Guide to the Assessment of Rates of Veterans' Pensions (No. 2) 2016 (Cth)
Australian Government
Guide to the Assessment of Rates of Veterans’ Pensions (No. 2) 2016
Instrument 2016 No. R43
| I, Dan Tehan, Minister for Veterans’ Affairs, under subsection 29(3) of the Veterans’ Entitlements Act 1986, approve: (a) the revocation by the Repatriation Commission of the Guide to the Assessment of Rates of Veterans’ Pensions 2016 (Instrument 2016 No. R1); and (b) the following Guide to the Assessment of Rates of Veterans’ Pensions prepared by the Repatriation Commission. Dated this 19th day of August 2016 Dan Tehan |
| The Repatriation Commission: (a) under subsection 29(2) of the Veterans’ Entitlements Act 1986 (the Act), revokes the Guide to the Assessment of Rates of Veterans’ Pensions 2016 (Instrument 2016 No. R1); and (b) under subsection 29(1) of the Act prepares the following Guide to the Assessment of Rates of Veterans’ Pensions. Dated this 9th day of August 2016 The Seal of the ) SEAL presence of: ) Simon Lewis C Orme MA Kelly ……………………………………………………………………………………………….. SIMON LEWIS CRAIG ORME MAJOR GENERAL MARK KELLY DSC AM CSC AO DSC PRESIDENT DEPUTY PRESIDENT COMMISSIONER |
1. Name
This instrument is the Guide to the Assessment of Rates of Veterans’ Pensions (No. 2) 2016.
2. Short Title
The short title for this instrument is GARP V.
3. Commencement
This instrument commences on the day after it is registered.
Guide to the Assessment
of Rates of Veterans' Pensions
Department of Veterans' Affairs
Canberra
Contents
Introduction ............................................................................................................ 1
How to Use this Guide ............................................................................................ 5
Medical Impairment ........................................................................................... 13
Part A: System Specific Assessment ….................................................................... 15
Chapter 1: Cardiorespiratory Impairment ............................................................ 17
Cardiorespiratory Worksheet ...................................................................... 42
Chapter 2: Hypertension and Non-Cardiac Vascular Conditions ......................... 43
Part 2.1: Hypertension ................................................................................. 43
Part 2.2: Vascular Conditions of the Lower Limb ....................................... 47
Part 2.3: Other Non-Cardiac Vascular Conditions ...................................... 52
Chapter 3: Impairment of Spine and Limbs ......................................................... 53
Part 3.1: Upper Limbs ................................................................................. 53
Part 3.2: Lower Limbs ................................................................................. 65
Part 3.3: Spine ............................................................................................. 77
Part 3.4: Resting Joint Pain ......................................................................... 83
Part 3.5: Ranges of Joint Movement ........................................................... 84
Part 3.6: Spine and Limbs Age Adjustment ................................................ 85
Spine and Limbs Worksheet ........................................................................ 87
Chapter 4: Emotional and Behavioural ................................................................ 89
Emotional and Behavioural Worksheet ..................................................... 100
Chapter 5: Neurological Impairment .................................................................. 103
Chapter 6: Gastrointestinal Impairment ..............................................................115
Part 6.1: Diseases of the Digestive System ................................................115
Part 6.2: Abdominal Wall Hernias and Obesity ........................................ 126
Chapter 7: Ear, Nose, and Throat Impairment .................................................... 127
Part 7.1: Hearing Loss and Tinnitus .......................................................... 127
Part 7.2: Ear, Nose, and Throat ................................................................. 150
Hearing Impairment Worksheets
Index .......................................................................................................... 152
Worksheets ................................................................................................ 153
Chapter 8: Visual Impairment ............................................................................ 159
Part 8.1: Impairment of Visual Function ................................................... 159
Part 8.2: Other Ocular Impairment ........................................................... 167
Visual Impairment Worksheet ................................................................... 168
Chapter 9: Renal and Urinary Tract Function .................................................... 169
Part 9.1: Renal Function ............................................................................ 169
Part 9.2: Lower Urinary Tract Function .................................................... 173
Chapter 10: Sexual Function, Reproduction, and Breasts .................................... 177
Part 10.1: Sexual Function ........................................................................ 178
Part 10.2: Reproduction ............................................................................ 182
Part 10.3: Breasts ....................................................................................... 187
Chapter 11: Skin Impairment .............................................................................. 189
Chapter 12: Endocrine and Haemopoietic Impairment ...................................... 193
Part 12.1: The Endocrine System .............................................................. 193
Part 12.2: The Haemopoietic System ........................................................ 197
Part B: Non-System Specific Assessment ........................................................... 199
Chapter 13: Negligible Impairment .................................................................... 201
Chapter 14: Malignant Conditions ..................................................................... 203
Chapter 15: Intermittent Impairment .................................................................. 209
Intermittent Impairment Worksheets ........................................................ 217
Chapter 16: Activities of Daily Living ............................................................... 219
Chapter 17: Disfigurement and Social Impairment ............................................ 225
Part C: Impairment Ratings: Combining, Apportioning, Partially
Contributing ....................................................................................................... 229
Chapter 18: Combined Values Chart .................................................................. 231
Chapter 19: Partially Contributing Impairment .................................................. 237
Chapter 20: Apportionment ................................................................................ 241
Chapter 21: Paired Organs Policy ....................................................................... 259
Lifestyle Effects ................................................................................................. 261
Chapter 22: Lifestyle Effects .............................................................................. 263
Degree of Incapacity ......................................................................................... 275
Chapter 23: Conversion to Degree of Incapacity ............................................... 277
Chapter 24: Degree of Incapacity for Specific Disabilities ................................ 279
Index ................................................................................................................... 281
Introduction
Purpose
This Guide is to be applied to assess the extent of incapacity from war-caused or defence-caused injury or disease. Its provisions are binding on the Repatriation Commission, the Veterans' Review Board, and the Administrative Appeals Tribunal.
Legal background
The Veterans' Entitlements Act 1986 (the Act) provides for pensions to veterans for incapacity resulting from war or defence-caused injuries and diseases (sections 13 and 70).
The terms "injury" and "disease" are defined in subsection 5D(1) of the Act. A veteran's incapacity is defined by subsection 5D(2) as the effects of that injury or disease.
The Act provides three fundamental rates of pension: a general rate, an intermediate rate, and a special rate.
Section 22 of the Act provides that the percentage of general rate of pension payable is to be determined by reference to the extent of the veteran's incapacity as assessed in accordance with this Guide. Section 29 of the Act provides that the Repatriation Commission prepare the Guide, setting out:
"(a) criteria by reference to which the extent of the incapacity of a veteran resulting
from war-caused injury or war-caused disease, or both, shall be assessed; and
(b) methods by which the extent of that incapacity, as assessed in accordance with those criteria, shall be expressed as a percentage of incapacity from that injury or disease, or both, being a percentage not exceeding one hundred per centum."
Subsection 22(4) of the Act sets out the criteria in accordance with this Guide that must be met in order to qualify for the extreme disablement adjustment.
Definitions
For the purposes of this Guide, and unless a contrary intention appears:
"Act" means the Veterans' Entitlements Act 1986 as amended from time to time;
"accepted condition" means an injury or disease that has been determined under the Act to be war-caused or defence-caused;
"add" means find the arithmetic sum of two or more numbers; "clinical features" includes signs and symptoms;
"combine" means produce a result by combining two or more numbers by applying Table 18.1 (Combined Values Chart) in Chapter 18 in accordance with that chapter;
"condition" means an injury or a disease;
"defence-caused injury" and "defence-caused disease" have the meaning given in section 70 of the Act;
"disease" has the meaning given by section 5D of the Act;
"Guide" means this Guide to the Assessment of Rates of Veterans' Pensions;
"impairment rating" means a measure of the degree of medical impairment due to accepted conditions, on a scale of 0 to 100;
"incapacity" has the meaning given in subsection 5D(2) of the Act; "injury" has the meaning given by section 5D of the Act;
"non-accepted condition" means an injury or disease that:
+ has not been determined under the Act to be war-caused or defence-caused;
or
+ has been determined under the Act not to be war-caused or defence-caused;
"Statement of Principles" means:
+ a Statement of Principles determined by the Repatriation Medical Authority under section 196B of the Act; or
+ a determination made by the Repatriation Commission under section 180A
of the Act; or
+ a statement of principles concerning a particular kind of injury or disease made available to the Veterans' Review Board by the Repatriation Commission under paragraph 138(2)(a) of the Act;
"veteran" means a person (including a deceased person) in respect of whom an injury or disease has been determined under the Act to be war-caused or defence-caused;
"war-caused injury" and "war-caused disease" have the meaning given in section 9 of the Act;
"worksheet" means a page or pages of this Guide, identified as a "worksheet",
Introduction
that gives a structure by which certain calculations may be set out to assist in determining an impairment rating.
Definitions of words and phrases that are used in only one chapter are to be found in that chapter.
Acknowledgment of sources
The following published works were found to be useful in the preparation of this edition of the Guide:
Guides to the Evaluation of Permanent Impairment, 4th edition, American Medical
Association, 1993;
International Classification of Impairments, Conditions, and Handicaps, World
Health Organisation, Geneva, 1980; and
Publication No 118 of the National Acoustic Laboratories, Improved Procedure for Determining Percentage Loss of Hearing, by J. Macrae, Australian Government Publishing Service, Canberra, 1988.
How to Use this Guide
The subject of assessment
This Guide is to be applied to assess the degree of incapacity from injuries or diseases or both that have been determined to be war-caused or defence-caused.
In making an assessment the clinical features of war-caused or defence-caused injuries or diseases are to be taken into account. Clinical features of sequelae of accepted conditions can only be assessed after the sequelae have been determined to be war- caused or defence-caused.
The elements of assessment
The two elements of the assessment of degree of incapacity are medical impairment and lifestyle effects. Lifestyle effects are dealt with in Chapter 22. Other chapters address medical impairment.
Medical impairment
Medical impairment has two components:
+ physical loss of, or disturbance to, any body part or system; and
+ the resultant functional loss.
Chapters 1 to 16 of the Guide contain two principal types of tables. Physical loss is to be rated against criteria in "Other Impairment" tables. Functional loss is to be rated against criteria in "Functional Loss" tables.
Greater emphasis has been given throughout this Guide to functional loss as a basis for assessment. It is measured by reference to an individual's performance efficiency compared with that of an average, healthy person of the same age and sex, in a set of defined vital functions. This is a means of compensating for the loss of ability to perform everyday functions.
Each table contains benchmark values, generally at intervals of five points. In some cases the range between nil and five includes a rating of two points. In some other cases intervals are greater than five points because lesser increments of impairment cannot be distinguished.
Each benchmark is a threshold value, that is, the rating applies only if the threshold is achieved or exceeded. Ratings are not to be rounded up to the next benchmark. Similarly, ratings between benchmark values contained in the tables are not to be interpolated.
In some tables more than one criterion is stated opposite a benchmark value. The different criteria are marked by dot points. Where more than one criterion is stated for a particular value, the condition being assessed only has to satisfy one of the criteria in order to attract the impairment rating of that value.
Each chapter contains step-by-step instructions to be followed in the use and application of the tables.
Whole person impairment
Medical impairment is expressed in impairment points, out of a maximum rating of
100. On this scale, zero points corresponds to no or negligible impairment from accepted conditions, and 100 points corresponds to death. Effectively, impairment points are percentages of the impairment of the whole person.
Functional loss
Medical impairment is measured chiefly by loss of vital functions, addressed in twelve system specific chapters, as follows:
+ Cardiorespiratory Impairment
+ Hypertension and Non-Cardiac Vascular Conditions
+ Impairment of Spine and Limbs
+ Emotional and Behavioural
+ Neurological Impairment
+ Gastrointestinal Impairment
+ Ear, Nose, and Throat Impairment
+ Visual Impairment
+ Renal and Urinary Tract Function
+ Sexual Function, Reproduction, and Breasts
+ Skin Impairment
+ Endocrine and Haemopoietic Impairment
Functional loss is to be rated against criteria in Functional Loss tables. Each functional loss associated with an accepted condition is to be identified and rated individually. In most cases a single condition gives rise to a single functional loss.
If there is a multisystem condition in which a single condition gives rise to multiple functional losses, then such a single condition is to be rated using several Functional Loss tables. The separate ratings are only to be combined with each other in the final combining of all ratings from all accepted conditions. If two or more conditions contribute to the same functional loss, a single rating only is to be given for that functional loss.
Other Impairment
Other Impairment is the physical loss of, or disturbance to, any body part or system. This concept is extended in some chapters to include discomfort, pain, poor prognosis and other, less tangible, effects of accepted conditions. It is to be rated against criteria in Other Impairment tables.
As a general rule, ratings from Other Impairment and Functional Loss tables are not to be combined for the same condition. Exceptions to this rule are expressly indicated in particular chapters. When ratings from both types of table can be applied, the higher rating is to be chosen.
Lifestyle effects
Lifestyle effects are to be assessed by applying Tables 22.1 to 22.5 in Chapter 22 in accordance with that chapter.
The tables
Types of Tables. There are five types of tables in the Guide. They are "Functional Loss", "Other Impairment", "Scale", "Procedural", and "Lifestyle". Each table carries its type identification and number in the top left hand corner.
Some chapters are divided into parts. The tables in these chapters carry a number in three segments (separated by full stops):
Table
7.1.1
Chapter Table
Number
Part
Number
Number
Tables in chapters not divided into parts carry a number in two segments:
Table
1.1
Chapter Table
Number Number
Gender Use. Some tables are for men only, some for women only, and others (the majority) are not gender specific. Each table is clearly marked in the top right hand corner:
+the symbol means that the table is only to be used for the assessment of female veterans;
+the symbol means that the table is only to be used for the assessment of male veterans;
+ the symbol means that the table may be used for either male or female
veterans.
Age Adjustment. Some tables incorporate age dependent criteria. Some other tables have no such criteria and require subsequent age adjustment by applying tables provided for that purpose.
Each table is clearly marked in the bottom left hand corner with instructions on age adjustment for ratings derived from that table.
Non-system specific assessments
There are five chapters describing alternate methods of assessing certain conditions. They are:
+ Chapter 13 Negligible Impairment
+ Chapter 14 Malignant Conditions
+ Chapter 15 Intermittent Impairment
+ Chapter 16 Activities of Daily Living
+ Chapter 17 Disfigurement and Social Impairment
A condition may be assessable under both system specific chapter(s) and non-system specific chapter(s), for example, carcinoma of the lung or epilepsy.
As a general rule, ratings from Chapters 14, 15, and 16 are not to be combined with any impairment ratings for the same condition derived from one or more system specific chapters. The impairment ratings from the system-specific chapters and the non-system specific chapters are to be compared and the higher impairment rating is to be selected.
Ratings from Chapters 13 and 17 are to be dealt with differently. Any applicable ratings from Chapters 13 and 17 are to be combined with any applicable ratings from other chapters in the final combining of all ratings.
Conditions and their sequelae
Only the clinical features of an accepted condition may be taken into account in making an assessment. If the accepted condition causes some other distinct and diagnosable condition (sequela), the symptoms of the sequela cannot be taken into
account when assessing the original accepted condition. Sequelae can only be assessed when they have themselves been separately determined to be war-caused or defence- caused.
As a general guide, a condition that is the subject of a Statement of Principles in force on 18 April 1998 should be taken as a separate disease entity. For the purposes of the preceding sentence, "Statement of Principles" has the meaning given to it on page 2 of this Guide.
Applying the instructions
To the extent of any inconsistency between an instruction in "How to Use this Guide" and a specific instruction concerning a particular matter in another chapter of this Guide, the specific instruction in that other chapter is to apply to that particular matter.
If assessment of impairment is not possible
If it is impossible to assess the impairment of an accepted condition that has previously been assessed under this or an earlier edition of the Guide, the impairment rating that was last given for that accepted condition (under this or the earlier edition of the Guide, as the case may be) is to be taken to be the impairment rating for that condition.
For example, if the veteran has an accepted visual loss, which at the last assessment had been given a rating of 15 impairment points, and is now afflicted with dementia, which prevents the assessment of that visual loss, the impairment rating for that visual loss would be taken to be 15 impairment points for the purposes of the current assessment.
If the impairment from a particular accepted condition has not previously been assessed (under this or an earlier edition of the Guide) and it is otherwise impossible to assess the impairment of that condition in accordance with this Guide, a best estimate must be made based on what medical and other evidence is available concerning the extent of impairment from that condition. Such assessment of impairment must take into account the contribution to impairment from other conditions and the expected course of the condition, including the effect of aging by reference to age adjustment tables, as appropriate. The impairment rating given by this method must be as consistent as possible with the relevant steps and tables in this Guide.
Pain and suffering
Pain and suffering have been taken into account in this Guide in the following manner:
+ if pain and suffering restrict everyday activities, the functional loss caused is rated in the appropriate table;
+ if pain and suffering occur without restriction to any activity the appropriate
Other Impairment table is used; and
+ allowance for pain and suffering is included in the lifestyle assessment.
Medication or treatment
In some cases, type of medication or treatment has been used as an indicator of the severity of disablement. Such tables contain appropriate criteria about medication. No additional rating is therefore required.
Persistent side effects of long term treatment are to be assessed as part of the condition being treated, using the appropriate system specific tables. Persistent side effects are those side effects of the treatment that persist during therapy but which resolve on (or shortly after) cessation of therapy.
Permanent side effects of long term treatment cannot be assessed as part of the condition being treated. Permanent side effects are those side effects of the treatment that persist during therapy and which do not resolve on (or shortly after) cessation of therapy. Such permanent side effects would generally be covered by a Statement of Principles. The permanent side effects must first be determined to be war-caused or defence-caused, before they can be assessed.
Time reference
The severity of many conditions fluctuates over time and may be better assessed by an averaging process. Therefore, because some criteria refer to the occurrence of symptoms during a period, it will be necessary to assess an averaged severity during that period. Twelve months is usually a suitable period, as it allows any seasonal fluctuation to be observed, but the period may be varied according to circumstances.
For tests done on a particular date, specifically spirometry, audiometry and creatinine clearance calculated from the formula, the veteran's age for the purpose of obtaining an impairment rating shall generally be his or her age on the date of the test.
Duration of assessment period
While the Act requires the assessment of a rate or rates of pension over an "assessment period" (see section 19 of the Act), that assessment can in practice only be made by reference to the available medical and other material that, of necessity, relates to a particular point or period in time. Therefore, the assessment of the impairment and lifestyle ratings during the "assessment period" must be based on the assessor's reasonable satisfaction as to those ratings throughout the assessment period, based on the available material. If there is a significant change in impairment or lifestyle during an assessment period, the assessment period must be divided into appropriate periods to reflect those changes, and separate assessments made of the degree of incapacity.
Apportionment of impairment ratings
It is sometimes necessary, for an accepted condition, to compare an impairment rating derived from one table with an impairment rating derived from another table. When two or more conditions contribute to the impairment ratings from either or
both tables, and comparison is necessary, the method called "apportionment" is to be applied before making the comparison.
Details of the application of apportionment are given in Chapter 20.
Paired organs policy
The paired organs policy is described in Chapter 21.
Combining impairment ratings
If all accepted conditions have been given impairment ratings, the ratings are to be combined by applying Table 18.1 (Combined Values Chart).
Details on how to apply Table 18.1 are given in Chapter 18.
The combined impairment rating obtained by applying Table 18.1 (Combined Values Chart) is to be rounded to the nearest five points. If Table 18.1 is not required to be applied because only one impairment rating has been obtained and that rating is not a multiple of five, that rating is to be rounded to the nearest five points (or to zero) to produce the impairment rating for the purposes of applying Table 23.1 in Chapter 23 (Conversion to Degree of Incapacity), and for the purposes of the extreme disablement adjustment.
Degree of incapacity
The combined impairment rating which is obtained by applying Chapter 18 (Combined Values Chart) is to be combined with the lifestyle rating to determine the degree of incapacity, by applying Table 23.1 (Conversion to Degree of Incapacity) in accordance with Chapter 23.
Degree of incapacity for specific disabilities
If a veteran has one or more accepted conditions that are listed in Column 1 of Table 24.1, then the degree of incapacity of the veteran must be determined in accordance with Chapter 24. The veteran’s degree of incapacity from accepted conditions determined by applying Chapters 1-23 of the Guide, is to be compared with the degree of incapacity determined by applying Chapter 24, and the higher degree of incapacity is to be taken. This is the veteran's final degree of incapacity from all accepted conditions.
NOTES
Medical Impairment
Part A:
System Specific
Assessment
Chapter 1
Cardiorespiratory Impairment
INTRODUCTION
Cardiorespiratory impairment results from conditions that affect the function of the heart or lungs. The procedures described in this chapter are to be applied in assessing most conditions of the heart and lungs, and will usually also be appropriate for conditions affecting the function of the thorax or diaphragm, lesions of the nerves that supply the muscles of respiration, and conditions such as anaemia. The principal exception is any condition which is predominantly intermittent in nature and which would be better assessed by applying Chapter 15 (Intermittent Impairment).
Different procedures (described in Chapter 2) are to be applied to assess hypertension and non-cardiac vascular conditions (such as aortic aneurysm and varicose veins).
In general, cardiorespiratory impairment is to be measured by reference to exercise tolerance. Exercise tolerance is quantified in terms of METs (see pages 26-27). However, if a respiratory component is present, measurements of lung function, such as forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and maximal expiratory flow (MEF25-75) are to be used in addition to exercise tolerance. FEV1 and FVC are to be measured by spirometry. For the purposes of assessment in accordance with this Guide, the terms "MEF25-75" and "FEF25-75" (forced expiratory flow between 25% and 75% of the vital capacity) are to be taken as equivalent.
The conversion of loss of exercise tolerance and measurements of lung function into an impairment rating is set out in Table 1.2 and Table 1.3.
Certain cardiorespiratory conditions cannot be rated by applying exercise tolerance. These include:
+ conditions that do not decrease exercise tolerance;
+ conditions that do not produce symptoms; and
+ intermittent conditions.
"Exercise tolerance" refers to a person's ability to exercise from a cardiorespiratory point of view rather than to a person's total ability to exercise. For example, a veteran who has osteoarthritis of both knees may be greatly limited in walking but may still be able to swim a considerable distance. Such a veteran would still have good exercise tolerance from a cardiorespiratory point of view, though total ability to exercise would be reduced.
A veteran whose ability to exercise has been significantly reduced by other conditions (such as musculoskeletal conditions or being grossly overweight), or who no longer has cardiac or respiratory symptoms on exercise, cannot always be given an appropriate impairment rating for reduced exercise tolerance. However, the need to apply Chapter 19 (Partially Contributing Impairment) should always be considered before disregarding exercise tolerance figures.
Calculation of the impairment rating for accepted cardiorespiratory conditions
Follow the steps below to determine the impairment rating for cardiorespiratory conditions:
(Each step is elaborated in the following pages.)
STEP Establish what cardiorespiratory conditions are Page
1 present. 19
STEP Assess the information that is available and decide Page
2 whether it is reliable and sufficient. 19
STEP Determine the impairment rating based on effort Page
3 tolerance. 21
STEP (Omit this step if no respiratory disease is present.) Page
4 Determine the impairment rating based on measure- 25
ments of lung function.
STEP Determine the total accepted cardiorespiratory Page
5 functional impairment rating. 32
STEP Consider the effects of cardiac failure (if any). Page
6 36
STEP Moderate the total cardiorespiratory functional Page
7 impairment rating to allow for effects of any non- 37
accepted conditions.
STEP Determine whether any ratings from the relevant Other Page
8 Impairment tables apply (Tables 1.7, 1.8, 1.9, 1.10). 37
Step 1: Establish what cardiorespiratory conditions are present.
For the purpose of assessing cardiorespiratory impairment, both the accepted and the non-accepted conditions are be taken into account. Both will affect the way in which cardiorespiratory functional impairment is calculated. (Their combined effect is taken into account in the application of Table 1.5 in Step 5.)
Any non-accepted conditions are to be subsequently allowed for by applying
Chapter 19 (Partially Contributing Impairment) see Step 7.
When considering the question: 'What cardiorespiratory conditions are present in this veteran?', it is not appropriate to rely simply on a list of accepted conditions. Both previously claimed but rejected cardiorespiratory conditions and unclaimed cardiorespiratory conditions may also be present.
Step 2: Assess the information that is available and decide whether it is reliable and sufficient.
To make a reliable cardiorespiratory assessment, there should be an adequate medical history of the veteran's cardiorespiratory conditions. In addition, there should be information relating to the veteran's effort tolerance and, if any respiratory disease is present, there should also be one or more sets of spirometry or other physiological measurements of respiratory function. The criteria by which the evaluation of the information is to be made are set out below.
Medical history
An adequate history of the veteran's illness and a description of the current symptoms and details of the current treatment should be available.
The history should be reviewed at the start of the cardiorespiratory assessment procedure to establish whether any major cardiorespiratory event (for example a myocardial infarction or bypass surgery) has occurred within the period of assessment.
An examination of the history will indicate whether any Other Impairment ratings (from Tables 1.7, 1.8, 1.9, 1.10) are applicable. For example, in the case of ischaemic heart disease, the history will reveal whether the veteran has had any myocardial infarctions, whether coronary bypass surgery has been performed and the outcome of any such surgery. In other cases, for example when respiratory disease is present, the current treatment will reveal whether any Other Impairment rating for cardiorespiratory conditions is applicable.
In long-standing respiratory conditions, there will often be a disease complex present that is more extensive than that implied by the original diagnostic label. For example, asthma may lead to chronic obstructive respiratory disease and chronic bronchitis may lead to small airways disease. Such extensions of the disease process are to be
assessed as part and parcel of the original condition unless there is clear reason why they should not be for example, they have been determined to be non-accepted conditions.
Effort tolerance
Effort tolerance information should always be obtained except if the veteran has a condition that renders the collection of reliable effort tolerance information impracticable.
Examples of conditions that may render the collection of reliable effort tolerance information impracticable include:
+ hemiparesis following a stroke;
+ quadriplegia or hemiplegia;
+ severe arthritis of the lower limbs; and
+certain mental conditions such as dementia (in which the veteran's ability to co- operate or provide useful information may be restricted).
The date of the effort tolerance information used must be appropriate to the period of assessment: the effort tolerance information should be not more than six months older than the relevant time in the assessment period to which the information is to be applied.
Measurements of lung function
Spirometry should always be obtained if any condition affecting the function of the lungs is present unless it is not practicable or appropriate to perform spirometry because:
+ the veteran is very old or frail and cannot reasonably attend a clinic where
spirometry can be performed; or
+the veteran lives in a remote locality and cannot reasonably attend a clinic where spirometry can be performed; or
+the veteran's impairment from other accepted conditions is of such a degree that it would result in a combined impairment rating of at least 68 points.
The date of the spirometry used must be appropriate to the period of assessment: the spirometry should be not more than six months older than the relevant time in the assessment period to which the information is to be applied.
The nature of the spirometry should be appropriate: the nature of the spirometric readings should be consistent with the known conditions affecting the veteran and should also be consistent with such other information (eg, old spirometry) as is available or can reasonably be obtained. There should be no unexplained inconsistencies between the various reports.
If the nature of the spirometry cannot be reconciled with other relevant information, the spirometry may need to be repeated or the veteran referred to a respiratory physician for clarification of the situation.
If a veteran has emphysema, as evidenced by diminished carbon monoxide diffusing capacity, and diagnosed by a specialist respiratory physician, assessment can be made on the basis of effort tolerance alone.
Step 3: Determine the impairment rating based on effort tolerance.
To determine the impairment rating based on effort tolerance follow the substeps below.
(Each step is elaborated in the following pages.)
Substep
3A
Determine the symptomatic activity level by applying Table1.1 Activity Levels (with energy expenditure in METs).
Page
21
Substep
3B
Convert that symptomatic activity level into an impairment rating. This step involves consulting either Table 1.2 - Loss of Cardiorespiratory Function: Exercise Tolerance (Males); or Table 1.3 - Loss of Cardiorespiratory Function: Exercise
Tolerance (Females).
Page
25
After both substeps have been completed, a single rating will have been obtained. This rating is known as the impairment rating for effort tolerance.
If symptoms do not occur, a rating for the condition may be found in Table 1.6 (Cardiac Failure) if applicable, or in the relevant Other Impairment table.
Substep 3A: Determine the symptomatic activity level.
The symptomatic activity level is the exercise level (measured in METs) at which symptoms occur. One MET represents the energy expenditure associated with the consumption of 3.5 mL oxygen per kilogram of body weight per minute. Table 1.1 lists various activities grouped according to their energy expenditure in METs.
The symptomatic activity level is the level at which the activities from within any one METs category consistently give rise to symptoms of the accepted cardiorespiratory condition, such as angina, dyspnoea, palpitations, or fatigue. The symptomatic activity level may be determined by reference to a report specifically provided for the purpose as well as by reference to clinical notes and by comparison of the information with the activities listed in Table 1.1. (The symptomatic activity level may be determined by reference to activities other than those contained in Table 1.1 if the energy expenditure (in METs) of those activities is available in the medical or scientific literature.)
In determining the symptomatic activity level, greater reliance is to be placed on activities that involve steady, as opposed to sporadic, expenditure of energy. Such activities are more reliable as indicators of exercise tolerance. Less reliance is to be placed on activities that can be completed in less than a few minutes, as symptoms may take longer than this to occur.
Responses of the type ‘I cannot do such and such' or 'I do not do so and so' are not useful in assessing the symptomatic activity level. What must be established is that level of exercise that the veteran is able to do but which results in angina, breathlessness, or some other cardiorespiratory symptom.
Symptoms that occur while an activity is performed are not necessarily a result of the energy expenditure occasioned by the activity. Many specific activities can be performed in a way which would mean that they were no longer examples of the METs level in which they are placed in Table 1.1. For example, while driving a car sedately is an example of 2-3 METs, driving a car in a Grand Prix is not.
Estimations of exercise tolerance above the 6-7 METs level should only be made using exercise tests. The following activities are listed for information only.
7-8 METs + Chopping hardwood.
+ Very heavy exercise + Callisthenics.
+ Jogging (8 km/h). + Squash (non
+ Horseback riding (galloping). - competitive).
+ Carrying heavy objects
(30 kg) on level ground. 10+ METs
+ Sawing hardwood with + Running quickly hand tools. (10 km/h).
+ Cycling quickly (25 km/h).
8-9 METs Carrying loads (10 kg)
+ Running (9 km/h). up a gradient.
+ Skiing (cross-country). + Football (any code).
Alternate procedures for establishing the symptomatic activity level
. The symptomatic activity level may be determined by exercise tests. These tests include:
+ use of treadmills; or
+ cycles; or
+ rowing machines.
Because of their greater objectivity, the results of exercise tests (when available) are to be used in preference to the method of calculating exercise tolerance as described above. Moreover, exercise tests must always be used to make an estimate of exercise tolerance above 6-7 METs.
. If certain levels of activity have been prohibited by the treating doctor, because of the adverse effect the prohibited activity is likely to have on the veteran's health as a result of the accepted condition, then the level of exercise that has been prohibited may be regarded as the symptomatic activity level.
SCALE
1.1
CARDIORESPIRATORY IMPAIRMENT: ACTIVITY LEVELS (with energy expenditure in METs)
1-2 METs Energy expended at rest or minimal activity
·Lying down.
·Sitting and drinking tea.
·Using sewing machine (electric).
·Sitting down.
·Sitting and talking on telephone.
·Travelling in car as passenger.
·Standing.
·Sitting and knitting.
·Playing cards.
·Strolling (slowly).
·Light sweeping.
·Clerical work (desk work only).
2-3 METs Energy expended in dressing, washing and performing light house- hold duties
·Light household duties.
·Walking slowly (3.5 km/h).
·Playing piano, violin, or organ.
·Typing.
·Cooking or preparing meals.
·Playing billiards.
·Clerical work which involves moving around.
·Setting table.
·Driving power boat.
·Washing dishes.
·Playing golf (with power buggy).
·Bench assembly work (seated).
·Dressing, showering.
·Horseback riding at walk.
·Using self-propelled mower.
·Light tidying, dusting.
·Lawn bowls.
·Polishing silver.
·Driving car.
3-4 METs Energy expended in walking at an average pace
·Walking at average walking pace (5 km/h).
·Golf (pulling buggy).
·Machine assembly.
·Cleaning car (excludes vigorous polishing).
·Minor car repairs.
·Tidying house.
·Welding.
·Cleaning windows.
·Table tennis.
Ratings derived from METs are age adjusted
(continued next page)
SCALE
1.1 (cont'd)
CARDIORESPIRATORY IMPAIRMENT: ACTIVITY LEVELS (with energy expenditure in METs) continued
·Pushing light power mower over flat suburban lawn at slow steady pace.
·Vacuuming.
·Sedate cycling (10 km/h).
·Shifting chairs.
·Light gardening (weeding and water).
·Hanging out washing.
·Making bed.
4-5 METs Moderate activity: encompasses more strenuous daily activities with the exclusion of manual labour and vigorous exercise
·Mopping floors.
·Golf (carrying bag).
·Light carpentry (eg chiselling, hammering).
·Scrubbing floors.
·Ballroom dancing.
·Beating carpets.
·Tennis doubles (social, non-competitive).
·Stocking shelves with light objects.
·Polishing furniture.
·Wallpapering.
·Shopping and carrying groceries (10 kg).
·Gentle swimming.
·Painting outside of house.
·Hoeing (soft soil).
·Stacking firewood.
5-6 METs Heavy exercise: manual labour or vigorous sports
·Walking 6.5 km/h (sustained brisk walk, discomfort in talking at the
same time).
·Walking slowly but steadily up stairs.
·Carpentry (eg sawing and planing with hand tools).
·Swimming laps (non-competitive).
·Pushing a full wheelbarrow (20 kg).
·Shovelling dirt (12 throws a minute).
·Digging in garden.
6-7 METs
·Badminton (competitive).
·Tennis (singles, non-competitive).
·Water skiing.
·Loading truck with bricks.
·Using a pick and shovel to dig trenches.
The activities listed under each heading are examples. There will be other activities that have the same METs expenditure and hence can be used for reference if their METs level is known.
Ratings derived from METs are age adjusted
Substep 3B: Convert the symptomatic activity level into an impairment rating.
The symptomatic activity level is used, in conjunction with the veteran's age, height, and sex, to obtain an impairment rating.
In the case of a male, Table 1.2 is to be applied.
In the case of a female, Table 1.3 is to be applied.
For the purposes of Tables 1.2 and 1.3, a veteran's age is taken to be his or her age in whole years at the date of the report relating to the exercise tolerance (unless the report is of a retrospective type and clearly refers to some earlier period, in which case the veteran's age is taken to be his or her age in whole years at the relevant time).
Step 4: (Omit this step if no respiratory disease is present.) Determine the impairment rating based on measurements of lung function.
FEVl, FVC, and MEF25-75 are the usual physiological measurements of lung function. Determinations of FEVl, FVC, and MEF25-75 should be conducted by an experienced operator without specific administration of a bronchodilator. The best set of results should be selected, that is, the set of results which indicates the greatest degree of health and, consequently, the lowest degree of impairment.
If both pre-bronchodilator and post-bronchodilator results are available the pre- bronchodilator results are to be applied in determining the impairment rating based on measurements of lung function.
To determine the impairment rating based on measurements of lung function, follow the substeps below.
Substep Obtain the measured FEVl, FVC, and MEF25-75 from the data.
4A
Substep
4B
Work out the predicted FEVl, FVC, and MEF25-75 for a person of the
same age, height, and gender. This can be done either by applying the
nomograms Figure 1a (for males) or Figure 1b (for females) or by applying the formula relating to each nomogram.
Substep Express the measured FEV1 as a percentage of the predicted FEV1, and
4C Express the measured FVC as a percentage of the predicted FVC, and Express the measured MEF25-75 (if appropriate) as a percentage of the predicted MEF25-75.
These conversions are performed by applying the formula:
Measured value as % of predicted value =
Actual value x 100
Predicted value
Substep Determine an impairment rating from a physiological measurement by
4D using the percentage obtained in substep 4C in conjunction with Table
1.4. Separate impairment ratings can be obtained from each physiological
measurement (that is, from the FEV1, FVC, and MEF25-75).
Substep The final impairment rating is the highest (or equal highest) of the ratings
4E obtained in substep 4D.
Functional Loss
Table 1.2
LOSS OF CARDIORESPIRATORY FUNCTION: EXERCISE TOLERANCE
(Males)
Age Symptomatic Activity Level Age Symptomatic Activity Level
(METs*) (METs*)
less
than 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 10+ 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 10+
25 90 80 70 60 50 40 30 20 10 55 80 70 55 40 25 15 10 25 90 80 70 60 50 40 30 20 10 56 80 70 54 39 24 15 9 26 90 80 70 60 50 40 30 20 10 57 80 69 53 38 23 14 8 27 89 80 70 59 48 38 28 19 10 58 80 69 52 37 22 14 7 28 89 80 70 59 47 37 27 19 10 59 80 68 51 36 21 13 6 29 88 80 70 58 46 36 26 18 10 60 80 68 50 35 20 13 5 30 88 80 70 58 45 35 25 18 10 61 80 67 49 34 19 12 4 31 87 80 70 57 44 34 24 17 10 62 80 67 48 33 18 12 3 32 87 80 70 57 43 33 23 17 10 63 80 66 47 32 17 11 2 33 86 80 70 56 42 32 22 16 10 64 80 66 46 31 16 11 34 86 80 70 56 41 31 21 16 10 65 80 65 45 30 15 10 35 85 80 70 55 40 30 20 15 10 66 80 64 44 29 15 9 36 85 80 70 55 39 29 20 15 9 67 79 63 43 28 14 8 37 85 79 69 54 38 28 19 14 8 68 79 62 42 27 14 7 38 85 79 69 54 37 27 19 14 7 69 78 61 41 26 13 6 39 85 78 68 53 36 26 18 13 6 70 78 60 40 25 13 5 40 85 78 68 53 35 25 18 13 5 71 77 59 39 24 12 4 41 85 77 67 52 34 24 17 12 4 72 77 58 38 23 12 3 42 85 77 67 52 33 23 17 12 3 73 76 57 37 22 11 2 43 85 76 66 51 32 22 16 11 2 74 76 56 36 21 11 1 44 85 76 66 51 31 21 16 11 75 75 55 35 20 10 45 85 75 65 50 30 20 15 10 76 75 55 35 19 9 46 85 75 64 49 30 20 15 9 77 75 54 34 18 8 47 84 74 63 48 29 19 14 8 78 75 54 34 17 7 48 84 74 62 47 29 19 14 7 79 75 53 33 16 6 49 83 73 61 46 28 18 13 6 80 75 53 33 15 5 50 83 73 60 45 28 18 13 5 81 75 52 32 14 4 51 82 72 59 44 27 17 12 4 82 75 52 32 13 3 52 82 72 58 43 27 17 12 3 83 75 51 31 12 2 53 81 71 57 42 26 16 11 2 84 75 51 31 11 1 54 81 71 56 41 26 16 11 85 75 50 30 10 above 85 75 50 30 10
*One MET represents the energy expenditure associated with the consumption of 3.5 mL oxygen/kg body weight/min.
Ratings derived from METs are age adjusted
Functional Loss
Table 1.3
LOSS OF CARDIORESPIRATORY FUNCTION: EXERCISE TOLERANCE
(Females)
Age Symptomatic Activity Level Age Symptomatic Activity Level
(METs*) (METs*)
less
than 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 10+ 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 10+
25 90 80 70 55 40 30 20 15 10 55 80 65 50 30 20 15 10 25 90 80 70 55 40 30 20 15 10 56 80 65 49 29 20 15 9 26 90 80 69 54 40 30 20 15 10 57 80 64 48 28 19 14 8 27 89 79 68 53 39 29 20 15 10 58 80 64 47 27 19 14 7 28 89 79 67 52 39 29 20 15 10 59 80 63 46 26 18 13 6 29 88 78 66 51 38 28 20 15 10 60 80 63 45 25 18 13 5 30 88 78 65 50 38 28 20 15 10 61 80 62 44 24 17 12 4 31 87 77 64 49 37 27 20 15 10 62 80 62 43 23 17 12 3 32 87 77 63 48 37 27 20 15 10 63 80 61 42 22 16 11 2 33 86 76 62 47 36 26 20 15 10 64 80 61 41 21 16 11 34 86 76 61 46 36 26 20 15 10 65 80 60 40 20 15 10 35 85 75 60 45 35 25 20 15 10 66 80 59 39 20 15 9 36 85 75 60 45 34 25 20 15 9 67 79 58 38 19 14 8 37 85 75 60 44 33 24 19 14 8 68 79 57 37 19 14 7 38 85 75 60 44 32 24 19 14 7 69 78 56 36 18 13 6 39 85 75 60 43 31 23 18 13 6 70 78 55 35 18 13 5 40 85 75 60 43 30 23 18 13 5 71 77 54 34 17 12 4 41 85 75 60 42 29 22 17 12 4 72 77 53 33 17 12 3 42 85 75 60 42 28 22 17 12 3 73 76 52 32 16 11 2 43 85 75 60 41 27 21 16 11 2 74 76 51 31 16 11 1 44 85 75 60 41 26 21 16 11 75 75 50 30 15 10 45 85 75 60 40 25 20 15 10 76 75 49 29 15 9 46 85 74 59 39 25 20 15 9 77 75 48 28 14 8 47 84 73 58 38 24 19 14 8 78 75 47 27 14 7 48 84 72 57 37 24 19 14 7 79 75 46 26 13 6 49 83 71 56 36 23 18 13 6 80 75 45 25 13 5 50 83 70 55 35 23 18 13 5 81 75 44 24 12 4 51 82 69 54 34 22 17 12 4 82 75 43 23 12 3 52 82 68 53 33 22 17 12 3 83 75 42 22 11 2 53 81 67 52 32 21 16 11 2 84 75 41 21 11 1 54 81 66 51 31 21 16 11 85 75 40 20 10 above 85 75 40 20 10 *One MET represents the energy expenditure associated with the consumption of
3.5mL oxygen/kg body weight/min.
Ratings derived from METs are age adjusted
FIGURE 1a - PREDICTION NOMOGRAM: MALE (BTPS)
Height FVC FEV
Age
(cm) (litre) (litre)
MEF25-75
(years)
190 20
6
5
5
180 30
5
4
170 40
4
4
3
160 50
150
3
2 3 60
2
140 70
For veterans older than 80 years the various scales are to be extended linearly.
80
This nomogram corresponds to the formulas:
FEV1 = 0.0553 x Height - 0.036 x Age - 4.182
FVC = 0.0713 x Height - 0.0265 x Age - 6.463
MEF25-75 = 2.683 + 0.0195 x Height - 0.043 x Age
FIGURE 1b - PREDICTION NOMOGRAM: FEMALE (BTPS)
Height FVC FEV
Age
(cm) (litre) (litre)
MEF25-75
(years)
180 20
4
170 30
4
3
160 40
3
150
2 50
3
2
0 60
70
For veterans older than 80 years the various scales are to be extended linearly.
80
This nomogram corresponds to the formulas:
FEV1 = 0.0347 x Height - 0.0252 x Age - 1.929
FVC = 0.04315 x Height - 0.02185 x Age - 2.83
MEF25-75 = 2.918 + 0.0125 x Height - 0.034 x Age
Functional Loss
Table 1.4
LOSS OF CARDIORESPIRATORY FUNCTION: PHYSIOLOGICAL MEASUREMENTS
FEV1 FVC MEF25-75
as a as a as a
Impairment percentage percentage percentage
Rating of predicted of predicted of predicted
NIL 85 85 85
TWO 84
SIX 84 84
SEVEN 83
EIGHT 83 83
TEN 82 82
ELEVEN 81 82 81
TWELVE
THIRTEEN 80 80
FOURTEEN 79 81 79
FIFTEEN
SIXTEEN 78 80 78
SEVENTEEN 77 77
EIGHTEEN 76 79 76
NINETEEN
TWENTY 75 78 75
TWENTY-ONE 74 74
TWENTY-TWO 73 77 73
TWENTY-THREE 72 72
TWENTY-FOUR 71 76 71
TWENTY-FIVE
TWENTY-SIX 70 75 70
TWENTY-SEVEN 69 74 69
TWENTY-EIGHT 68 68
TWENTY-NINE 67 73 67
THIRTY 66 72 66
THIRTY-ONE 65 71 65
THIRTY-TWO 64 64
THIRTY-THREE 63 70 63
THIRTY-FOUR 62 69 62
THIRTY-FIVE 61 68 61
THIRTY-SIX 60 67 60
THIRTY-SEVEN 59 59
Ratings derived from this table are age adjusted
(continued next page)
Functional Loss Table 1.4 (cont'd)
LOSS OF CARDIORESPIRATORY FUNCTION: PHYSIOLOGICAL MEASUREMENTS (continued)
FEV1 FVC MEF25-75
as a as a as a
Impairment percentage percentage percentage
Rating of predicted of predicted of predicted
THIRTY-EIGHT 58 66 58
THIRTY-NINE 57 65 57
FORTY 64
FORTY-ONE 56 63 56
FORTY-TWO 55 62 55
FORTY-THREE 54 61 54
FORTY-FOUR 53 60 53
FORTY-FIVE 52 52
FORTY-SIX 51 59 51
FORTY-SEVEN 50 58 50
FORTY-EIGHT 49 57 49
FORTY-NINE 48 56 48
FIFTY 47 55 47
FIFTY-ONE 46 54 46
FIFTY-TWO 45 53 45
FIFTY-THREE 44 52 44
FIFTY-FOUR 43 51 43
FIFTY-FIVE 42 50 42
FIFTY-SIX 41 49 41
FIFTY-SEVEN 40 40
FIFTY-EIGHT 39 48 39
FIFTY-NINE 38 47 38
SIXTY 37 46 37
SIXTY-ONE 36 45 36
SIXTY-TWO 35 44 35
SIXTY-THREE 34 43 34
SIXTY-FOUR 33 42 33
SIXTY-FIVE 32 41 32
SIXTY-SEVEN 30 39 30
SIXTY-EIGHT 29 38 29
SIXTY-NINE 28 37 28
SEVENTY 27 36 27
Ratings derived from this table are age adjusted
Whenever the measured parameter is less than 85% of the predicted, Table 1.4 corresponds to the following formulas:
Impairment rating based on FEV1 = 98-% FEV1 + Impairment rating based on FVC = 108-% FVC +
Impairment rating based on MEF25-75 = 98-% MEF +
50
(% FEV1-90)
100
(%FVC-88.5)
50
(% MEF-90)
When the measured parameter is 85% or more of the predicted, then the impairment rating is defined as NIL
"%FEV1" means measured FEV1 expressed as a percentage of predicted FEV1. "%FVC" means measured FVC expressed as a percentage of predicted FVC.
"%MEF" means measured MEF25-75 expressed as a percentage of predicted
MEF25-75 .
In each case the percentage is to be rounded to the nearest integer before the formula is applied.
If these formulas are applied the resulting impairment rating is always to be rounded to the nearest integer.
Step 5: Calculate the total accepted cardiorespiratory functional impairment rating.
At this stage there will usually be an impairment rating derived from effort tolerance information and there may also be an impairment rating derived from measurements of lung function. These must be combined into a single cardiorespiratory functional impairment rating. The method by which that is to be done is set out in Table 1.5.
For the purposes of Table 1.5, the following abbreviations have been used:
| Abbreviation "FI" | means | Meaning cardiorespiratory functional impairment rating. |
| "No FI" | means | a cardiorespiratory functional impairment rating cannot be calculated from either effort tolerance information or measurements of lung function. |
| "METs" | means | the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from METs alone. |
"Spirometry" means the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from measurements of respiratory function. "average of
means
the average of the cardiorespiratory functional impairment
METs and rating derived from METs alone and the cardiorespiratory Spirometry" functional impairment rating derived from measurements of respiratory function alone using the ordinary formula for averaging two quantities or by use of the nomogram in Figure 1c. In either case, the result is to be rounded to the nearest integer.
Procedural
Table 1.5
CARDIORESPIRATORY FUNCTIONAL IMPAIRMENT
Respiratory disease present No
respiratory disease
Spirometry obtainable
Spirometry
not obtainable
Cardiac disease present METs data obtainable FI = higher of METs and Spirometry FI = METs FI = METs METs data
not obtainable
FI = Spirometry No FI No FI No cardiac disease METs data obtainable FI = average of METs and Spirometry FI = METs METs data
not obtainable
FI = Spirometry No FI
In applying this table, both accepted and nonaccepted conditions are to be taken into account.
No age adjustment permitted for this table
From Table 1.5 it will be seen that:
+if cardiac conditions exist in the absence of respiratory disease, cardiorespiratory functional impairment should be measured by effort tolerance alone;
+if respiratory conditions exist in the absence of cardiac disease, the cardiorespiratory functional impairment rating is the rounded average of (i) impairment as measured by effort tolerance, and (ii) impairment as measured by spirometry;
+if both cardiac and respiratory conditions co-exist, the cardiorespiratory functional impairment rating is the greater of (i) the impairment rating as measured by effort tolerance, and (ii) the impairment rating as measured by spirometry.
In applying these rules, both accepted and non-accepted cardiac and respiratory conditions are to be taken into account.
Only one rating for effort tolerance is to be given irrespective of the number of conditions that contribute to the relevant impairment.
Only one rating is to be given for physiological measurements of lung function irrespective of the number of conditions that contribute to the relevant impairment.
This single "total cardiorespiratory functional impairment" is due to the combined effect of all cardiorespiratory conditions whether accepted or not.
FIGURE 1c - LOSS OF RESPIRATORY FUNCTION RESPIRATORY NOMOGRAM
METs Impairment Rating Impairment Impairment of Physiological Rating Rating Measurements
100 100 100
90 90 90
80 80 80
70 70 70
60 60 60
50 50 50
40 40 40
30 30 30
20 20 20
10 10 10
0 0 0
This nomogram is to be used in accordance with the instructions in Step 5 and the procedural Table 1.5.
Results from this nomogram are to be rounded to the nearest five points. 2.5 is to be rounded up to 5 and 7.5 is to be rounded up to 10.
This nomogram corresponds to the formula:
Impairment
Rating =
METs Impairment Rating + Impairment Rating of Physiological Measurement
2
Step 6: Consider the effects of cardiac failure (if any).
For the purposes of assessment under this Guide, cardiac failure is considered to be a surrogate measure of cardiorespiratory impairment. When cardiac failure is present, the impairment rating calculated using effort tolerance will usually exceed any possible impairment rating from Table 1.6. Table 1.6 is of particular importance in assessing a veteran who is unable to be rated using effort tolerance because of significant conditions such as hemiplegia.
Functional Loss
Table 1.6
Impairment
CARDIAC FAILURE
Ratings Criteria
NIL No cardiac failure; that is, neither symptoms nor
X-ray evidence of cardiac failure.
·No symptoms, but X-ray evidence of early cardiac failure.
·Evidence of right ventricular failure.
FIFTEEN Left or biventricular cardiac failure demonstrated by ejection fraction of between 40% and 60% and persisting despite therapy.
TWENTY Left or biventricular cardiac failure demonstrated on X-ray or by ejection fraction of less than or equal to 40% and persisting despite therapy.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
A rating from Table 1.6 is to be compared with the total cardiorespiratory functional impairment rating (obtained in Step 5) and the higher of the two is to be chosen.
Step 7: Moderate the total cardiorespiratory functional impairment rating to allow for effects of any non-accepted conditions.
Partially contributing impairment
If non-accepted conditions contribute to the impairment, Chapter 19 (Partially Contributing Impairment) is to be applied to determine impairment from the accepted conditions.
If cardiac conditions exist in the absence of respiratory disease: if there is more than one cardiac condition present (for example ischaemic heart disease and a valvular heart disease) and some are accepted and some are not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition.
If a respiratory condition exists in the absence of cardiac disease, the symptomatic activity level will generally be the exercise level (in METs) at which dyspnoea occurs. If there is more than one respiratory condition present and at least one is accepted and at least one is not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition or conditions.
If cardiac and respiratory conditions co-exist, and at least one is accepted and at least one is not accepted, it is necessary to determine the total cardiorespiratory functional impairment rating (as set out in the previous steps), and then to moderate that rating by applying Chapter 19 to determine the impairment due to the accepted condition.
The result that is then derived is the "total accepted cardiorespiratory functional impairment rating".
Step 8: Determine whether any ratings from the cardiorespiratory Other
Impairment tables apply.
Cardiorespiratory Other Impairment tables
Once the total accepted cardiorespiratory functional impairment rating has been determined, it must be compared with the relevant cardiorespiratory Other Impairment tables. For assessment purposes, four categories of cardiorespiratory condition are recognised. These categories are:
+ ischaemic heart disease;
+ valvular heart disease;
+ miscellaneous heart disease; and
+ lower respiratory tract conditions.
There are four cardiorespiratory Other Impairment tables - corresponding to each of the above categories. These tables are:
| Table 1.7 - | Cardiorespiratory Impairment: Ischaemic; |
| Table 1.8 - | Cardiorespiratory Impairment: Valvular; |
| Table 1.9 - | Cardiorespiratory Impairment: Miscellaneous; and |
| Table 1.10 - | Cardiorespiratory Impairment: Respiratory. |
Only one rating is to be selected from each of these cardiorespiratory Other Impairment tables (Tables 1.7, 1.8, 1.9, and 1.10) for any condition or combination of conditions.
If accepted conditions belonging to more than one of the four categories of cardiorespiratory disease above are present, then the relative contribution of their effect on the total accepted cardiorespiratory functional impairment must be estimated by applying Chapter 20 (Apportionment). The rating for each condition will be the higher of the cardiorespiratory functional impairment rating attributed to it and its cardiorespiratory Other Impairment rating.
The cardiorespiratory worksheet (at page 42) should also be consulted.
Other Impairment Table 1.7
CARDIORESPIRATORY IMPAIRMENT: ISCHAEMIC HEART DISEASE
Impairment
Ratings Criteria
NIL No history of symptoms but evidence of transient ischaemia on exercise ECG testing.
·Coronary artery disease, characterised by typical history of angina pectoris.
·Coronary artery disease, characterised by history of uncomplicated myocardial infarct, with no subsequent evidence of cardiac failure and infrequent or no angina.
·Coronary artery disease, with single vessel disease (other than left main coronary) demonstrated on angiogram.
·Coronary artery disease with successful coronary artery surgery, followed by no angina or only infrequent angina but no further infarcts or cardiac failure.
FIFTEEN Coronary artery disease with multi-vessel disease (not successfully corrected) demonstrated on angiogram.
·Coronary artery disease characterised by a history of myocardial infarct followed, immediately or after a lapse of time, by continuing angina or further infarcts.
·Coronary artery disease characterised by left main coronary artery disease (not successfully corrected) demonstrated on angiogram.
·Coronary artery disease with successful coronary artery surgery, followed, after a lapse of time, by frequent angina or further infarcts or cardiac failure.
Only one rating is to be selected from this table for any condi tion or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
Other Impairment Table 1.8
CARDIORESPIRATORY IMPAIRMENT: VALVULAR HEART DISEASE
Impairment
Ratings Criteria
·Mitral valve prolapse with no or minimal symptoms.
·Aortic sclerosis with no or minimal symptoms.
FIVE Diagnosed valvular heart disease (other than mitral valve prolapse or aortic sclerosis) with no symptoms and no X-ray evidence of cardiac failure.
TEN Valvular heart disease with successful valve replace- ment, not requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.
FIFTEEN Valvular heart disease with successful valve replace- ment, requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.
No age adjustment permitted for this table
Only one rating is to be selected from this table for any condi tion or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
Other Impairment Table 1.9
CARDIORESPIRATORY IMPAIRMENT: MISCELLANEOUS
Impairment
Ratings Criteria
NIL Flow murmurs.
TWO Chronic asymptomatic arrhythmia, eg atrial fibril- lation, atrial or ventricular ectopic beats.
FIVE Need for a permanent pacemaker.
No age adjustment permitted for this table
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
Arrhythmias are usually to be rated by applying Chapter 15 (Intermittent Impairment) unless they cause a permanent restriction of exercise tolerance, in which case they are to be assessed by their effect on effort tolerance.
Other Impairment Table 1.10
| Impairment NIL FIVE TEN TWENTY |
CARDIORESPIRATORY IMPAIRMENT: LOWER RESPIRATORY TRACT
Criteria
Asymptomatic pleural plaques.
·Recurrent lower respiratory infections (at least 6 per year).
·Intermittent use of bronchodilator medication.
·Daily use of inhaled steroids required.
·Regular, daily use of bronchodilator medication.
·Chronic cough, with production of at least 50 mL sputum/day.
·Regular, daily use of bronchodilator medication required in addition to daily inhaled steroids.
·Chronic cough, with production of at least 100 mL sputum/day.
Repeated courses (at least several courses per year) or permanent use of oral steroids required.
No age adjustment permitted for this table
Only one rating is to be selected from this table for any condi tion or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
Peripheral Vascular Conditions
Tables 1.2 and 1.3 are to be applied to assess those conditions that affect exercise tolerance from a cardiorespiratory point of view. Peripheral vascular conditions typically cause loss of function of the lower limbs only and therefore are to be assessed under lower limb impairment (using Chapter 3).
Atherosclerosis frequently causes both a cardiorespiratory condition and a peripheral vascular condition. In such cases, if both types of conditions are accepted conditions, then both conditions are to be rated using the appropriate assessment procedure.
The rating of asthma depends on the clinical circumstances. If asthma has caused chronic airways obstruction the method of assessment described in this chapter is to be applied. If there is little fixed obstruction and a large reversible component, the rating is to be based on the occurrence of attacks using the method of intermittent impairment (Chapter 15). Asthma can also be rated, if there is minimal loss of function, from Table 1.10.
Guide to the Assessment of
Rates of Veterans' Pensions
5th edition
Veteran's given names:
Condition(s) accepted for assessment
METs Assessment
Date of report: Age:
Limiting symptoms =
METs level =
METs impairment A
rating:
Cardiorespiratory Worksheet
File No:
Veteran's surname:
Veteran's height: Veterans D.o.B: Gender:
Lung Function Assessment
Date of test: Age:
Actual
Predicted
(Act/Pred) x 100
Impairment (Table 1.4)
Physiological impairment rating (use highest B
assessment value):
Find the accepted functional impairment from values A and B by using Table 1.5
Please note that Partially Contributing Impairment (Chapter 19) may need to be used in calculating the accepted functional impairment.
Was Chapter 19 used? Yes Accepted functional C
No impairment
| D | E | F | G | |
| Category | Relative contribution to functional impairment (as ratio) | Functional impairment for each category (by apportionment) | Applicable Other Impairment rating | Final rating for category (greater of |
| Ischaemic | ||||
| Valvular | ||||
| Other cardiac | ||||
| Respiratory |
The ratings in column G are not to be rounded or combined at this stage They are all to be carried forward to be combined in the final combining of all ratings
Signature Name (Please print) Date
/ /
Chapter 2
Hypertension and Non-Cardiac
Vascular Conditions
This chapter contains three parts:
Part 2.1 - Hypertension Part 2.2 - Vascular Conditions of the Lower Limbs Part 2.3 - Other Non-Cardiac Vascular Conditions
INTRODUCTION
This chapter is to be applied in determining impairment ratings for hypertension and non-cardiac vascular conditions. For conditions affecting the heart itself refer to Chapter 1 (Cardiorespiratory Impairment).
PART 2.1: HYPERTENSION
Hypertension, of itself, does not affect effort tolerance. Therefore, uncomplicated hypertension is not to be assessed under Chapter 1 (Cardiorespiratory Impairment) but in the manner set out below.
Calculation of the impairment rating for hypertension
Follow the steps below to calculate the impairment rating for hypertension.
STEP Establish whether any target organ damage is present. Page
1 44
STEP
2
(Omit this step if there is no target organ damage.)
Calculate the total functional impairment for any accepted target organ damage.
Page
44
STEP Calculate the Other Impairment rating for the accepted Page
3 hypertension by applying Table 2.1.1. 45
STEP (Omit this step if there is no target organ damage.) Page
4 Compare the rating obtained in Step 2 with the rating 46 obtained in Step 3. Take the higher of these two ratings.
Step 1: Establish whether any target organ damage is present.
For the purposes of this chapter, "target organ damage" means any of the following:
+ hypertensive retinopathy, grade III or IV;
+hypertensive cardiac disease, with ECG or X-ray evidence of left ventricular hypertrophy;
+hypertensive nephropathy demonstrated at biopsy, or by presence of proteinuria or elevated serum creatinine level; or
+ hypertensive cerebral haemorrhage.
Certain other conditions have hypertension as a contributing factor in their aetiology (for example: ischaemic heart disease and peripheral vascular disease). Such conditions are not to be regarded as being target organ damage when applying Part 2.1.
Step 2: Calculate the total functional impairment due to any accepted target organ damage.
Accepted hypertensive retinopathy is to be assessed by applying Chapter 8.
If other ophthalmic conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.
Accepted hypertensive cardiac disease is to be assessed by applying Chapter 1.
If other cardiorespiratory conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.
Accepted hypertensive nephropathy is to be assessed by applying Chapter 9.
If other renal conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.
Accepted hypertensive cerebral haemorrhage is to be assessed according to the specific effects of the haemorrhage.
The impairment ratings attributable to the accepted target organ damage are to be combined by applying Chapter 18 (Combined Values Chart) to obtain the total impairment rating for accepted target organ damage.
Target organ damage which is not an accepted condition cannot be assessed under this Guide. Target organ damage can be assessed under this Guide only after it has been claimed and has become an accepted condition.
The criterion in Table 2.1.1 which refers to "hypertension of such a degree that target organ damage is present" is not an assessment of the target organ damage itself but is a measure of the severity of the hypertension.
Step 3: Determine an impairment rating for hypertension from Table 2.1.1.
Other Impairment Table 2.1.1
Impairment
HYPERTENSION
Ratings Criteria
NIL Hypertension adequately controlled by diet and weight loss without long-term medication.
*The first six months immediately following the loss
For purposes of this table, a leg, foot, hand, arm or eye is deemed to be lost if it is rendered permanently and wholly useless.
No age adjustment permitted for this table
INDEX
A
abdominal cramps ....................................... 122 abdominal pain ............................................ 122 ability to concentrate ..................................... 95 accepted condition
definition of ................................................ 2
Accepted Percentage Hearing Loss ............. 128
......................................... 133-134, 154-155 definition of ............................................ 128
Act
definition of ................................................ 1
Activities of Daily Living ............. 115, 169-170
........................ 172, 189, 190, 193, 197, 219 add
definition of ................................................ 2 age adjustment .......................... 8, 9, 54, 58, 65
................ 70, 77, 80, 85, 129, 137-138, 145 agoraphobia ......................................... 267-268 agraphia ............................................... 109-110 air conduction ............... 128, 131-132, 134-138 definition of ............................................ 128 alopecia ....................................................... 192
Alzheimer's disease .................................... 114
Amenorrhoea ............................................... 185 amputation ........... 49, 52, 60-61, 63, 70, 73-75 anaemia .......................................... 17, 197-198 hydrochromic .......................................... 197 pernicious ............................................... 197 refractory ................................................ 198 anal fissure .................................................. 122 angina ...................................................... 21, 39 angina pectoris .............................................. 39 angiogram ..................................................... 39 ankle .............................................................. 66
ankylosis
ankle .................................................... 68-69 elbow ........................................................ 57 hip ........................................................ 68-69 knee ..................................................... 68-69 shoulder .................................................... 57 spine ......................................................... 78 thumb ....................................................... 57 toe ........................................................ 68-69 wrist .......................................................... 57
anticoagulant medication .............................. 40 anxiety .......................................................... 92 aortic sclerosis .............................................. 40 aphakia ................................................ 162, 164
APHL .... See Accepted Percentage hearing Loss apportionment .............................. iv, 10, 38, 42
................... 44, 48-49, 60, 75, 116, 191, 205
................................. 207, 211, 222, 241-245 apraxia ........................................ 55, 58, 66, 70 arrhythmia ..................................................... 40 arthritis .............................................. 17, 20, 75 assessment
elements of ................................................. 5 subject of .................................................... 5 asthma ................................................... 41, 209 atherosclerosis ......................................... 41, 52 atrial fibrillation ............................................ 40 audiogram ..... 129, 131-134, 145-146, 153-157 criteria of reliability ................................ 131
avoidance
definition of ............................................ 226 avoided activities ........................................ 215
B
bilateral conductive deafness .............. 127, 131
........................................ 136, 152, 154, 156 bilateral conductive deafness with right
sensorineural deafness ............................ 131 bilateral mixed deafness ...................... 131, 152 bilateral sensorineural deafness ........... 152, 153 binocular impairment rating ................ 162, 259 blepharoconjunctivitis ................................. 167 blindness ..................................................... 159 bone conduction .... 131-132, 134-138, 153-155 definition of ............................................ 128 breast .......................................................... 187 bronchilator medication ................................ 41 bronchodilation ............................................. 25 bursts of anger .............................................. 93
C
calcaneal spurs .............................................. 76 cancer .................................................. 187, 204 cardiac failure ........................... See heart failure cardiorespiratory impairment ...... 17, 19, 36, 42 cataract ........................................................ 164 cataracts ...................................................... 159 cerebrovascular disease ......................... 52, 114 cervical incompetence ................................. 185
cervical spine ................................................ 77 chemotherapy ............................... 181, 204-205 cholecystectomy .......................................... 124 chondromalacia patellae ................................ 66 chronic airways obstruction .......................... 41 chronic bronchitis .......................................... 19 chronic obstructive respiratory disease ......... 19 circumcision ................................................ 179 claustrophobia ............................................. 268 claw toes ....................................................... 76 climax
inability to achieve .................................. 181 clinical features
definition of ................................................ 2 clitoridectomy ............................................. 181 cognitive function ................................. 103-104 colostomy ............................................ 119, 204 combine
definition of ................................................ 2 combined impairment rating .... 11, 20, 204-205
.................. 210-211, 228, 231-233, 242-243
Combined Values Chart .... iv, 2, 11, 44, 91, 103
................ 114, 124, 149, 160, 162, 173-174
................ 187, 198, 205, 211, 214, 231, 241 communication .................................... 103, 107 comprehension ............................................ 107 compulsive gambling .................................... 93 condition
definition of ................................................ 2 conjunctivitis ............................................... 159 constipation ......................................... 119, 122 contraceptive pill ......................................... 177 side effects of .......................................... 177 coronary artery disease .................................. 39 coronary bypass surgery ................................ 19 corrected visual acuity .................. 159-160, 162
cough
chronic ...................................................... 41 counselling .................................................... 99 cranial nerves .............................................. 112 creatinine clearance ..................................... 171 crush fractures of the vertebrae ..................... 70 cycle .............................................................. 22 cystitis ......................................................... 176
D
defence-caused disease
definition of ................................................ 2 defence-caused injury
definition of ................................................ 2 degree of incapacity .............. vi, 5, 11, 277-279 dementia ............................................ 9, 20, 219 depression ..................................................... 92 diabetes mellitus ......................................... 196 diarrhoea ..................................................... 122 disease
definition of ................................................ 2 disfigurement ............................... 189, 225-228 disfiguring condition
definition of ............................................ 226
objective component ............................... 227 subjective component ............................. 227 dislocation of shoulder ............................. 60-61 disorders of the anus and rectum ................. 119 disorders of the large and small bowel ........ 119 diverticulosis ............................................... 122 domestic and employment activities ..... 272-273
domestic situation
in psychiatric conditions ........................... 96 dressing ............................................... 219, 221 driving a car
in a Grand Prix ......................................... 22 sedately ..................................................... 22 dumping syndrome ...................................... 121 dysgraphia ............................................ 109-110 dysmenorhoea ............................................. 177 dyspepsia .............................................. 89, 119 non-ulcer ................................................. 120 dysphagia .................................................... 117 dysphasia .................................................... 112 dyspnoea ....................................................... 21
E
ears ....................................................... 149-150
ECT .............................................................. 99 ectopic beats
atrial ......................................................... 40 ventricular ................................................. 40 ectropion ............................................. 167, 190 eczema ........................................................ 192 effects of past gastric surgery ...................... 119 effort tolerance ... 18-22, 32, 34, 36, 40, 43, 198 elbow ............................................................. 55 embarrassment ............................... 98, 225-227 employment and domestic activities ..... 263-264 encephalopathy ........................................... 123 endocrine condition .............................. 193-195 endometriosis .............................................. 186 entropion ............................................. 167, 190 epilepsy ....................................................... 114 epiphora ...................................................... 167
Esterman grid ............................... 161-162, 168 exercise tolerance ......................... 17-27, 40-41 females ..................................................... 27 males ........................................................ 26 exfoliative skin disorders ............................ 226 expression ................................................... 107
F
facial scarring .............................................. 226 faecal incontinence ...................................... 119 fatigue ............................................... 21, 58, 70 feeding ................................................ 219, 221
FEV1 ........................................... 17, 25, 32, 42 fingers ........................................................... 55 flail joint
definition of .............................................. 56
flashbacks ..................................................... 92 fractured neck of femur ................................. 66 functional effects
in psychiatric conditions ........................... 94 functional loss
definition .................................................... 5 how measured ............................................. 6
FVC ............................................ 17, 25, 32, 42
G
gait
disorders of ............................................. 226 gall bladder ................................. 115, 119, 124 gastric surgery ............................................. 121 gastrointestinal impairment ......................... 115 gastrostomy ................................................. 118 gaze defects ................................................. 164 genu valgum .................................................. 76 genu varum ................................................... 76 glaucoma ..................................... 159, 161, 164 glomerulonephritis ...................................... 171 glycosuria .................................................... 195 grotesque involuntary bodily movements .... 226 group therapy ................................................ 99
Guide
definition of ................................................ 2 gynaecomastia ............................................. 188
H
haemodialysis .............................................. 170 haemopoietic system ........................... 193, 197 haemorrhoids .............................................. 122 halitosis ....................................................... 120 hallucinations ................................................ 92 hallux valgus ................................................. 76 hammer toes .................................................. 76 headache ........................................................ 89 hearing loss .......................... 107, 127, 129-132
......... 134-136, 145-149, 152, 153, 154, 259 types of ................................................... 130
Hearing Threshold Level ..................... 128, 131 definition of ............................................ 128 heart failure ......................... 18, 36, 39, 50, 219 hemianopia .................................................. 112 hemifacial spasm ......................................... 114
hemiparesis
following stroke ........................................ 20 lower limb ............................................... 112 upper limb .............................................. 112 hemiplegia ............................................... 20, 36 hepatitis ....................................................... 123
hernia
abdominal wall ....................................... 126 hiatus ...................................................... 120 inguinal ................................................... 126 ventral ..................................................... 126
heterophoria ................................................ 164 hip ........................................................... 66, 70 hip replacement ............................................. 74 hospitalisation ............................................... 99 hydrocele ..................................................... 184 hydronephrosis ............................................ 171 hyperglycaemia ........................................... 195 hyperglycaemics, oral .................................. 195 hypertension ....................................... 17, 43-46 hypertensive cardiac disease ......................... 44 hypertensive cerebral haemorrhage .............. 44 hypertensive nephropathy ............................ 44 hypertensive retinopathy .............................. 44 hypnotics ....................................................... 99 hysterectomy ............................................... 185
I
ileostomy ..................................................... 118
Impairment of speech .................................. 150 impairment rating
definition of ................................................ 2 impotence ............................... 89, 179, 183-184
Inability to concentrate .................................. 98 inappropriate actions ..................................... 93 incapacity
definition of ................................................ 2 incontinence ................................................ 175 infertility
females ................................................... 182 males ...................................................... 182
injury
definition of ................................................ 2 instructions
impossible to follow ................................... 9 resolving inconsistency ............................... 9 to be followed ............................................. 6
intermittent attack duration ......................... 213 intermittent attack severity .......................... 212 intermittent condition ..................... 17, 209-214 intermittent grading code ............. 210, 213-214 intermittent impairment ......................... iv, 8, 17
............... 40-41, 89, 113, 115, 121, 123-124
150-151, 173-174, 177, 186, 189, 190, 194-
195, 201, 219
intrusive thoughts .......................................... 92 involuntary facial expressions ..................... 226 irritable bowel ............................................. 122 ischaemic heart disease ...................... 19, 37-38
.......................................... 44, 194, 241, 243
J
jejunostomy ................................................. 118 joints
average range of movements .................... 67 replacements ............................................. 73
K
knee ............................ 17, 66, 68-69, 74-75, 83 knee replacement ........................................... 74
L
left conductive deafness .............. 127, 130, 137
................................................. 137-138, 152 left mixed deafness ............................. 131, 152 left sensorineural deafness ................... 130-131 leisure activities
in psychiatric conditions ........................... 98 leukaemia .................................................... 197 life expectancy
general .................................................... 223 malignant condition ................................ 206 lifestyle effect ........................... 5, 263-264, 279 lifestyle effects ............................................ 5, 7
Lifestyle Questionnaire ............................... 264
Lifestyle Rating Self Assessment Form ............
......................................................... 263-264 liver ............................................................. 119 locomotion .......................................... 219, 221 loss of balance ............................................. 150 loss of concentration ..................................... 92 loss of co-ordination
lower limbs ............................................... 66 loss of gastrointestinal function
faecal excretion ....................................... 116 ingestion of food ..................................... 116 maintenance of nutrition ......................... 116 loss of smell ................................................ 150 loss of speech .............................................. 109 loss of taste ................................................. 150 lower limbs .................................. 20, 41, 47-49
........................................... 65-66, 70-75, 83 lower respiratory tract conditions .................. 37 lumpectomy ................................................. 188 lung function ............................... 17, 20, 25, 32
M
monocular impairment rating ...... 160, 162, 164 motor neurone disease ................................. 114 movement in bed ................................. 219, 221 multiple sclerosis ........................................ 114 muscle weakness ......................... 55, 58, 66, 70 myocardial infarct ......................................... 39
N
nasal conditions ........................................... 151 need to wear corrective lenses ..................... 160 negligible impairment ............................. 6, 201 nephrectomy ................................................ 171 nervous sweating ........................................... 93 neurological conditions 55, 58, 66, 70, 103, 113 neurological impairment ............................. 103 nightmares ................................................ 92-93 nomogram .............................. 25, 28-29, 33, 35 non-accepted conditions ......... 18-19, 37, 56, 58
............... 67, 70, 80, 117-118, 149, 198, 205
................................. 211, 223, 228, 237-238 definition of ................................................ 2 non-cardiac vascular conditions .............. 17, 43 non-system specific assessments .................... 8 nystagmus ................................................... 164
O
obesity ................................................. 115, 126 occupation
in psychiatric conditions ........................... 95 oedema .................................................... 47, 49 oesophagitis ................................................ 120 oesophagostomy .......................................... 118 oral cavity and oesophagus ......................... 119 ordinary public places
definition of ............................................ 226 osteoarthritis ........................................... 17, 75
Other Impairment
definition .................................................... 5 how measured ............................................. 7
malabsorption ............................................. 118 male pattern baldness .................................. 192 malignant condition ..................... iv, 8, 115, 182
................................. 187, 197, 203-207, 219 mammary discharge .................................... 188 manic behaviour ............................................ 93 manifest distress ................................... 93, 100 mastectomy .......................................... 187-188 medical impairment ......................................... 5
MEF 25-75 ................................. 17, 25, 32, 42 menorrhagia ................................................ 185
METs ....................... 17, 21-24, 32, 37, 42, 241 mitral valve prolapse ..................................... 40 mobility ................................ 263-264, 267-268 monocular assessment .......... 160-162, 164, 259
P
pain
how assessed .............................................. 9 in joints ..................................................... 83 sciatic ............................................. 71-72, 83 paired organs policy ............... 11, 129, 147-148
........................................ 155, 157, 166, 259 palpitations ................................................... 21 pancreas ...................................................... 119 pancreatic disease ........................................ 123 pancreatitis .................................................. 123 partially contributing impairment .............. iv, 18
...... 19, 37, 42, 44, 48-49, 56, 58, 67, 70, 73
.......... 78-81, 84, 89-91, 149, 191, 198, 205,
......................... 211, 222, 225, 228, 237-238
penis ............................................................ 179 percentage bilateral loss of hearing due
to age .......................................................... 146 percentage loss of weight ............................ 117 percentage unilateral loss of hearing due
to age .......................................................... 146 peripheral neuropathy .................................. 111 peripheral vascular disease ........... 44, 47-49, 75 peritoneal dialysis ....................................... 170 perseveration ................................................. 93 personal hygiene ........................... 94, 219, 221 personal relationships ...... 96-97, 264, 266-267 pes planus ..................................................... 76
Peyronie's disease ....................................... 179 photophobia ................................................ 167 pleural plaques .............................................. 41 polycythaemia ............................................. 197 position of function
definition of .............................................. 56 post ejaculatory pain ................................... 179 posture
disorders of ............................................. 226 precluded activities ..................................... 215 premenstrual tension ................................... 177 premorbid weight ........................................ 117 preoccupation ................................................ 93 presbyacusis ................. 128, 145-146, 153-155 definition of ............................................ 128 pressured speech ........................................... 93 pruritus ........................................................ 192 pruritus ani .................................................. 122 psoriasis ...................................................... 192 psychiatric conditions .............................. 89-91 ptosis ........................................................... 167 pyelonephritis .............................................. 171
right sensorineural deafness ......... 130-131, 152
Rinne's test ................................................. 132 rowing machines ........................................... 22
S
salpingitis .................................................... 185 sedatives ........................................................ 99 self assessment of lifestyle rating ................ 263 sensory function ........................... 103, 111-112 sensory loss ............................................ 82, 111 sequelae
distinguished from conditions ..................... 8 sexual function ..................... 112, 178-182, 193 sexual sensation .......................................... 181 shoulder ............................................. 55, 60, 83 skin condition ............................... 189-191, 225 small airways disease .................................... 19 social impairment ........................................ 225 social interaction
in psychiatric conditions ........................... 97 solar skin lesions ......................................... 192 specific disabilities ... 11, 53, 109-110, 225, 279 spinal column ................................................ 77 spinal cord ..................................................... 77 spine ..................................... 53, 56, 77-82, 204 spirometry ........................... 10, 14, 20, 33, 241
Statement of Principles
definition of ................................................ 2 steatorrhoea ................................................. 123 steroids .......................................................... 41 subjective distress ................................. 92, 100 substance abuse ............................................. 90 suffering
how assessed .............................................. 9
Q
quadriplegia .................................................. 20
R
radiotherapy ......................... 182, 187, 204-205 range of movement ............................. 54-56, 58
........................................... 65-67, 70, 77-84 recreational and community activities
......................................... 263-264, 270-271 reduced fertility
females ................................................... 183 males ...................................................... 183 reflux ........................................................... 120 refractive error ..................................... 159-161 renal function ............................... 169-170, 259 renal stones ................................................. 171 renal transplant ........................................... 171 restless pacing ............................................... 93 right conductive deafness .................... 127, 130
................................................. 136-138, 152 right mixed deafness ........................... 131, 152
T
tables
age adjustment ............................................ 8 gender indicators ........................................ 8 impairment rating values ............................ 6 numbering of .............................................. 7 types of ....................................................... 7 use of .......................................................... 6 target organ damage ................................. 43-46 tarsorrhaphy ................................................ 167
testes
loss of ..................................................... 184 thoraco-lumbar spine ......................... 77-80, 82
Threshold of Reliability ....................... 135-136 thumb ...................................................... 55, 64 tibial osteotomy ............................................. 74 tic douloureux ............................................. 114 time reference
in assessments .......................................... 10 in tests ...................................................... 10 tinea ............................................................ 192 tinnitus ................................................ 127, 149 toes ................................................................ 66
torn medial meniscus ..................................... 66
Total Bilateral Hearing Loss
definition of ............................................ 128 transfer
activities of daily living .......................... 221 activities of daily living, definition of ..... 219 lower limb function, definition of ............. 70 transfers .............................................. 219, 221 transient ischaemia ........................................ 39 treadmill ........................................................ 22
treatment
side effects, permanent ............................. 10 side effects, persistent ............................... 10 tremor .................................... 55, 58, 66, 70, 93 tubal ligation ............................................... 185
U
ulcer
duodenal ................................................. 119 gastric ..................................................... 119 peptic .............................................. 119, 121
unfavourable position
definition of .............................................. 56 upper limb .......... 54-56, 58, 60, 63-64, 83, 113 upper respiratory tract conditions ............... 151 urethral stricture .......................................... 175 urinary diversion ......................................... 175 urinary tract .................................. 169, 173-174
definition of ................................................ 6 worksheet
cardiorespiratory ................................. 38, 42 definition of ................................................ 2 emotional and behavioural ............... 100-101 hearing loss, how to use .......................... 129 hearing loss, index .................................. 152 hearing loss, their use ............................. 129 intermittent impairment .......................... 217 spine and limbs ......................................... 87 visual impairment ................................... 168 visual impairment, how to use . 160, 165-166 wrist .............................................................. 55
V
vaginal intercourse
persistent inability to participate in ........ 180 valve replacement .......................................... 40 valvular heart disease .............................. 37, 40 varicocele .................................................... 184 varicose ulcers ............................................... 49 varicose veins .................................... 17, 47, 49 vascular conditions of the lower limbs .......... 43
............................................................. 47-49 vascular leg ulcers ......................................... 47 veteran
definition of ................................................ 2 vile odours ................................................... 226 visual acuity ......................... 159-162, 164, 168 visual field defect ................................. 159-162 visual field loss ........................................... 161 visual function .............................. 159-160, 164 vulvectomy .................................................. 181
w
war-caused disease
definition of ................................................ 2 war-caused injury
definition of ................................................ 2 whole person impairment
NOTES
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