicatrice non vicieuse »)

"inconspicuous" means a skin disfigurement that is not readily discernable with the unaided eye. (« non apparent »)

Subdivision 1:  Facial Disfigurement

1.  Rating facial disfigurement

For the purpose of rating facial disfigurement, reference must be made to each of the following anatomical elements:

(a) the forehead;

(b) the orbits;

(c) the eyelids;

(d) the visible part of the ocular globes;

(e) the cheeks;

(f) the nose;

(g) the lips;

(h) the ears;

(i) the chin.

2.  Impairment rating procedure for facial disfigurement

2.1  The degree of facial disfigurement is first classified in terms of its physical appearance, in order to determine the appropriate impairment class.

2.2  For disfigurement classes 1-4, the impairment percentage for disfigurement is fixed with respect to scarring and the alterations in form and symmetry, up to a maximum impairment percentage for disfigurement prescribed for each class (see Table 13.1.)

2.3  Where there is evidence of both scarring and alterations in form and symmetry, both impairments are rated and the percentages for both are added up to the maximum percentage prescribed for that class.

2.4  For classes 5 and 6, scarring and the alterations in form and symmetry are considered jointly and the impairment percentage awarded is the maximum prescribed for the class (see Table 13.2.)

Table 13.1  Evaluation of facial disfigurement Part 1

Table 13.2: Evaluation of facial disfigurement Part 2

Subdivision 2: Disfigurement Of Other Parts Of The Body

1.  Impairment rating procedure for disfigurement of other parts of the body

1.1  Where there is impairment only by alteration in form and symmetry, the degree of impairment is calculated and the percentage of disfigurement prescribed for that part of the body is awarded (see Table 13.3).

1.2  Where there is impairment only by scarring, the surface area of the scar is measured and the impairment percentage prescribed per cm2 is awarded, up to the maximum impairment percentage prescribed for that part of the body (see Table 13.3).

1.3  Where there are both alterations in the form and symmetry and scarring, the higher of the two percentages obtained under either heading is awarded, without exceeding up to the maximum impairment percentage prescribed for that part of the body (see Table 13.3).

1.4  The maximum impairment per region is listed in the last column of Table 13.3.  Where a body region has two sides (right/left or front/back) the maximum impairment % listed in the table is to be considered the maximum per side.

1.5  For the purposes of rating disfigurement for other parts of the body, the body regions may be defined as follows:

(a) scalp and skull – Beginning at the hairline in front and following the hairline around the side to the back;

(b) neck – The skin overlying C1-C7 posteriorly and the cricoid cartilage to the sternal notch anteriorly;

(c) arms, shoulders and elbow – Extending from the acromion process and axillary folds to the olecranon process and cubital fossa.  The scapulae, supraspinous fossa and supraclavicular fossa are considered as part of the trunk for the purposes of rating of disfigurement;

(d) forearms - Beginning at the distal aspect of the elbow (as defined above) and extending to the wrist crease;

(e) wrists and hands - Beginning at the wrist crease and extending distally to the fingertips;

(f) trunk – This region includes both the suprascapular and supraclavicular fossae.  It extends distally to the inguinal ligaments (anteriorly) and the iliac crests (posteriorly);

(g) lower Limbs – Begins at the distal aspect of the trunk (as defined above) and extends distally to the tips of the toes.  Note that the buttock is considered to be part of the lower limb and not the trunk.

2.  Disfigurement due to discoloration

Permanent, post-traumatic alteration of the skin's natural color (as compared to adjacent unaffected areas), but does not include pigmented scars, pigmented amputation stumps or pigmented skin due to venous or lymphatic insufficiency. (see Table 13.4)

Table 13.3:  Evaluation Of Disfigurement For Other Parts Of The Body