Guidelines For Evaluation of Permanent Impairment

Queensland’s Guidelines for evaluation
of permanent impairment, 2nd edition
Current as of 1 July 2016

Published 1 July 2016.
Approved for publication by the Workers’ Compensation Regulator.
Questions about this publication should be directed to:
Workers’ Compensation Regulator

Office of Industrial Relations
Queensland Treasury
PO Box 69
Brisbane QLD 4001
Phone: 1300 362 128

Website: https://www.worksafe.qld.gov.au/
Disclaimer
This publication contains information regarding work health and safety, injury management and workers
compensation. It includes some of the obligations required under workers compensation and work health
and safety legislation that is administered by the Queensland Treasury. To ensure compliance with legal
obligations refer to the appropriate Acts.
This publication may refer to legislation that has been amended or repealed. When reading this
publication you should always refer to the latest laws. Information on the latest laws can be checked at
the Queensland legislation website - https://www.legislation.qld.gov.au/
© The State of Queensland (Queensland Treasury) 2016.

The Queensland Government supports and encourages the dissemination and exchange of information.
However, copyright protects this document. The State of Queensland has no objection to this material
being reproduced, made available online or electronically but only if it is recognised as the owner of
the copyright and this material remains unaltered. Copyright enquiries about this publication should be
directed to Queensland Treasury,
GPO Box 69, Brisbane, QLD 4001.
Table of Contents
Foreword…………………………………………………………… 1
1. Introduction…………………………………………………… 2
2. Upper extremity………………………………………………. 11
3. Lower extremity………………………………………………. 15
4. The spine………………………………………………………. 28
5. Nervous system………………………………………………...36
6. Ear, nose, throat and related structures…………………….. 40
7. Urinary and reproductive systems…………………………... 44
8. Respiratory system…………………………………………… 48
9. Hearing………………………………………………………... 50
10. The visual system……………………………………………... 65
11. Psychiatric and psychological disorders……………………. 66
12. Haematopoietic system……………………………………….. 74
13. The endocrine system………………………………………… 76
14. The skin……………………………………………………….. 87
15. Cardiovascular system……………………………………….. 93
16. Digestive system…………………………………………….... 94
17. Evaluation of permanent impairment arising from chronic
Pain…………………………………………………………… 96
Appendix 1: Key definitions……………………………………... 99
Appendix 2: Working groups on permanent impairment……... 100
Foreword
Queensland’s Guidelines for Evaluation of Permanent Impairment (the Queensland Guide)
are issued for the purpose of assessing the degree of permanent impairment that arises from
an injury or disease within the context of workers’ compensation. When a person sustains a
permanent impairment it is intended that the Queensland Guide be used by medical assessors
trained in the evaluation of permanent impairment to ensure an objective, fair and consistent
method for evaluating the degree of impairment.
The Queensland Guide is based on a template guide that was developed through a national
process facilitated by Safe Work Australia. This national guide was initially developed for use
in the New South Wales workers’ compensation system and incorporates numerous
improvements identified by the WorkCover NSW Whole Person Impairment Coordinating
Committee over its 13 years of continuous use. The many hours of dedication and thoughtful
consideration that members of the WorkCover NSW Whole Person Impairment Coordinating
Committee and South Australia Permanent Impairment Committee have given to the review
and improvement of the provisions in this Guide that have been adapted into this version of
the Queensland Guide is acknowledged and greatly appreciated (see Appendix 2).
The methodology in the Queensland Guide is largely based on the American Medical
Association’s Guides to the Evaluation of Permanent Impairment, Fifth Edition (AMA5). The
AMA Guides are the most authoritative and widely used source for evaluating permanent
impairment around the world. Extensive work by eminent Australian medical specialists
representing Australian medical associations and Colleges has gone into reviewing the AMA5
to ensure they are aligned with clinical practice in Australia.
The Queensland Guide consist of an introductory chapter followed by a dedicated chapter for
each body system.
The Introduction is divided into three parts. The first part outlines the background and
development of the Queensland Guide including reference to the relevant legislative
instrument that gives effect its use in Queensland’s scheme. The second part covers general
assessment principles intended for the use of medical practitioners who are applying the
Queensland Guide in their assessment of permanent impairment that results from a work
related injury or disease. The third part addresses administrative issues relating to the use of
the Queensland Guide.
As the template national guide has been progressively adapted from the original NSW Guide
and is to be adopted by other jurisdictions, some aspects have been necessarily modified and
generalised. Some provisions may differ between different jurisdictions, for further
information please see the Comparison of Workers’ Compensation Arrangements in Australia
and New Zealand report, which is available on Safe Work Australia’s website.
Publications such as this only remain useful to the extent that they meet the needs of users and
those injured who sustain a permanent impairment. It is therefore important that the protocols
set out in the Queensland Guide are applied consistently and methodically. Any difficulties or
anomalies need to be addressed through modification of the publication and not by
idiosyncratic reinterpretation of any part. All queries about the Queensland Guide or
suggestions for improvement should be addressed to the Office of Industrial Relations at:
wcpolicy@justice.qld.gov.au or PO Box 69, Brisbane QLD 4001.
Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 1 of 103

1. Introduction
PART 1 – INTENT AND LEGISLATIVE BASIS FOR THE QUEENSLAND GUIDE
1.1 Queensland’s Guidelines for Evaluation of Permanent Impairment (the Queensland

Guide) is approved by the Workers’ Compensation Regulator under section 183 of the
Workers’ Compensation and Rehabilitation Act 2003 (the WCR Act) and is to be used
within Queensland’s workers’ compensation scheme to evaluate and decide the degree
of permanent impairment arising from work-related injuries or diseases, in accordance
with section 179 of the WCR Act.
The Queensland Guide adopts the fifth edition of the American Medical Association’s
Guides to the Evaluation of Permanent Impairment (AMA5) in most cases. Where
there is any deviation, the difference is defined in the Queensland Guide and the
procedures contained therein are to prevail if there is any inconsistency with AMA5.
Date of Effect
1.2 The Queensland Guide applies to the assessment of impairments arising from all
injuries incurred on or after 15 October 2013.
When conducting a permanent impairment assessment in accordance with the

Queensland Guide, assessors are required to use the version current at the time of the
assessment.
Development of this Guide
1.3 This Guide is based on a template guide that was developed through a national process
facilitated by Safe Work Australia. The template national guide is based on a similar
set of guidelines that was developed and used extensively in the New South Wales’
workers compensation system. Consequently provisions of the Queensland Guide are
the result of extensive and in-depth deliberations by groups of medical specialists
convened to review the AMA5 in the Australian workers’ compensation context. It
has been adopted for use in multiple Australian jurisdictions.
1.4 Use of the Queensland Guide is monitored by the jurisdictions that have adopted it and
may be reviewed if significant anomalies or insurmountable difficulties in their use
become apparent.
1.5 The Queensland Guide is intended to assist a suitably qualified and experienced
medical practitioner or assessor to assess a claimant’s degree of permanent
impairment.
PART 2 – PRINCIPLES OF ASSESSMENT
1.6 The following is a basic summary of some key principles of permanent impairment
assessments:
(a) Assessing permanent impairment involves clinical assessment of the claimant as

they present on the day of assessment taking account of the claimant’s relevant
medical history and all available relevant medical information in order to
determine:
 Whether the condition is stable and stationary;

 Whether the claimant’s compensable injury/condition has resulted in an
impairment;
 Whether the resultant impairment is permanent;
 The degree of permanent impairment that results from the injury; and
 The proportion of permanent impairment due to a previous impairment, if
any, in accordance with diagnostic and other objective criteria as outlined
in this Guide.
(b) Assessors are required to exercise their clinical judgement in determining a

diagnosis when assessing permanent impairment and when making deductions for
pre-existing impairments.
(c) In calculating the final level of impairment, the assessor needs to clarify the degree
of impairment that results from the compensable injury/condition. Any deductions
for pre-existing impairments are to be clearly identified in the report and
calculated. If, in an unusual situation, a related injury/condition has not previously
been identified, an assessor should record the nature of any previously unidentified
injury/condition in their report and specify the causal connection to the relevant
compensable injury or medical condition.
(d) The referral for an assessment of permanent impairment is to make clear to the
assessor the injury or medical condition for which an assessment is sought – see
also paragraphs 1.43 and 1.44.
1.7 Medical assessors are expected to be familiar with Chapters 1 and 2 of the AMA5 in
addition to the information contained in this Introduction.
1.8 The degree of permanent impairment that results from the injury/condition must be
determined using the tables, graphs and methodology given in this Guide or the AMA5
or any other methodology referred to in this guide, where appropriate.
1.9 This Guide may specify more than one method that assessors can use to establish the
degree of a claimant’s permanent impairment. In that case, assessors should use the
method that yields the highest degree of permanent impairment. (This does not apply
to gait derangement - see paragraphs 3.5 and 3.10).
Body systems covered by this Guide
1.10 The AMA5 is used for most body systems, with the exception of psychiatric and
psychological disorders, chronic pain, visual and hearing injuries.
1.11 The AMA5 chapter on Mental and Behavioural Disorders (Chapter 14) is omitted. The
Queensland Guide contain a substitute chapter on the assessment of psychiatric and
psychological disorders (Chapter 11) which was written by a group of Australian
psychiatrists.
1.12 The AMA5 chapter on pain (Chapter 18) is excluded entirely at the present time.
Conditions associated with chronic pain should be assessed on the basis of the
underlying diagnosed condition, and not on the basis of the chronic pain. Where pain
is commonly associated with a condition, an allowance is made in the degree of
impairment assigned in the Queensland Guide. Complex regional pain syndrome
should be assessed in accordance with Chapter 17 of the Queensland Guide.

1.13 On the advice of medical specialists (ophthalmologists), assessments of visual injuries
are conducted according to American Medical Association Guides to the Evaluation
of Permanent Impairment, 4th Edition (AMA4).
1.14 Evaluation of permanent impairment due to hearing loss adopts the methodology
indicated in the Queensland Guide (Chapter 9) with some reference to the AMA5
(Chapter 11, pp 245–251) but uses National Acoustic Laboratory (NAL) Tables from
the NAL Report No 118, Improved Procedure for Determining Percentage Loss of
Hearing, January 1988.
Stable and stationary
1.15 Assessments are only to be conducted when the medical assessor considers that the
degree of permanent impairment of the claimant is unlikely to improve further and is
stable and stationary. This is considered to occur when the worker’s condition is well
stabilised and is unlikely to change substantially in the next year with or without
medical treatment.
1.16 If the medical assessor considers that the claimant’s treatment has been inadequate and
maximum medical improvement has not been achieved, the assessment should be
deferred and comment made on the value of additional/different treatment and/or
rehabilitation – subject to paragraph 1.34.
Multiple impairments
1.17 Impairments arising from the same injury are to be assessed together. Impairments that
result from more than one injury arising out of the same incident are to be assessed
together to calculate the degree of permanent impairment of the claimant.
1.18 The Combined Values Chart (pp 604-606, AMA5) is used to derive a % WPI that
arises from multiple impairments. An explanation of its use is found on pp 9-10 of the
AMA5. When combining more than two impairments, the Assessor should commence
with the highest impairment and combine with the next highest and so on.
1.19 The exception to this rule is in the case of psychiatric or psychological injuries. Where
applicable, impairments arising from primary psychological and psychiatric injuries
are to be assessed separately from the degree of impairment that results from any
physical injuries arising out of the same incident. The results of the two assessments
cannot be combined.
1.20 In the case of a complex injury, where different medical assessors are required to
assess different body systems, a ‘lead assessor’ should be nominated to coordinate and
calculate the final degree of permanent impairment as a percentage of whole person
impairment (% WPI) resulting from the individual assessments.
Psychiatric/ psychological injuries
1.21 Psychiatric and psychological injuries in Queensland are defined as including both
primary and secondary psychological injuries.
1.22 As referenced in paragraph 1.19, impairments arising from psychological and

psychiatric injuries are to be assessed separately from the degree of impairment that

results from any physical injuries arising out of the same incident. The results of the
two assessments cannot be combined.
Conditions which are not covered in this Guide – equivalent or analogous conditions
1.23 The AMA5 (p11) states: “Given the range, evolution and discovery of new medical
conditions, this Guide cannot provide an impairment rating for all impairments ... In
situations where impairment ratings are not provided, the Guidelines suggest that
medical practitioners use clinical judgment, comparing measurable impairment
resulting from the unlisted condition to measurable impairment resulting from similar
conditions with similar impairment of function in performing activities of daily
living.” The assessor must stay within the body part/region when using analogy.
The assessor’s judgment, based upon experience, training, skill, thoroughness in

clinical evaluation, and ability to apply the Guidelines criteria as intended, will enable
an appropriate and reproducible assessment to be made of clinical impairment.”
Activities of Daily Living
1.24 Many tables in the AMA5 (e.g. spine section) give class values for particular
impairments, with a range of possible impairment values within each class.
Commonly, the tables require the assessor to consider the impact of the injury/illness
on activities of daily living in determining the precise impairment value. The activities
of daily living which should be considered, if relevant, are listed in Table 1-2, p4, of
the AMA5. The impact of the injury on activities of daily living is not considered in
assessments of the upper or lower extremities.
1.25 The assessment of the impact of the injury/condition on activities of daily living should
be verified wherever possible by reference to objective assessments, for example,
physiotherapist or occupational therapist functional assessments and other medical
reports.
Rounding
1.26 Occasionally the methods of this Guide will result in an impairment value which is not
a whole number (e.g. an assessment of peripheral nerve impairment in the upper
extremity). All such values must be rounded to the nearest whole number before
moving from one degree of impairment to the next (e.g. from finger impairment to
hand impairment, or from hand impairment to upper extremity impairment) or from a
regional impairment to a whole person impairment. Figures should also be rounded
before using the combination tables. This will ensure that the final whole person
impairment will always be a whole number. The usual mathematical convention is
followed where rounding occurs - values less than 0.5 are rounded down to the nearest
whole number and values of 0.5 and above are rounded up to the next whole number.
The method of calculating levels of binaural hearing loss is shown in Chapter 9,
paragraph 9.15 in this Guide.
Deductions for pre-existing impairment
1.27 The degree of permanent impairment resulting from pre-existing impairments should
not be included in the final calculation of permanent impairment if those impairments
are not related to the compensable injury. The assessor needs to take account of all

available evidence to calculate the degree of permanent impairment that pre-existed
the injury.
1.28 In assessing the degree of permanent impairment resulting from the compensable
injury/condition, the assessor is to indicate the degree of impairment due to any
previous injury, pre-existing condition or abnormality. This proportion is known as
“the deductible proportion” and should be deducted from the degree of permanent
impairment determined by the assessor. For the injury being assessed, the deduction
is 1/10th of the assessed impairment, unless at odds with the available evidence.
Adjustment for the effects of orthoses and prostheses
1.29 Assessments of permanent impairment are to be conducted without assistive devices,

except where these cannot be removed. The assessor will need to make an estimate as
to what is the degree of impairment, without such a device, if it cannot be removed for
examination purposes. Further details may be obtained in the relevant chapters of this
Guide.
1.30 Impairment of vision should be measured with the claimant wearing their prescribed
corrective spectacles and/or contact lenses, if this was usual for them before the injury.
If, as a result of the injury, the claimant has been prescribed corrective spectacles
and/or contact lenses for the first time, or different spectacles and/or contact lenses
than those prescribed pre-injury, the difference should be accounted for in the
assessment of permanent impairment.
Adjustment for the effects of treatment
1.31 In circumstances where the treatment of a condition leads to a further, secondary

impairment, other than a secondary psychological impairment, the assessor should use
the appropriate parts of this Guide to evaluate the effects of treatment, and use the
Combined Values Chart (pp 604-606 AMA5) to arrive at a final percentage Whole
Person Impairment.
1.32 Where the effective long term treatment of an illness or injury results in apparent
substantial or total elimination of the claimant’s permanent impairment, but the
claimant is likely to revert to the original degree of impairment if treatment is
withdrawn, the assessor may increase the percentage of whole person impairment by
1, 2 or 3% WPI. This percentage should be combined with any other impairment
percentage, using the Combined Values Chart. This paragraph does not apply to the
use of analgesics or anti-inflammatory medication for pain relief.
1.33 Where a claimant has declined treatment which the assessor believes would be
beneficial, the impairment rating should be neither increased nor decreased – see
paragraph 1.35 for further details.
Refusal of treatment
1.34 If the claimant has been offered, but has refused, additional or alternative medical
treatment that the assessor considers is likely to improve the claimant's condition, the
medical assessor should evaluate the current condition, without consideration of
potential changes associated with the proposed treatment. The assessor may note the
potential for improvement in the claimant's condition in the evaluation report, and the

reasons for refusal by the claimant, but should not adjust the level of impairment on
the basis of the claimant's decision.
Future deterioration of a condition
1.35 Similarly, if a medical assessor forms the opinion that the claimant's condition is stable
for the next year, but that it may deteriorate in the long term, the assessor should make
no allowance for this deterioration but notes its likelihood in the report.
Inconsistent presentation
1.36 The AMA5 states: “Consistency tests are designed to ensure reproducibility and
greater accuracy. These measurements, such as one that checks the individual’s range
of motion are good but imperfect indicators of people’s efforts. The assessor must use
their entire range of clinical skill and judgment when assessing whether or not the
measurements or test results are plausible and consistent with the impairment being
evaluated. If, in spite of an observation or test result, the medical evidence appears
insufficient to verify that an impairment of a certain magnitude exists, the assessor
may modify the impairment rating accordingly and then describe and explain the
reason for the modification in writing.” (p 19). This paragraph applies to inconsistent
presentation only.
Ordering of additional investigations
1.37 As a general principle, the assessor should not order additional radiographic or other
investigations purely for the purpose of conducting an assessment of permanent
impairment.
1.38 However, if the investigations previously undertaken are not as required by this Guide
or are inadequate for a proper assessment to be made, the medical assessor should
consider the value of proceeding with the evaluation of permanent impairment without
adequate investigations.
1.39 In circumstances where the assessor considers that further investigation is essential for
a comprehensive evaluation to be undertaken and deferral of the evaluation would
considerably inconvenience the claimant (e.g. when the claimant has travelled from a
country region specifically for the assessment), the assessor may proceed to order the
appropriate investigations provided that there is no undue risk to the claimant. The
approval of the referring body for the additional investigation will be required to
ensure that the costs of the test are met promptly.
PART 3 – ADMINISTRATIVE PROCESS
Medical Assessors
1.40 An assessor will be a medical practitioner with qualifications, training and experience
relevant to the body system being assessed who has undertaken the requisite training
in use of this Guide. For the purpose of industrial deafness assessments, the assessor

may be a registered audiologist who has undertaken the requisite training in the use of
this Guide.
1.41 Assessors may be one of the claimant’s treating practitioners or an assessor engaged
to conduct an assessment for the purposes of determining the degree of permanent
impairment.
Information required for assessments
1.42 Information for claimants regarding independent medical examinations and

assessments of permanent impairment should be supplied by the referring body when
advising the appointment details.
1.43 On referral, the medical assessor should also be provided with all other relevant
medical and allied health information, including results of all clinical investigations
related to the injury/condition in question.
1.44 Most importantly, assessors must have available to them all information about the
onset, subsequent treatment, relevant diagnostic tests, and functional assessments of
the person claiming a permanent impairment. The absence of required information
could result in an assessment being discontinued or deferred. Section 1.5 of Chapter 1
of the AMA5 (p10) applies to the conduct of assessments and expands on this concept.
1.45 This Guide and the AMA5 indicate the information and investigations that are required
to arrive at a diagnosis and to measure permanent impairment. Assessors must apply
the approach outlined in this Guide. Referrers must consult this publication to gain an
understanding of the information that should be provided to the assessor in order to
conduct a comprehensive evaluation.
Reports
1.46 A report of the evaluation of permanent impairment should be accurate,

comprehensive and fair. It should clearly address the question/s being asked of the
assessor. In general, the assessor will be requested to address issues of:
 current clinical status, including the basis for determining whether the injury is
stable and stationary;
 the degree of permanent impairment that results from the injury/condition; and
 the proportion of permanent impairment due to any previous impairment, if
applicable.
1.47 The report should contain factual information based on all available medical
information and results of investigations, the assessor’s own history taking and clinical
examination. The other reports or investigations that are relied upon in arriving at an
opinion should be appropriately referenced in the assessor’s report.
1.48 As this Guide is to be used to assess permanent impairment, the report of the evaluation
should provide a rationale consistent with the methodology and content of this Guide.
It should include a comparison of the key findings of the evaluation with the
impairment criteria in this Guide. If the evaluation was conducted in the absence of

any pertinent data or information, the assessor should indicate how the impairment
rating was determined with limited data.
1.49 The assessed degree of permanent impairment is to be expressed as a % WPI.
1.50 The report should include a conclusion of the assessor, including the final % WPI.
This is to be included as the final paragraph in the body of the report, and not as a
separate report or appendix.
The report must state the matters taken into account, and the weight given to the
matters, in deciding the degree of permanent impairment. The report should contain:
 a medical history
 clinical evaluation details such as the range of movement, neurological
findings and any relevant investigations
 whether the injury is stable and stationary, that is, the worker’s condition is
well stabilised and is unlikely to change substantially in the next year with or
without further medical or surgical treatment
 methodology used (with reference to AMA Guides chapter, section and table)
 conclusions with reasons
 the nature of the permanent impairment (description of work related medical
injury/illness) and calculated applicable % WPI
 any other issues which are relevant to the impairment assessment, for example,
whether the clinical findings and/or degree of impairment is medically
consistent with the injury’s stated mechanism; and
 any pre-existing impairment considerations.
Assessors should not comment on whether the claim should have been accepted or not.
This is not in the scope of the impairment assessment. Once the insurer has accepted
the claim, the decision cannot be reversed even with medical evidence to the contrary.
Assessors are to use whatever reporting template is provided by the insurer or referring
body. A suggested DPI report template complying with these instructions is available
at www.worksafe.qld.gov.au.
Reports that comply with these requirements are paid at a higher level than other
assessment reports. If the assessment report does not comply, the insurer or referring
body may request further details before payment is processed.
1.51 Reports are to be provided within ten working days of the assessment being completed,
or as agreed between the referrer and the assessor.
Quality assurance
1.52 The degree of permanent impairment that results from the injury must be determined
using the tables, graphs and methodology given in this Guide, as presented in the
training in the use of this Guide and the applicable legislation. If it is not clear that a

report has been completed in accordance with this Guide, clarification may be sought
from the assessor who prepared the report.
1.53 An assessor who is identified as frequently providing reports that are not in accord
with this Guide may be asked to show cause as to why their name should not be
removed from the list of trained assessors.
Code of conduct
1.54 Assessors are referred to the Medical Board of Australia’s Good Medical Practice: A
Code of Conduct for Doctors in Australia, 8.7 Medico- legal, insurance and other
assessments.
1.55 Assessors are reminded that they have an obligation to act in an ethical, professional
and considerate manner when examining a claimant for the determination of
permanent impairment.
1.56 Effective communication is vital to ensure that the claimant is well-informed and able
to maximally cooperate in the process. Assessors should:
 Ensure that the claimant understands who the assessor is and the assessor’s role in
the evaluation;
 Ensure that the claimant understands how the evaluation will proceed;
 Take reasonable steps to preserve the privacy and modesty of the claimant during
the evaluation; and
 Not provide any opinion to the claimant about their claim.
1.57 Complaints received in relation to the behaviour of an assessor during an evaluation

initially will be handled by the referring insurer or body. If complaints recur or the
initial review reveals that a problem potentially exists, the complaint will be referred
to the Workers’ Compensation Regulator, who may refer the matter to the appropriate
agency (either the Australian Health Practitioner Regulations Agency or the
Audiology registration body) for its investigation and appropriate action.
Disputes over assessed degree of permanent impairment
1.58 If inconsistencies are identified between a DPI report and the provisions Queensland
Guide, the insurer should resolve or clarify the inconsistency directly with the author/s
of the report in the first instance.
1.59 If a worker disagrees with their assessed degree of impairment, the worker must advise
the insurer within 20 business days after the insurer issues the notice of assessment
that the worker does not agree with the assessment. All DPI decisions of the Medical
Assessment Tribunals are final.

2. Upper extremity
Chapter 16, AMA5 (page 433) applies to the assessment of permanent impairment of the
upper extremities, subject to the modifications set out below. Before undertaking an
impairment assessment, users of this Guide must be familiar with the following:
 The Introduction in this Guide
 Chapters 1 and 2 of AMA5
 The appropriate chapter/s of this Guide for the body system they are assessing.
 The appropriate chapter/s of AMA5 for the body system they are assessing.
The provisions in this Guide take precedence over AMA5.
Introduction
2.1 The upper extremities are discussed in AMA5, chapter 16 (pp 433-521). This chapter
provides guidelines on methods of assessing permanent impairment involving these
structures. It is a complex chapter that requires an organised approach with careful
documentation of findings.
2.2 Evaluation of anatomical impairment forms the basis for upper extremity impairment
assessment. The ratings reflect the degree of impairment and its impact on the ability
of the person to perform ADL. There can be clinical conditions where evaluation of
impairment may be difficult. Such conditions are evaluated by their effect on function
of the upper extremity, or, if all else fails, by analogy with other impairments that have
similar effects on upper limb function.
The approach to assessment of the upper extremity and hand
2.3 Assessment of the upper extremity mainly involves clinical evaluation. Cosmetic and
functional evaluations are performed in some situations. The impairment must be
permanent and stable. The claimant will have a defined diagnosis that can be
confirmed by examination.
2.4 The assessed impairment of a part or region can never exceed the impairment due to
amputation of that part or region. For an upper limb, therefore, the maximum
evaluation is 60 per cent WPI, the value for amputation through the shoulder.
2.5 Range of motion is assessed as follows:

 A goniometer or inclinometer must be used where clinically indicated.
 Passive range of motion may form part of the clinical examination to ascertain
clinical status of the joint, but impairment should only be calculated using
active range of motion measurements. Impairment values for degree
measurements falling between those listed must be adjusted or interpolated.
 If the assessor is not satisfied that the results of a measurement are reliable,
repeated testing may be helpful in this situation.
 If there is inconsistency in range of motion then it should not be used as a valid
parameter of impairment evaluation. Refer to section 1.36 of this Guide.
 If range of motion measurements at examination cannot be used as a valid
parameter of impairment evaluation, the assessor should then use discretion in
considering what weight to give other available evidence to determine if an
impairment is present.

2.6 To achieve an accurate and comprehensive assessment of the upper extremity, findings
should be documented on a standard form. AMA5 figures 16-1a and 16-1b (pp 436-
437) are extremely useful both to document findings and to guide the assessment
process.
2.7 The hand and upper extremity are divided into regions: thumb, fingers, wrist, elbow,
and shoulder. Close attention needs to be paid to the instructions in figures 16-1a and
16-1b (pp 436-437 AMA5) regarding adding or combining impairments.
2.8 Table 16-3 (p 439 AMA5) is used to convert upper extremity impairment to WPI.
When the combined values chart is used, the assessor must ensure that all values
combined are in the same category of impairment (that is WPI, upper extremity
impairment percentage, hand impairment percentage and so on). Regional
impairments of the same limb (e.g. several upper extremity impairments), should be
combined before converting to percentage WPI. (Note that impairments relating to the
joints of the thumb are added rather than combined-AMA5, p 454, 16.4d thumb ray
motion impairment.)
Specific Interpretation of the AMA5 – The Hand and Upper Extremity
Impairment of the upper extremity due to peripheral nerve disorders
2.9 If an upper extremity impairment results solely from a peripheral nerve injury, the
assessor should not also evaluate impairment(s) from section 16.4, abnormal motion
(pp 450-479 AMA5) for that upper extremity. Section 16.5 should be used for
evaluation of such impairments.
For peripheral nerve lesions use table 16-15 (p 492 AMA5) together with tables 16-10
and 16-11 (pp 482 and 484 AMA5) for evaluation.
The assessment of carpal tunnel syndrome post-operatively is undertaken in the same

way as assessment without operation.
2.10 When applying tables 16-10 (pp 482 AMA5) and table 16-11 (p 484 AMA5) the
examiner must use clinical judgement to estimate the appropriate percentage within
the range of values shown for each severity grade. The maximum value is not applied
automatically.
Impairment due to other disorders of the upper extremity
2.11 The section 'Impairment of the upper extremity due to other disorders' (AMA5 section
16.7 pp 498-507) should be used only when other criteria (as presented in sections 16.2
-16.6 (pp 441-498 AMA5)) have not adequately encompassed the extent of the
impairments. Impairments from the disorders considered in section 16.7 are usually
estimated using other criteria. The assessor must take care to avoid duplication of
impairments.
2.12 In section 16.7 (impairment of the upper extremities due to other disorders) AMA5
notes 'the severity of impairment due to these disorders is rated separately according
to table 16-19 through 16-30 and then multiplied by the relative maximum value of
the unit involved as specified in table 16-18'. This statement should not include tables

16-25 (carpal instability), 16-26 (shoulder instability) and 16-27 (arthroplasty),
noting that these tables are already expressed in terms of upper extremity impairment.
2.13 Strength evaluation, as a method of upper extremity impairment assessment, should

only be used in rare cases and its use justified when loss of strength represents an
impairing factor not adequately considered by more objective rating methods. If
chosen as a method, the caveats detailed on AMA5 p 508, under the heading '16.8a
Principles' need to be observed, i.e. decreased strength cannot be rated in the presence
of decreased motion, painful conditions, deformities and absence of parts (e.g. thumb
amputation).
Conditions affecting the shoulder region
2.14 Most shoulder disorders with an abnormal range of movement are assessed according
to AMA5 Section 16.4 - Evaluating Abnormal Motion. (Please note that AMA5
indicates that internal and external rotation of the shoulder are to be measured with
the arm abducted in the coronal plane to 90 degrees and with the elbow flexed to 90
degrees. In those situations where abduction to 90 degrees is not possible,
symmetrical measurement of rotation is to be carried out at the point of maximal
abduction).
Rare cases of rotator cuff injury, where the loss of shoulder motion does not reflect
the severity of the tear, and there is no associated pain, may be assessed according
to AMA5 Section 16.8c – strength evaluation. Other specific shoulder disorders,
where the loss of shoulder motion does not reflect the severity of the disorder,
associated with pain should be assessed by comparison with other impairments that
have similar effect(s) on upper limb function.
As noted in AMA5 16.7b 'Arthroplasty', "In the presence of decreased motion,
motion impairments are derived separately and combined with the arthroplasty
impairment". This includes those arthroplasties in Table 16-27 designated as
(isolated).
Please note that in Table 16-27 (p506 AMA5) the figure for resection arthroplasty of
the distal clavicle (isolated) has been changed to 5% upper extremity impairment,
and the figure for resection arthroplasty of the proximal clavicle (isolated) has been
changed to 8% upper extremity impairment.
Please note that in Table 16-18 (p499 AMA5) the figures of impairment suggested
for the sternoclavicular joint have been changed from 5% upper extremity
impairment and 3% whole person impairment, to 25% upper extremity impairment
and 15% whole person impairment.
2.15 Ruptured long head of biceps shall be assessed as an upper extremity impairment
(UEI) of three per cent UEI or two per cent WPI where it exists in isolation from
other rotator cuff pathology. Impairment for ruptured long head of biceps cannot be
combined with any other rotator cuff impairment or with loss of range of movement.
2.16 Diagnosis of impingement is made on the basis of positive findings on appropriate

provocative testing and is only to apply where there is no loss of range of motion.
Symptoms must have been present for at least 12 months. An impairment rating of
three per cent UEI or two per cent WPI shall apply.

Fractures involving joints
2.17 Displaced fractures involving joint surfaces are generally to be rated by range of
motion. If, however, this loss of range is not sufficient to give an impairment rating,
and movement is accompanied by pain and there is 2mm or more of displacement,
allow two per cent UEI (one per cent WPI).
Epicondylitis of the elbow
2.18 This condition is rated as two per cent UEI (one per cent WPI). In order to assess
impairment in cases of epicondylitis, symptoms must have been present for at least
18 months. Localised tenderness at the epicondyle must be present and provocative
tests must also be positive. If there is an associated loss of range of movement, these
figures are not combined, but the method giving the highest rating is used.
Resurfacing procedures
2.19 No additional impairment is to be awarded for resurfacing procedures used in the

treatment of localised cartilage lesions and defects in major joints.
Calculating motion impairment
2.20 When calculating impairment for loss of range of movement, it is most important to
always compare measurements of the relevant joint(s) in both extremities. If a
contralateral 'normal/uninjured' joint has less than average mobility, the impairment
value(s) corresponding to the uninvolved joint serves as a baseline and is subtracted
from the calculated impairment for the involved joint. The rationale for this decision
should be explained in the report (AMA5, p 543, 16.4c).
Complex regional pain syndrome (upper extremity)
2.21 Complex regional pain syndrome types 1 and 2 should be assessed using the method
in this Guide, chapter 17.

3. Lower extremity
lower extremities, subject to the modifications set out below. Before undertaking an
The provisions of this Guide take precedence over AMA5.
Introduction
3.1 The lower extremities are discussed in AMA5 chapter 17 (pp 523-564). This section
is complex and provides a number of alternative methods of assessing permanent
impairment involving the lower extremity. An organised approach is essential and
findings should be carefully documented on a worksheet.
The approach to assessment of the lower extremity
3.2 Assessment of the lower extremity involves physical evaluation, which can use a
variety of methods. In general, the method should be used that most specifically
addresses the impairment present. For example, impairment due to a peripheral nerve
injury in the lower extremity should be assessed with reference to that nerve rather
than by its effect on gait.
3.3 There are several different forms of evaluation that can be used, as indicated in
AMA5 sections 17.2b to 17.2n (pp 528–554). AMA5 Table 17-2 (p 526) indicates
which evaluation methods can be combined and which cannot. It may be possible to
perform several different evaluations, as long as they are reproducible and meet the
conditions specified below and in AMA5. The most specific method of impairment
assessment should be used. (Please note that in Table 17-2 the boxes in the fourth
row (on muscle strength) and seventh column (on amputation) should be a closed
box  rather than an open box ).
3.4 It is possible to use an algorithm to aid in the assessment of lower extremity

impairment. Use of a worksheet is essential. Table 3.5 at the end of this chapter on
page 27 is such a worksheet and may be used in assessment of permanent impairment
of the lower extremity.
3.5 In the assessment process, the evaluation giving the highest impairment rating is
selected. That may be a combined impairment in some cases, in accordance with the
Guide to the appropriate combination of evaluation methods table (table 17-2, p 526
AMA5), using the combined values chart (pp 604-606 AMA5).
3.6 When the combined values chart is used, the assessor must ensure that all values
combined are in the same category of impairment rating (i.e. percentage of WPI,
lower extremity impairment percentage, foot impairment percentage, and so on).
Regional impairments of the same limb (e.g. several lower extremity impairments)
should be combined before converting to percentage WPI.

3.7 Table 17-2 (p 526 AMA5) needs to be referred to frequently to determine which
impairments can be combined and which cannot. The assessed impairment of a part
or region can never exceed the impairment due to amputation of that part or region.
For the lower limb, therefore, the maximum evaluation is 40 per cent WPI, the value
for proximal above knee amputation.
Specific interpretation of AMA5 — the lower extremity
Leg length discrepancy
3.8 When true leg length discrepancy is determined clinically (AMA5 section 17.2b, p
528), the method used must be indicated (e.g. tape measure from anterior superior
iliac spine to the medial malleolus). Clinical assessment of leg length discrepancy is
an acceptable method but if full length computerised tomography films are available
they should be used in preference. Such an examination should not be ordered solely
for determining leg lengths.
3.9 When applying table 17–4 (p 528, AMA5), the element of choice should be removed
and impairments for leg length discrepancy should be read as the higher figure of the
range quoted.
Note that the figures for lower limb impairment in table 17-4 (p 528, AMA5) are
incorrect and the correct figures are shown below.
Table 17-4 Impairment Due to Limb Length

Discrepancy
Discrepancy Whole person (Lower
(cm) Extremity) impairment
(%)
0 - 1.9 0
2 - 2.9 3 (8)
3 - 3.9 5 (13)
4 - 4.9 7 (18)
5+ 8 (19)
Gait derangement
3.10 Assessment of gait derangement is only to be used as a method of last resort. Methods
of impairment assessment most fitting the nature of the disorder should always be
used in preference. If gait derangement (AMA5 section 17.2c, p 529) is used, it
cannot be combined with any other evaluation in the lower extremity section of
AMA5.
3.11 Any walking aid used by the subject must be a permanent requirement and not
temporary.
3.12 In the application of table 17-5 (p 529 AMA5), delete item b, as the Trendelenburg
sign is not sufficiently reliable.
Muscle atrophy (unilateral)

3.13 This section (AMA5 section 17.2d, p 530) is not applicable if the limb other than that
being assessed is abnormal (e.g. if varicose veins cause swelling, or if there is another
injury or condition which has contributed to the disparity in size).
3.14 In the use of table 17-6 (p 530 AMA5) the element of choice has been removed in
the impairment rating and only the higher figure used.
Note that the figures for lower limb impairment in table 17-6 (p 530 AMA5) are
incorrect and the correct figures are shown below.
Table 17-6 Impairment Due to Unilateral Leg Muscle Atrophy
Difference in Impairment degree Whole person

circumference (cm) (Lower Extremity)
impairment (%)
a. Thigh: The circumference is measured 10cm above the patella with the
knee fully extended and the muscles relaxed.
0 – 0.9 None 0 (0)
1 – 1.9 Mild 2 (6)
2 – 2.9 Moderate 4 (11)
3+ Severe 5 (12)
Difference in Impairment degree Whole person

circumference (cm) (Lower Extremity)
impairment (%)
b. Calf: The maximum circumference on the normal side is compared
with the circumference at the same level on the affected side.
0 – 0.9 None 0 (0)
1 – 1.9 Mild 2 (6)
2 – 2.9 Moderate 4 (11)
3+ Severe 5 (12)
Manual muscle strength testing
3.15 The Medical Research Council (MRC) gradings for muscle strength are universally
accepted. They are not linear in their application, but ordinal. Only the six grades (0-
5) should be used, as they are reproducible among experienced assessors. The
descriptions in table 17-7 (p 531 AMA5) are correct. The results of electro-
diagnostic methods and tests are not to be considered in the evaluation of muscle
testing which can be performed manually. Table 17-8 (p 532 AMA5) is to be used
for this method of evaluation.
Range of motion
3.16 Although range of motion (ROM) (AMA5 section 17.2f, pp 533-538) appears to be
a suitable method for evaluating impairment, it may be subject to variation because
of pain during motion at different times of examination, possible lack of cooperation
by the person being assessed and inconsistency. If there is such inconsistency then
ROM cannot be used as a valid parameter of impairment evaluation. In table 17-10

(knee impairment) (p537 AMA5) the sentence should read ‘Deformity measured by
femoral-tibial angle; 3° to 9° valgus is considered normal.
Table 17-10 (p 537 AMA5) is misleading as it has valgus and varus deformity in the
same table as restriction of movement, possibly suggesting that these impairments
may be combined. This is not the case. Any valgus/ varus deformity present which
is due to the underlying lateral or medial compartment arthritis, cannot be combined
with loss of range of movement. Therefore, when faced with an assessment in which
there is a rateable loss of range of movement as well as a rateable deformity, calculate
both impairments and use the greater. Valgus and varus knee angulation are to be
measured in a weight-bearing position using a goniometer. It is important to bear in
mind that valgus and/or varus alignments of the knee may be constitutional. It is also
important to always compare with the opposite knee.
3.17 If range of motion is used as an assessment measure, then tables 17-9 to 17-14 (p 537
AMA5) are selected for the joint or joints being tested. If a joint has more than one
plane of motion, the impairment assessments for the different planes should be added.
For example, any impairments of the six principal directions of motion of the hip
joint are added (p 533 AMA5).
Please note that in table 17-11 (ankle motion) (p 537 AMA5) the range for mild
flexion contracture should be one to 10 degrees, for moderate flexion contracture
should be 11 to 19 degrees, and the figure for severe flexion contracture should be
20 degrees plus.
The revised table 17-11 is as follows:

Table 17-11: Ankle motion impairment estimates
Whole person (lower extremity) [foot

impairment]
Motion Mild Moderate Severe
3% (7%) 6% (15%) 12%
[10%] [21%] (30%)
[43%]
Plantar 11° – 20° 1° - 10° None
flexion
capability
Flexion 1° - 10° 11° - 19° 20°+
contracture
Extension 10°- 0° - -
(neutral)
When calculating impairment for loss of range of movement, it is most important to

always compare measurements of the relevant joint(s) in both extremities. If a
contralateral 'normal/uninjured' joint has less than average mobility, the impairment
value(s) corresponding to the uninvolved joint serves as a baseline and is subtracted
from the calculated impairment for the involved joint. The rationale for this decision
should be explained in the report (AMA5, p 454, 16.4c).

Ankylosis
3.18 Ankylosis is to be regarded as the equivalent to arthrodesis in impairment terms only.

For the assessment of impairment, when a joint is ankylosed (AMA5 section 17.2g,
pp 538-543), the calculation to be applied is to select the impairment if the joint is
ankylosed in optimum position (see table 3.1 below), and then if not ankylosed in the
optimum position by adding (not combining) the values of percentage of WPI using
tables 17-15 to 17-30 (pp 538-543 AMA5).
Table 3.1 Impairment for ankylosis in the optimum position
Joint Whole person Lower Ankle or foot

extremity
Hip 20% 50% –
Knee 27% 67% –
Pantalar 19% 47% 67%
Ankle 15% 37% 53%
Triple 6% 15% 21%
Subtalar 4% 10% 14%
Note that the figures in table 3.1 suggested for ankle impairment are greater than
those suggested in the AMA5.
Ankylosis of the ankle in the neutral/optimal position equates with 15 (37) [53] per
cent impairment as per table 3.1.Table 3.1(a) is provided below as guidance to
evaluate additional impairment owing to variation from the neutral position. The
additional amounts at the top of each column are added to the figure for impairment
in the neutral position. In keeping with AMA5, p 541, the maximum impairment for
ankylosis of the ankle remains at 25 (62) [88] per cent impairment.
Table 3.1(a) Impairment for ankylosis in variation from the optimum position
Whole person (lower extremity) [foot] impairment (%)
Position 2 (5) [7] 4 (10) [14] 7 (17) [24] 10 (25) [35]

1. Dorsiflexion 5-9° 10 - 19 ° 20 - 29 ° 30 °+
2. Plantar flexion - 10 - 19 ° 20 - 29 ° 30 °+
3. Varus 5-9° 10 - 19 ° 20 - 29 ° 30 °+
4. Valgus - 10 - 19 ° 20 - 29 ° 30 °+
5. Internal rotation 0-9° 10 - 19 ° 20 - 29 ° 30 °+
6. External rotation 15 - 19 ° 20 - 29 ° 30 - 39 ° 40 °+
Arthritis
3.19 Impairment due to arthritis (AMA5 section 17.2n, pp 544-545) following a work-
related injury is uncommon, but may occur in isolated cases. The presence of arthritis

may indicate a pre-existing condition and this should be assessed and an appropriate
deduction made (see Chapter 1).
3.20 The presence of osteoarthritis is defined as cartilage loss. Cartilage loss can be
measured by properly aligned plain x-ray, or by direct vision (arthroscopy) but
impairment can only be assessed by the radiologically determined cartilage loss
intervals in AMA5, table 17-31 (p 544). When assessing impairment of the knee
joint which has three compartments, only the compartment with the major
impairment is used in the assessment. That is, measured impairments in the different
compartments cannot be added or combined.
3.21 Detecting the subtle changes of cartilage loss on plain radiography requires
comparison with the normal side. All joints should be imaged directly through the
joint space, with no overlapping of bones. If comparison views are not available,
AMA5 table 17-31 (p 544) is used as a guide to assess joint space narrowing.
3.22 One should be cautious in making a diagnosis of cartilage loss on plain radiography
if secondary features of osteoarthritis, such as osteophytes, subarticular cysts or
subchondral sclerosis are lacking, unless the other side is available for comparison.
The presence of an intra-articular fracture with a step in the articular margin in the
weight bearing area implies cartilage loss.
3.23 The accurate radiographic assessment of joints always requires at least two views. In
some cases, further supplementary views will optimise the detection of joint space
narrowing or the secondary signs of osteoarthritis.
Sacro-iliac joints: Being a complex joint, modest alterations are not detected on
radiographs, and cross- sectional imaging may be required. Radiographic
manifestations accompany pathological alterations. The joint space measures
between 2mm and 5mm. Osteophyte formation is a prominent characteristic of
osteoarthritis of the sacro-iliac joint.
Hip: An anteroposterior view of the pelvis and a lateral view of the affected hip are
ideal. If the affected hip joint space is narrower than the asymptomatic side, cartilage
loss is regarded as being present. If the anteroposterior view of pelvis has been
obtained with the patient supine, it is important to compare the medial joint space of
each hip as well as superior joint space, as this may be the only site of apparent
change. If both sides are symmetrical, then other features, such as osteophytes,
subarticular cyst formation, and calcar thickening should be taken into account to
make a diagnosis of osteoarthritis.
Knee:
 Tibio-femoral joint: The best view for assessment of cartilage loss in the knee
is usually the erect intercondylar projection, as this profiles and stresses the
major weight bearing area of the joint which lies posterior to the centre of the
long axis. The ideal x-ray is a posteroanterior view with the patient standing,
knees slightly flexed, and the x-ray beam angled parallel to the tibial plateau
(Rosenberg view). Both knees can readily be assessed with the one exposure.
In the knee it should be recognised that joint space narrowing does not
necessarily equate with articular cartilage loss, as deficiency or displacement
of the menisci can also have this effect. Secondary features, such as
subchondral bone change and past surgical history, must also be taken into
account.

 Patello-femoral joint: Should be assessed in the “skyline” view, again
preferably with the other side for comparison. The x-ray should be taken with
30 degrees of knee flexion to ensure that the patella is load-bearing and has
engaged the articular surface femoral groove.
Footnote to Table 17-31 (p544 AMA5) regarding patello-femoral pain and
crepitation: This item is only to be used if there is a history of direct injury to
the front of the knee, or in cases of patellar translocation/dislocation without
there being direct anterior trauma. This item cannot be used as an additional
impairment when assessing arthritis of the knee joint itself, of which it forms
a component. If patello-femoral crepitus occurs in isolation (i.e. no other signs
of arthritis) following either of the above, then it can be combined with other
diagnosis based estimates (table 17-33, AMA5, p 546). Signs of crepitus need
to be present at least one year post injury.
Note: Osteoarthritis of the patello-femoral joint cannot be used as an additional
impairment when assessing arthritis of the knee joint itself, of which it forms
a component.
Ankle: The ankle should be assessed in the mortice view (preferably weight-
bearing), with comparison views of the other side, although this is not as necessary
as with the hip and knee.
Subtalar: This joint is better assessed by CT (in the coronal plane) than by plain
radiography. The complex nature of the joint does not lend itself to accurate and easy
plain x-ray assessment of osteoarthritis.
Talonavicular and calcaneocuboid: Anteroposterior and lateral views are

necessary. Osteophytes may assist in making the diagnosis.
Intercuneiform and other intertarsal joints: Joint space narrowing may be

difficult to assess on plain radiography. CT (in the axial plane) may be required.
Associated osteophytes and subarticular cysts are useful adjuncts to making the
diagnosis of osteoarthritis in these small joints.
Great toe metatarsophalangeal: Anteroposterior and lateral views are required.

Comparison with the other side may be necessary. Secondary signs may be useful.
Interphalangeal: It is difficult to assess small joints without taking secondary signs

into account. The plantar-dorsal view may be required to get through the joints, in a
foot with flexed toes.
3.24 If arthritis is used as the basis for assessing impairment, then the rating cannot be
combined with gait disturbance, muscle atrophy, muscle strength or range of
movement assessments. It can be combined with a diagnosis-based estimate (table
17-2, AMA5, p 526).
Amputation
3.25 Where there has been amputation of part of a lower extremity, table 17-32 (p 545
AMA5) applies. In that table the references to three inches for below-the-knee
amputation should be converted to 7.5cm.

Diagnosis-based estimates (lower extremity)
3.26 Section 17.2j (pp 545-549 AMA5) lists a number of conditions that fit a category of
diagnosis-based estimates. They are listed in tables 17-33, 17-34 and 17-35 (pp 546-
549 AMA5). When using this table it is essential to read the footnotes carefully. The
category of mild cruciate and collateral ligament laxity has inadvertently been
omitted in table 17-33 of AMA5. The appropriate rating is 5 (12) percent whole
person (lower extremity) impairment.
3.27 It is possible to combine impairments from tables 17-33, 17-34 and 17-35 for
diagnosis-related estimates with other components (e.g. nerve injury) using the
combined values chart (pp 604-606 AMA5) after first referring to this Guide to the
appropriate combination of evaluation methods (see table 3.5).
3.28 Pelvic fractures: Pelvic fractures are to be assessed as per table 4.3 in this Guide
and not using the reference to the pelvis in table 17-33 (p 546 AMA5).
Hip: The item in relation to femoral neck fracture 'malunion' is not to be used in
assessing impairment. Use other available methods.
Femoral Osteotomy: Good result: 10 (25) whole person (lower extremity)

impairment. Poor result: Estimate according to examination and arthritic
degeneration
Tibial plateau fractures: The following table 3.2 replaces the instructions for tibial
plateau fractures in table 17-33 (p 546 AMA5).
Table 3.2 Impairment for tibial plateau fractures
In deciding whether the facture falls into the mild, moderate or severe categories, the
assessor must take into account:
(i) The extent of involvement of the weight bearing area of the tibial plateau.
(ii) The amount of displacement of the fracture/s.
(iii) The amount of comminution present.
Grade WPI (LEI)%

Undisplaced 2 (5)
Mild 5 (12)
Moderate 10 (25)
Severe 15 (37)
Patello-femoral joint replacement: Assess the knee impairment in the usual way
and combine with nine per cent WPI (22 per cent lower extremity impairment) for
isolated patello-femoral joint replacement.
Total Ankle Replacement:

Table 3-3: Rating for ankle replacement results
The points system for rating total ankle replacements is to be the same as for total
hip and total knee replacements, with the following impairment ratings:
Result (LEI) WPI %
Good result, 85-100 points: (30) 12

Fair result, 50-84 points: (40) 16
Poor result, < 50 points: (50) 20
Number of Points Number of Points

a. Pain DEDUCTIONS
(minus) d and e
None 50
d. Varus
Slight <5° 0
Stairs only 40 5° − 10° 10
Walking and stairs 30 >10° 15
Moderate
Occasional 20 e. Valgus
Continual 10 <5° 0
5° − 10° 10
Severe 0 >10° 15
b. Range of motion SUB-TOTAL
(i) Flexion:
>20° 15
11° − 20° 10
5° − 10° 5
<5° 0
(ii) Extension
>10° 10
5° − 10° 5
<5° 0
c. Range of motion
(i) Limp
None 10
Slight 7
Moderate 4
Severe 0
(ii) Supportive Device

None 5
Cane 3
One Crutch 1
2 Crutches 0
(iii) Distance Walked

Unlimited 5
Six blocks 4
Three blocks 3
Indoors 2
Bed or Chair 0
(iv) Stairs
Normal 5
Using rail 4
One at a time 2
Unable to climb 0

SUB-TOTAL
Tibia-os calcis angle: The table given below for the impairment of loss of the tibia-
as calcis angle is to replace table 17-29 (p 542 AMA5) and the section in table 17-33
(p 546 AMA5) dealing with loss of tibia-as calcis angle. These two sections are
contradictory, and neither gives a full range of loss of angle.
Table 3.4 Impairment for loss of the tibia-os calcis angle

Angle (degree) Whole Person (lower extremity) [foot]
impairment (%)
110 – 100 5 (12) [17]
99 – 90 8 (20) [28]
< 90 +1 (2) [3] per ° up to

15 (37) [54]
Hindfoot Intra-articular fractures: In the interpretation of table 17-33 (p 547

AMA5), reference to the hindfoot, intra-articular fractures, the words subtalar bone,
talonavicular bone, and calcaneocuboid bone imply that the bone is displaced on one
or both sides of the joint mentioned. To avoid the risk of double assessment, if
avascular necrosis with collapse is used as the basis of impairment assessment, it
cannot be combined with the relevant intra-articular fracture in table 17-33 column
2. In table 17-33 column 2, metatarsal fracture with loss of weight transfer means
dorsal displacement of the metatarsal head.
Plantar fasciitis: If there are persistent symptoms and clinical findings after 18
months, this is rated as two per cent lower extremity impairment (one per cent WPI).
Resurfacing procedures: No additional impairment is to be awarded for resurfacing

procedures used in the treatment of localised cartilage lesions and defects in major
joints.
3.29 Table 17-34 and table 17-35 (pp 548-549 AMA5) use a different concept of
evaluation. A point score system is applied, and then the total of points calculated for
the hip (or knee) joint is converted to an impairment rating from table 17-33. Tables
17-34 and 17-35 refer to the hip and knee joint replacement respectively. Note that,
while all the points are added in table 17-34, some points are deducted when table
17-35 is used. (Note that hemi-arthroplasty rates the same as total joint replacement.)
3.30 In respect of 'distance walked' under 'b. Function' in table 17-34 (p 548 AMA5), the
distance of six blocks should be construed as 600m, and three blocks as 300m.
Note that Table 17-35 (p 549 AMA5) is incorrect. The correct table is shown on the
following page. Refer to the unaffected limb to take into account any constitutional
variation.

Table 17-35 Rating Knee replacement Results
Number of Points
a. Pain
None 50
Mild or occasional 45
Stairs only 40
Walking and stairs 30
Moderate
Occasional 20
Continual 10
Severe 0
b. Range of Motion
Add 1 point per 5 ° up to 125 ° 25 (maximum)

c. Stability
(maximum movement in any position)
Anterioposterior
< 5 mm
5-9 mm 10
> 9 mm 5
0
Mediolateral
5°
6-9 ° 15
10-14 ° 10
> 14 ° 5
0
Subtotal
Deductions (minus) d, e, f
d. Flexion contracture
5-9 ° 2
10-15 ° 5
16-20 ° 10
> 20 ° 20
e. Extension Lag
< 10 ° 5
10-20 ° 10
> 20 ° 15
f. Tibio-femoral alignment *–> 15°

valgus 20
11-15° valgus 3 points per degree
5-10 ° valgus 0
0-4 ° valgus 3 points per degree
Any varus 20
Deductions subtotal:

Skin loss (lower extremity)
3.31 Skin loss (p 550 AMA5) can only be included in the calculation of impairment if it
is in certain sites and meets the criteria listed in table 17-36 (p 550 AMA5).
Peripheral nerve injuries (lower extremity)
3.32 When assessing the impairment due to peripheral nerve injury (pp 550-552 AMA5)
assessors should read the text in this section. Note that the separate impairments for
the motor, sensory and dysaesthetic components of nerve dysfunction in table 17-37
(p 552 AMA5) are to be combined.
3.33 Note that the (posterior) tibial nerve is not included in table 17-37, but its contribution
can be calculated by subtracting ratings of common peroneal nerves from sciatic
nerve ratings
3.34 Peripheral nerve injury impairments can be combined with other impairments, but
not those for gait derangement, muscle atrophy, muscle strength or complex regional
pain syndrome, as shown in table 17-2 (p 526 AMA5). Motor and sensory
impairments given in table 17-37 are for complete loss of function and assessors must
still use table 16-10 and 16-11 in association with table 17-37.
Complex regional pain syndrome (lower extremity)
3.35 Complex regional pain syndrome types 1 and 2 are to be assessed using the method
in chapter 17 of this Guide.
Peripheral vascular disease (lower extremity)
3.36 Lower extremity impairment due to vascular disorders (pp 553-554 AMA5) is
evaluated using table 17-38 (p 554 AMA5). Note that table 17-38 gives values for
lower extremity not WPI. In that table there is a range of lower extremity impairments
within each of the classes 1 to 5. As there is a clinical description of which conditions
place a person's lower extremity in a particular class, the assessor has a choice of
impairment rating within a class, the value of which is left to the clinical judgement
of the assessor.
Measurement of selected joint motion
3.37 When measuring dorsiflexion at the ankle, the test is carried out initially with the
knee in extension and then repeated with the knee flexed to 45 degrees. The average
of the maximum angles represents the dorsiflexion range of motion (figure 17-5, p
535 AMA5).

Table 3.5: Lower extremity worksheet
AMA5 AMA5 Potential Selected
Item Impairment Table page impairment impairment
1 Limb length 17–4 528
discrepancy
2 Gait derangement 17–5 529
3 Unilateral muscle 17–6 530

atrophy
4 Muscle weakness 17–8 532
5 Range of motion 17–9 to 537

17–14
6 Joint ankylosis 17–15 to 538–543
17–30
7 Arthritis 17–31 544
8 Amputation 17–32 545
9 Diagnosis-based 17–33 to 546–549

estimates 17–35
10 Skin loss 17–36 550
11 Peripheral nerve 17–37 552

deficit
12 Complex regional Section 495–497
pain syndrome 16.5e
13 Vascular disorders 17–38 554
Combined impairment rating

(refer to Table 17–2, p 526 AMA5 for permissible
combinations)
Potential impairment is the impairment percentage for that method of assessment. Selected
impairment is the impairment, or impairments selected, that can be legitimately combined
with other lower extremity impairments to give a final lower extremity impairment rating.

4. The spine
spine, subject to the modifications set out below. Before undertaking an impairment
assessment, users of this Guide must be familiar with the following:
Introduction
4.1 The spine is discussed in chapter 15 (pp 373-431 AMA5). That chapter presents two
methods of assessment, the diagnosis-related estimates method and the range of
motion method. Evaluation of impairment of the spine is only to be done using
diagnosis-related estimates (DREs).
4.2 The DRE method relies especially on evidence of neurological deficits and less
common, adverse structural changes, such as fractures and dislocations. Using this
method, DREs are differentiated according to clinical findings that can be verified
by standard medical procedures.
4.3 The assessment of spinal impairment is made when the person's condition is stable
and stationary. This is considered to occur when the worker's condition is well
stabilised and unlikely to change substantially in the next year with or without
medical treatment. If surgery has been performed, the outcome of the surgery as well
as structural inclusions must be taken into consideration when making the
assessment.
Assessment of the spine
4.4 The assessment should include a comprehensive, accurate history, a review of all
pertinent records available at the assessment, a comprehensive description of the
individual's current symptoms and their relationship to daily activities, a careful and
thorough physical examination, and all findings of relevant laboratory, imaging,
diagnostic and ancillary tests available at the assessment. Imaging findings that are
used to support the impairment rating should be concordant with symptoms and
findings on examination. The assessor should record whether diagnostic tests and
radiographs were seen or whether they relied solely on reports.
4.5 The DRE model for assessment of spinal impairment should be used. The range of
motion model (sections 15.8-15.13 inclusive, AMA5 pp 398-427) should not be used.
4.6 If a person has spinal cord or cauda equina damage, including bowel, bladder and/or
sexual dysfunction, he or she is assessed according to the method described in section
15.7 and table 15.6 (a) to (g) (pp 395-398 AMA5).
4.7 If an assessor is unable to distinguish between two DRE categories, then the higher
of those two categories should apply. The reasons for the inability to differentiate
should be noted in the assessor's report.

4.8 Possible influence of future treatment should not form part of the impairment
assessment. The assessment should be made on the basis of the person's status at the
time of interview and examination, if the assessor is convinced that the condition is
stable and permanent. Likewise, the possibility of subsequent deterioration, as a
consequence of the underlying condition, should not be factored into the impairment
evaluation. Commentary can be made regarding the possible influence, potential or
requirements for further treatment, but this does not affect the assessment of the
individual at the time of impairment evaluation.
4.9 All spinal impairments are to be expressed as a percentage of WPI (%WPI).
4.10 Section 15.1a (pp 374-377 AMA5) is a valuable summary of history and physical
examination, and should be thoroughly familiar to all assessors
4.11 The assessor should include in the report a description of how the impairment rating
was calculated, with reference to the relevant tables and/or figures used.
4.12 The optimal method to measure the percentage compression of a vertebral body is a
well centred plain x-ray. Assessors should state the method they have used. The loss
of vertebral height should be measured at the most compressed part and must be
documented in the impairment evaluation report. The estimated normal height of the
compressed vertebra should be determined where possible by averaging the heights
of the two adjacent (unaffected and normal) vertebrae.
Specific interpretation of AMA5
4.13 The range-of-motion (ROM) method is not used, hence any reference to this is
omitted (including table 15-7, p 404 AMA5).
4.14 Motion segment integrity alteration can be either increased translational or angular
motion, or decreased motion resulting from developmental changes, fusion, fracture
healing, healed infection or surgical arthrodesis. Motion of the individual spine
segments cannot be determined by a physical examination, but is evaluated with
flexion and extension radiography.
4.15 The assessment of altered motion segment integrity is to be based upon a report of
trauma resulting in an injury, and not on developmental or degenerative changes.
4.16 When routine imaging is normal and severe trauma is absent, motion segment
disturbance is rare. Thus, flexion and extension imaging is indicated only when a
history of trauma or other imaging leads the physician to suspect alteration of motion
segment integrity.
4.17 The preferred method for recording of the range of motion is as a fraction or percent
of the range or loss of the range. For example, either 'cervical movement was one
half (or 50 per cent) of the normal range of motion' or 'there was a loss of one half
(or 50 per cent) of the normal range of movement of the cervical spine'.
DRE definitions of clinical findings

4.18 DRE II is a clinical diagnosis based upon the features of the history of the injury and
clinical features. Clinical features which are consistent with DRE II and which are
present at the time of assessment include radicular symptoms in the absence of
clinical signs (that is, non-verifiable radicular complaints), muscle guarding or
spasm, or asymmetric loss of range of movement. Localised (not generalised)
tenderness may be present. In the lumbar spine additional features include a reversal
of the lumbosacral rhythm when straightening from the flexed position and
compensatory movement for an immobile spine such as flexion from the hips. In
assigning category DRE II, the assessor must provide detailed reasons why the
category was chosen.
4.19 Asymmetric or non-uniform loss of range of motion may be present in any of the
three planes of spinal movement. Asymmetry during motion caused by muscle
guarding or spasm is included in the definition.
Asymmetric loss of range of motion may be present for flexion and extension. For
example, if cervical flexion is half the normal range (loss of half the normal range)
and cervical extension is one third of the normal range (loss of two-thirds of the
range), asymmetric loss of range of motion may be considered to be present.
4.20 While imaging and other studies may assist medical assessors in making a diagnosis,
the presence of a morphological variation from 'normal' in an imaging study does not
confirm the diagnosis. To be of diagnostic value, imaging studies must be concordant
with clinical symptoms and signs. In other words, an imaging test is useful to confirm
a diagnosis, but an imaging study alone is insufficient to qualify for a DRE category
(excepting spinal fractures).
4.21 The clinical findings used to place an individual in a DRE category are described in
box 15-1 (pp 382-383 AMA5).
The reference to 'electro-diagnostic verification of radiculopathy' should be

disregarded.
(The use of electro-diagnostic procedures such as electromyography is proscribed as

an assessment aid for decisions about the category of impairment into which a person
should be placed. It is considered that competent assessors can make decisions about
which DRE category a person should be placed in from the clinical features alone.
The use of electro-diagnostic differentiators is generally unnecessary).
4.22 The cauda equina syndrome is defined in AMA5 (Chapter 15, p 383, Box 15.1) as
'manifested by bowel or bladder dysfunction, saddle anaesthesia and variable loss of
motor and sensory function in the lower limbs'. For a cauda syndrome to be present
there must be bilateral neurological signs in the lower limbs and sacral region.
Additionally, there must be a radiological study which demonstrates a lesion in the
spinal canal causing a mass effect on the cauda equina with compression of multiple
nerve roots. The mass effect would be expected to be large and significant. A lumbar
MRI scan is the diagnostic investigation of choice for this condition. A cauda equina
syndrome may occasionally complicate lumbar spine surgery when a mass lesion will
not be present in the spinal canal on radiological examination.
4.23 The cauda equina syndrome and neurogenic bladder disorder are to be assessed by
the method prescribed in the spine chapter of AMA5, section 15.7, pp 395-398. For

an assessment of neurological impairment of bowel or bladder, there must be
objective evidence of spinal cord, or cauda equina injury.
Applying the DRE method
4.24 The specific procedures and directions section of AMA5 (section 15.2a, pp 380-381)
indicates the steps that should be followed to evaluate impairment of the spine
(excluding references to the ROM method). Table 4.1 is a simplified version of that
section, incorporating the amendments listed above.
Table 4.1: Procedures in evaluating impairment of the spine

History
Physical examination

Diagnosis

Use clinical findings to place an individual’s condition
in a DRE category according to Box 15.1, AMA5 pp 382–383

Choose the category that determines the percentage impairment:
Lumbar region AMA5 Table 15–3, p 384
Thoracic region AMA5 Table 15–4, p 389
Cervical region AMA5 Table 15–5, p 392
4.25 Common developmental findings, spondylosis, spondylolisthesis and disc

protrusions without radiculopathy occur in seven per cent, three per cent, and up to
30 per cent respectively in individuals up to the age of 40 (p 383 AMA5). Their
presence does not of itself mean that the individual has an impairment due to injury.
4.26 Loss of sexual function should only be assessed where there is other objective
evidence of spinal cord, cauda equina or bilateral nerve root dysfunction. The ratings
are described in table 15-6 (pp 396-397 AMA5). There is no additional impairment
rating system for loss of sexual function in the absence of objective neurological
findings. Loss of sexual function is not assessed as an ADL
4.27 Radiculopathy is the impairment caused by malfunction of a spinal nerve root or

nerve roots. In general, in order to conclude that radiculopathy is present, two or more
of the following criteria should be found, one of which must be major (major criteria
in bold):
 Loss or asymmetry of reflexes
 Muscle weakness that is anatomically localised to an appropriate spinal
nerve root distribution
 Reproducible impairment of sensation that is anatomically localised to an
appropriate spinal nerve root distribution
 Positive nerve root tension (Box 15-1, p382 AMA5)
 Muscle wasting – atrophy (Box 15-1, p382 AMA5)

 Findings on an imaging study consistent with the clinical signs (p382 AMA5)
4.28 Radicular complaints of pain or sensory features that follow anatomical pathways but
cannot be verified by neurological findings (somatic pain, non-verifiable radicular
pain) do not alone constitute radiculopathy.
4.29 Global weakness of a limb related to pain or inhibition or other factors does not
constitute weakness due to spinal nerve malfunction.
4.30 Vertebral body fractures and/or dislocations at more than one vertebral level are to
be assessed as follows:
 Measure the percentage loss of vertebral height at the most compressed part
for each vertebra, then
 Add the percentage loss at each level:
o Total loss of more than 50% = DRE IV
o Total loss of 25% to 50% = DRE III
o Total loss of less than 25% = DRE II
 If radiculopathy is present then the person is assigned one DRE category
higher
One or more end plate fractures in a single spinal region without measurable
compression of the vertebral body are assessed as DRE category II.
Posterior element fractures (excludes fractures of transverse processes and spinous

processes) at multiple levels are assessed as DRE Ill.
4.31 Displaced fractures of transverse or spinous processes at one or more levels are
assessed as DRE category II because the fracture does not disrupt the spinal canal (p
385 AMA5) and do not cause multilevel structural compromise.
4.32 Within a spinal region separate spinal impairments are not combined. The highest
value impairment within the region is chosen. Impairments in different spinal regions
are combined using the combined values chart (AMA5, pp 604-606).
If there are adjacent vertebral fractures at the transition zones (C7/T1, T12/L1), the
methodology in paragraph 4.30 is to be adopted. For fractures of C7 and T1, use the
WPI ratings for the cervical spine (AMA5 chapter 15, page 392, Table 15-5). For
fractures of T12 and L1 use the WPI rating for the thoracic spine (AMA5 chapter 15,
page 389, Table 15-4).
4.33 Impact of ADL. Tables 15-3, 15-4 and 15-5 of AMA5 give an impairment range for
DREs II to V. Within the range, zero, one, two or three per cent WPI may be assessed
using paragraphs 4.34 and 4.35 below. An assessment of the effect of the injury on
ADLs is not solely dependent on self-reporting, but is an assessment based on all
clinical findings and other reports.
4.34 The following diagram should be used as a guide to determine whether zero, one,
two or three per cent WPI should be added to the bottom of the appropriate
impairment range. This is only to be added if there is a difference in activity level as
recorded and compared to the worker's status prior to the injury.

4.35 The diagram is to be interpreted as follows:
Increase base impairment by:
 Three per cent WPI if worker's capacity to undertake personal care activities
such as dressing, washing, toileting and shaving has been affected.
 two per cent WPI if the worker can manage personal care, but is restricted with
usual household tasks such as cooking, vacuuming, making beds or tasks of
equal magnitude such as shopping, climbing stairs or walking reasonable
distances.
 one per cent WPI for those able to cope with the above, but unable to get back
to previous sporting or recreational activities such as gardening, running and
active hobbies etc.
4.36 For a single injury, where there has been more than one spinal region injured, the
effect of the injury on ADL is assessed once only.
For injuries to one spinal region on different dates, the effect of the injury on ADL is
assessed for the first injury. If, following the second injury, there is a worsening in
the ability to perform ADL, the appropriate adjustments are made within the range.
For example, if one per cent WPI for ADL is assessed following the first injury and
three per cent after the second injury, then two per cent WPI is assessed for the ADL
for the second injury.
For injuries to different spinal regions on different dates where there is a worsening
of ADL after the second injury, additional impairment may be assessed. For example,
if for an injury to the cervical spine one per cent for ADL was assessed, and following
a subsequent injury to the lumbar spine three per cent WPI was assessed, then two
per cent WPI is assessed for the lumbar injury.
4.37 Effect of surgery: Tables 15-3, 15-4 and 15-5 (pp 384, 389 and 392 AMA5) do not
adequately account for the effect of surgery upon the impairment rating for certain
disorders of the spine. The assessor should note that:

 Surgical decompression for spinal stenosis is DRE category III (AMA5 Table
15-3, 15-4, 15-5)
 Operations where the radiculopathy has resolved are considered under the
DRE category III (AMA5, Tables 15–3, 15–4, 15–5);
 Operations for spinal fusion (successful or unsuccessful) are considered
under DRE category IV (AMA5, Tables 15–3, 15–4, 15–5).
 DRE Category V is not to be used following spinal fusion, where there is a
persisting radiculopathy. Instead use Table 4.2 in this Guide; and
 Radiculopathy persisting after surgery is not accounted for by AMA5 Table
15-3, and incompletely by Tables 15-4 and 15-5, which only refer to
radiculopathy which has improved following surgery.
Table 4.2 indicates the additional ratings which should be combined with the rating
determined using the DRE method where an operation for an intervertebral disc
prolapse, spinal canal stenosis or spinal fusion has been performed.
Example 15-4 (p 386 AMA5) should therefore be ignored.

Table 4.2: Modifiers for DRE categories following surgery
Procedures Cervical Thoracic Lumbar
Spinal surgery with 3% 2% 3%
residual symptoms and
radiculopathy (refer to
4.27 in this Guideline)
Second and further levels 1% each 1% each 1% each
additional additional additional
level level level
Second operation 2% 2% 2%
Third and subsequent 1% each 1% each 1% each
operations
In summary, to calculate whole person impairment (WPI) for persisting radiculopathy (as per
definition) following surgery:
 Select the appropriate DRE category from Table 15-3, 15-4, or 15-5;
 determine a WPI value within the allowed range in table 15-3, 15-4 or 15-5
according to the impact on the worker's ADL;
 Combine this value with the appropriate additional amount from Table 4.2 to
determine the final WPI.
4.38 Disc Replacement Surgery. The impairment resulting from this procedure is to be
equated to that from a spinal fusion.
4.39 Arthritis: See sections 3.19–3.24 of this Guide.
4.40 Posterior spacing or stabilisation devices: The insertion of such devices does not
warrant any additional WPI.
4.41 Spinal cord stimulator or similar device: The insertion of such devices does not
warrant any additional WPI.

4.42 Impairment due to pelvic fractures should be evaluated with reference to the
following table 4.3, which replaces table 15-19 in AMA5.
Table 4.3: Pelvic fractures

%WPI
Disorder
1. Non-displaced, healed fractures 0
2. Fractures of the pelvic bones (including sacrum)

(i) maximum residual displacement <1cm 2
(ii) maximum residual displacement 1 to 2 cm 5
(iii) maximum residual displacement >2cm 8
(iv) bilateral pubic rami fractures, as determined by the most displaced
fragment
a. maximum residual displacement ≤2cm 5
b. maximum residual displacement >2cm 8
3. Traumatic separation of the pubic symphysis
(i) <1cm 5
(ii) 1 to 2 cm 8
(iii) >2cm 12
(iv) Internal fixation/ankylosis 5
4. Sacro-Iliac Joint dislocations or fracture dislocations

(i) maximum residual displacement ≤1cm 8
(ii) maximum residual displacement>1cm 12
(iii) internal fixation/ankylosis 5
8
5. If two out of three joints are internally fixed/ankylosed
If all three joints are internally fixed/ankylosed 10
6. Fractures of the coccyx
(i) Healed, (and truly) displaced fracture 1
(ii) Excision of the coccyx 5
7. Fractures of the acetabulum: Evaluate based on restricted range of

hip motion
The rating of WPI is evaluated based on radiological appearance at maximum medical

improvement, whether or not surgery has been performed. Multiple injuries of the
pelvis should be assessed separately and combined, with the maximum WPI for pelvic
fractures being 20 per cent.

5. Nervous system
nervous system, subject to the modifications set out below. Before undertaking an
Introduction
5.1 AMA5 chapter 13, the central and peripheral nervous system (pp 305-356), provides
guidelines on methods of assessing permanent impairment involving the central
nervous system. It is logically structured and consistent with the usual sequence of
examination of the nervous system. Cerebral functions are discussed first, followed
by the cranial nerves, station, gait and movement disorders, the upper extremities
related to central impairment, the brain stem, the spinal cord and the peripheral
nervous system, including neuromuscular junction and muscular system. A summary
concludes the chapter.
5.2 Spinal cord injuries are to be assessed using AMA5 chapter 15. Table 15.6 (pp 396-
397) is to be used for evaluation of spinal cord injuries. These impairments, once
selected, are then combined with the corresponding additional spinal impairment
from DRE categories II-V for cervical and lumbar impairment and categories II-IV
for thoracic impairment to obtain an exact total value.
5.3 Impairments of the peripheral nervous system are assessed by using the relevant parts
of the upper extremity, lower extremity and spine sections of AMA5.
The approach to assessment of permanent neurological impairment
5.4 AMA5 chapter 13 disallows combination of cerebral impairments. However, for the
purpose of this Guide, cerebral impairments should be evaluated and combined as
follows:
 Consciousness and awareness
 Mental status, cognition and highest integrative function
 Aphasia and communication disorders
 Emotional and behavioural impairments.
The assessor should take care to be as specific as possible and not to double-rate the
same impairment, particularly in the mental status and behavioral categories.
These impairments are to be combined using the combined values chart (pp 604-606
AMA5). These impairments should then be combined with other neurological
impairments indicated in AMA5 table 13-1 (p 308).
5.5 AMA5 sections 13.5 and 13.6 (pp 336-340) should be used for cerebral, basal
ganglia, cerebellar or brain stem impairments. This section therefore covers

hemiplegia, monoplegia (arm or leg) and upper or lower limb impairment due to
incoordination or movement disorder due to brain injury.
5.6 If a person has a spinal injury with spinal cord or cauda equina, bilateral nerve root
or lumbosacral plexus injury causing bowel, bladder and/or sexual dysfunction, he
or she is assessed according to the method described in section 15.7 and table 15.6
(a)-(g), pp 395-398, AMA5.
5.7 Complex regional pain syndrome types 1 and 2 are to be assessed using the method
in Chapter 17 of this Guide.
5.8 The nervous system chapter of AMA5 (chapter 13) lists many impairments where
the range for the associated WPI is 0-9 per cent or 0-14 per cent. Where there is a
range of impairment percentages listed, the assessor should nominate an impairment
percentage based on the complete clinical circumstances revealed during the
consultation and in relation to all other available information.
Specific interpretation of AMA5
5.9 In assessing disturbances of mental status and integrative functioning, and emotional
or behavioural disturbances, disturbances in the level of consciousness and
awareness, disturbances of sleep and arousal function and disorders of
communication (sections 13.3a, 13.3c, 13.3d, 13.3e, 13.3f, AMA5 pp 309-311, 317-
327), the assessor should make ratings based on clinical assessment and the results
of neuropsychometric testing where available.
For traumatic brain injury, there should be evidence of a severe impact to the head or
that the injury involved a high energy impact.
Clinical assessment must include at least one of the following:
 Significant medically verified abnormalities in the Glasgow Coma Scale score,
 Significant medically verified duration of post traumatic amnesia
 Significant intracranial pathology on CT scan or MRI.
Neuropsychological testing should be conducted by a registered clinical

neuropsychologist who is a member, or is eligible for membership, of the Australian
Psychological Society's College of Clinical Neuropsychology. Neuropsychological
test data is to be considered in the context of the overall clinical history, examination
and radiological findings and not in isolation.
5.10 Assessment of arousal and sleep disorders (AMA5 section 13.3c, pp 317-319):
refers to assessment of primary sleep disorders following neurological injury. The
assessor should make ratings of arousal and sleep disorders based on the clinical
assessment that would normally have been done for clinically significant disorders
of this type (i.e. sleep studies or similar tests).
5.11 Olfaction and taste: The assessor should use AMA5 Chapter 11, Section 11.4c (p
262) to assess olfaction and taste, for which a maximum of five per cent WPI is
allowable for total loss of either sense. The effect on activities of daily living should
be considered.

5.12 Visual impairment assessment (chapter 8, pp 209-222 AMA4): An
ophthalmologist should assess all impairments of visual acuity, visual fields, extra-
ocular movements or diplopia.
5.13 Trigeminal nerve assessment (p 331 AMA5): Sensory impairments of the

trigeminal nerve should be assessed with reference to AMA5 table 13-11 (p 331).
The words 'sensory loss or dysaesthesia' should be added to the table after the words
'neuralgic pain' in each instance. Lesions of the ophthalmic division of the trigeminal
nerve with impairment of corneal sensation should be apportioned with extra
weighting.
If present, motor loss for the trigeminal nerve should be assessed in terms of its
impact on mastication and deglutition (p 262 AMA5).
For bilateral injury to the trigeminal nerves, assess each side separately and combine
the assessed WPIs.
5.14 Spinal accessory nerve: AMA5 provides insufficient reference to the spinal
accessory nerve (cranial nerve XI). This nerve supplies the trapezius and
sternomastoid muscles. For loss of use of the nerve to trapezius, the assessor should
refer to AMA5 chapter 16 on upper limb assessment, and a maximum of 10 per cent
impairment of the upper limb may be assigned. For additional loss of use of
sternomastoid, a maximum of three per cent upper limb impairment may be added.
5.15 Impairment of sexual function caused by severe traumatic brain injury is to be

assessed by using table 13.21 (p 342 AMA5). For spinal cord, nerve root or more
peripheral nerve injury, sexual impairment should only be assessed where there is
appropriate objective evidence of spinal cord, cauda equina or bilateral nerve root
dysfunction or lumbosacral plexopathy.
5.16 Impairment due to miscellaneous peripheral nerves should be evaluated with

reference to the following table.

Table 5.1 Criteria for Rating Miscellaneous Peripheral Nerves
Whole Person Impairment Rating

Peripheral 0% 1% 2% - 3% 4% - 5%
Nerve
Clinical No neuralgia Sensory loss Mild to Severe
features only in an moderate neurogenic
anatomic neurogenic pain and
distribution pain and sensory
sensory alteration in an
alteration in an anatomic
anatomic distribution
distribution
Greater
Occipital Nerve
or
Lesser
Occipital Nerve
or
Greater
Auricular
Nerve
Intercostal
Nerve
Genitofemoral
Ilio-inguinal
Ilio-hypogastric
Pudendal

6. Ear, nose, throat and related structures
ear (with the exception of hearing impairment), nose, throat and related structures,
subject to the modifications set out below. Before undertaking an impairment
assessment, users of this Guide must be familiar with the following:
 The Introduction of this Guide
Introduction
6.1 AMA5 chapter 11 (pp 245-275) details the assessment of the ear, nose, throat and
related structures. With the exception of hearing impairment, which is dealt with in
chapter 9 of this Guide, AMA5 chapter 11 should be followed in assessing permanent
impairment, with the variations included below.
6.2 The level of impairment arising from conditions that are not work related needs to be
assessed by the medical assessor and taken into consideration in determining the level
of permanent impairment. The level at which pre-existing conditions and lifestyle
activities such as smoking contribute to the level of permanent impairment requires
judgement on the part of the clinician undertaking the impairment assessment. The
manner in which any deduction for these is applied needs to be recorded in the
assessing specialist's report.
The ear
6.3 Equilibrium is assessed according to AMA5 section 11.2b (pp 252-255), but add
these words to AMA5 table 11-4 (p 253) class 2: 'without limiting the generality of
the above, a positive Hallpikes test is a sign and an objective finding'.
The face (AMA5, pp255–259)
6.4 AMA5 table 11-5 (p 256) should be replaced with table 6.1 below when assessing
permanent impairment due to facial disorders and/or disfigurement.

Table 6.1: Criteria for rating permanent impairment due to facial disorders and/or
disfigurement
Class 1 Class 2 Class 3 Class 4
0%–5% 6%–10% 11%–15% 16%–50%
impairment of the impairment of the impairment of the impairment of the
whole person whole person whole person whole person
Facial abnormality Facial abnormality Facial abnormality Massive or total
limited to disorder of involves loss of involves absence of distortion of normal
cutaneous structures, supporting structure normal anatomic facial anatomy with
such as visible of part of face, with part or area of face, disfigurement so
simple scars (not or without cutaneous such as loss of eye severe that it
hypertrophic or disorder (e.g., or loss of part of precludes social
atrophic) or depressed cheek, nose, with resulting acceptance,
abnormal nasal, or frontal cosmetic deformity, or
pigmentation (refer bones) combine with any severe, bilateral,
to AMA5 Chapter 8 or functional loss, e.g., facial paralysis
for skin disorders) near complete loss vision (AMA4 affecting most
or of definition of the Chapter 8) branches
mild, unilateral, outer ear or or
facial paralysis severe unilateral loss of a major
affecting most facial paralysis portion of or entire
branches affecting most nose
or branches
nasal distortion that or
affects physical mild, bilateral, facial
appearance paralysis affecting
or most branches
partial loss or
deformity of the
outer ear
Note: Tables used to classify the examples in AMA5 section 11.3 (p 256-259) should also
be ignored and assessors should refer to the modified table above for classification.
6.5 AMA5 example 11-11 (p 257): Add 'visual impairment related to enophthalmos must
be assessed by an Ophthalmologist'.
The nose, throat and related structures
Respiration (AMA5 Section 11.4a, pp259–261)
6.6 In regard to sleep apnoea (third paragraph, AMA5 section 11.4a, p 259), a sleep study
and an examination by an ear, nose and throat specialist is mandatory before
assessment by an approved assessor.
6.7 The assessment of sleep apnoea is addressed in AMA5 section 5.6 (p 105) and
assessors should refer to this chapter, as well as paragraphs 8.8–8.10 in this Guide.
6.8 AMA5 table 11-6 criteria for rating impairment due to air passage defects (p
260 AMA5) should be replaced with table 6.2, below, when assessing permanent
impairment due to air passage defects.

Table 6.2: Criteria for rating permanent impairment due to air passage defects
Percentage impairment of the whole person
Class 1a Class 1 Class 2 Class 3 Class 4 Class 5
0%–5% 0%–10% 11%–29% 30%–49% 50%–89% 90%+
There are Dyspnea does Dyspnea does Dyspnea does not Dyspnea Severe dyspnea
symptoms of not occur at rest not occur at rest occur at rest occurs at rest, occurs at rest and
significant and and and although spontaneous
difficulty in dyspnea is not dyspnea is not dyspnea is individual is respiration is
breathing produced by produced by produced by not necessarily inadequate
through the walking freely walking freely walking freely bedridden and
nose. on a level on a level more than one or and respiratory
Examination surface, surface, two level blocks, dyspnea is ventilation is
reveals climbing stairs climbing one climbing one aggravated by required
significant freely, or flight of stairs, flight of stairs the and
partial performance of or performance even with periods performance
obstruction of examination
other usual of other usual of rest, or of any of the reveals partial
the right and/or activities of activities of performance of usual activities
left nasal cavity obstruction of the
daily living daily living other usual of daily living oropharynx,
or nasopharynx activities of daily (beyond
and but laryngopharynx,
or significant living personal
septal dyspnea is not dyspnea is larynx, upper
produced by produced by and cleansing, trachea (to the
perforation. dressing or
stress, stress, dyspnea is fourth cartilaginous
prolonged prolonged produced by grooming) ring), lower trachea
exertion, exertion, stress, prolonged and or bronchi
hurrying, hill- hurrying, hill- exertion, examination
climbing, or climbing, or hurrying, hill- reveals partial
recreational or recreational or climbing, or obstruction of
similar activities similar activities recreational or the
requiring (except similar activities oropharynx,
intensive effort* sedentary and laryngopharyx
and forms) examination , larynx, upper
examination and reveals partial trachea (to the
reveals partial examination obstruction of the fourth
obstruction of reveals partial oropharynx, cartilaginous
the oropharynx, obstruction of laryngopharynx, ring), lower
laryngopharynx, the oropharynx, larynx, upper trachea, and/or
larynx, upper laryngopharynx, trachea (to the bronchi
trachea (to the larynx, upper fourth
fourth trachea (to the cartilaginous
cartilaginous fourth ring), lower
ring), lower cartilaginous trachea or bronchi
trachea, bronchi, ring), lower
or complete trachea, bronchi,
(bilateral) or complete
obstruction of (bilateral)
the nose or obstruction of
nasopharynx the nose or
nasopharynx
*Prophylactic restriction of activity, such as strenuous competitive sport, does not exclude
subject from class 1.

Note: Individuals with successful permanent tracheostomy or stoma should be rated
at 25 per cent WPI. AMA5 example 11-16 (p 261): Partial obstruction of the larynx
affecting only one vocal cord is better linked to voice (AMA5 section 11.4e).
6.9 When using AMA5 Table 11-7 ‘Relationship of dietary restrictions to permanent
impairment’ (p 262), the first WPI category is to be 0–19 per cent, not 5-19 per cent.
Speech (AMA5, pp 262–264)
6.10 Regarding the first sentence of the 'examining procedure' subsection (pp 263-264
AMA5): the examiner should have sufficient hearing for the purpose- disregard
'normal hearing as defined in the earlier section of this chapter on hearing'.
6.11 Examining procedure (pp 263-264 AMA5), second paragraph: 'The examiner should
base judgements of impairment on two kinds of evidence: (1) attention to and
observation of the individual's speech in the office- for example, during conversation,
during the interview, and while reading and counting aloud- and (2) reports
pertaining to the individual's performance in everyday living situations'. Disregard
the next sentence: 'The reports or the evidence should be supplied by reliable
observers who know the person well.'
6.12 Examining procedure (pp 263-264 AMA5): where the word 'American' appears as a
reference, substitute 'Australian', and change measurements to the metric system (e.g.
8.5 inch = 22cm).
The voice (AMA5 Section 11.4e, pp 264–267)
6.13 Substitute the word 'laryngopharyngeal' for 'gastroesophageal' in all examples where
it appears.
6.14 Example 11.25 in AMA5 (p 269) ‘Impairment rating’, second sentence: add the
words “including respiratory impairment” into the sentence to read 'Combine with
appropriate ratings due to other impairments including respiratory impairment to
determine whole person impairment'.
Ear, nose, throat and related structures impairment evaluation summary
6.15 AMA5 table 11-10 (pp 272-275): Disregard this table, except for impairment of
olfaction and/or taste, and hearing impairment as determined in this Guide.

7. Urinary and reproductive systems
urinary and reproductive systems, subject to the modifications set out below. Before
undertaking an impairment assessment, users of this Guide must be familiar with the
following:
The provisions of this Guide take precedence over AMA5
Introduction
7.1 AMA5 chapter 7 (pp 143-171) provides clear details for assessment of the urinary
and reproductive systems. Overall the chapter should be followed in assessing
permanent impairment, with the variations included below.
7.2 For both male and female sexual dysfunction, identifiable pathology should be
present for an impairment percentage to be given.
Urinary diversion
7.3 AMA5 table 7-2 (p 150) should be replaced with table 7.1, below, when assessing
permanent impairment due to urinary diversion disorders. This table includes ratings
for neobladder and continent urinary diversion.
7.4 Continent urinary diversion is defined as a continent urinary reservoir constructed of

small or large bowel with a narrow catheterisable cutaneous stoma through which it
must be emptied several times a day.
Table 7.1: Criteria for rating permanent impairment

due to urinary diversion disorders
Diversion type % Impairment of the whole

person
Ureterointestinal 10%
Cutaneous ureterostomy 10%
Nephrostomy 15%
Neobladder/replacement 15%
cystoplasty
Continent urinary diversion 20%
Bladder
7.5 AMA5 table 7-3 (p 151) should be replaced with table 7. 2 below when assessing
permanent impairment due to bladder disease. This table includes ratings involving
urge and total incontinence (defined in 7.8 of this Guide).

Table 7.2: Criteria for rating permanent impairment due to bladder disease
Class 1 Class 2 Class 3

0%–15% impairment of 16%–40% impairment of 41%–70% impairment of
the whole person the whole person the whole person
Symptoms and signs of Symptoms and signs of Abnormal (i.e. under- or over-
bladder disorder bladder disorder e.g., urinary ) reflex activity (e.g.,
and frequency (urinating more intermittent urine dribbling,
requires intermittent than every two hours); loss of control, urinary
treatment severe nocturia (urinating urgency and urge incontinence
more than three times a once or more each day)
and
night); urge incontinence and/or
normal functioning between more than once a week
malfunctioning episodes no voluntary control of
and micturition; reflex or areflexic
requires continuous bladder on urodynamics
treatment and/or
total incontinence e.g., fistula
7.6 AMA5 example 7-16 (p151) should be reclassified as an example of class 2, as the
urinary frequency is more than every two hours and continuous treatment would be
expected.
Urethra
permanent impairment due to urethral disease. This table includes ratings involving
stress incontinence.
Table 7.3: Criteria for rating permanent impairment due to urethral disease

Symptoms and signs of Symptoms and signs of Urethral dysfunction
urethral disorder urethral disorder; stress resulting in intermittent
and urinary incontinence more urine dribbling, or stress
requires intermittent therapy than three times a week urinary incontinence at least
for control and daily
cannot effectively be
controlled by treatment
Urinary incontinence
7.8 Urge urinary incontinence is the involuntary loss of urine associated with a strong
desire to void. Stress urinary incontinence is the involuntary loss of urine occurring
with clinically demonstrable raised intra-abdominal pressure. It is expected that

urinary incontinence of a regular or severe nature (necessitating the use of protective
pads or appliances) will be assessed as follows:
Stress urinary incontinence (demonstrable clinically):11–25% according to

severity
Urge urinary incontinence: 16–40% according to severity
Mixed (urge and stress) incontinence: 16–40% according to severity
Nocturnal enuresis or wet in bed: 16–40% according to severity
Total incontinence (continuously wet, e.g., from fistula): 50–70%
The highest scoring condition is to be used to assess impairment — combinations are
not allowed.
Male reproductive organs
Penis
7.9 AMA5 (p 157): the box labelled 'class 3, 21-35 per cent' should read 'class 3, 20 per
cent impairment of the whole person' as the descriptor 'no sexual function possible'
does not allow a range. (The correct value is shown in AMA5 Table 7-5, p. 156).
Note, however, that there is a loading for age, so a rate higher than 20 per cent is
possible.
Testicles, epididymides and spermatic cords
permanent impairment due to testicular, epididymal and spermatic cord disease. This
table includes rating for infertility and equates impairment with female infertility (see
table 7.5, in this Guide). Infertility in either sex must be considered to be of equal
impact, age for age.
7.11 Male infertility is defined as azoospermia or other cause of inability to cause

impregnation even with assisted contraception techniques.
7.12 Loss of sexual function related to spinal injury should only be assessed as an
impairment where there is other objective evidence of spinal cord, cauda equina or
bilateral nerve root dysfunction. The ratings described in table 13-21 on p 342 of
AMA5 are used in this instance. There is no additional impairment rating system for
loss of sexual function in the absence of objective clinical findings.

Table 7.4: Criteria for rating permanent impairment due to testicular, epididymal and
spermatic cord disease

Testicular, epididymal or Testicular, epididymal or Trauma or disease produces
spermatic cord disease spermatic cord disease bilateral anatomic loss of the
symptoms and signs and symptoms and signs and primary sex organs
anatomic alteration anatomic alteration or
and and no detectable seminal or
no continuous treatment cannot effectively be hormonal function
required controlled by treatment or
and and infertility
no seminal or hormonal detectable seminal or
function or abnormalities hormonal abnormalities
or
solitary testicle
Female reproductive organs
Fallopian tubes and ovaries
permanent impairment due to fallopian tube and ovarian disease. This table includes
rating for infertility and equates impairment with male infertility (see table 7.4
above). Infertility in either sex must be considered to be of equal impact, age for age.
7.14 Female infertility: a woman in the childbearing age is infertile when she is unable
to conceive naturally. This may be due to anovulation, tubal blockage, cervical or
vaginal blocking or an impairment of the uterus.
Table 7.5: Criteria for rating permanent impairment due to fallopian tube and ovarian
disease

Fallopian tube or ovarian Fallopian tube or ovarian Fallopian tube or ovarian
disease or deformity disease or deformity disease or deformity
symptoms and signs do not symptoms and signs require symptoms and signs
require continuous treatment continuous treatment, but and
or tubal patency persists and total tubal patency loss or
only one functioning ovulation is possible failure to produce ova in the
fallopian tube or ovary in premenopausal period
the premenopausal period or
or bilateral fallopian tube or
bilateral fallopian tube or bilateral ovarian loss in the
ovarian functional loss in the premenopausal period;
postmenopausal period infertility

8. Respiratory system
respiratory system, subject to the modifications set out below. Before undertaking an
Introduction
8.1 AMA5 chapter 5 provides a useful summary of the methods for assessing permanent
impairment arising from respiratory disorders.
8.2 The level of impairment arising from conditions that are not work related needs to be
assessed by the medical assessor and taken into consideration in determining the level
of permanent impairment. The level at which pre-existing conditions and lifestyle
activities such as smoking contribute to the level of permanent impairment requires
judgement on the part of the clinician undertaking the impairment assessment. The
manner in which any deduction for these is applied needs to be recorded in the
assessing specialist's report.
Examinations, clinical studies and other tests for evaluating respiratory disease (AMA5
section 5.4)
8.3 AMA5 tables 5-2b, 5-3b, 5-4b, 5-5b, 5-6b and 5-7b (pp95-100) give the lower limits
of normal values for pulmonary function tests. These are used in table 5-12 to
determine the impairment classification for respiratory disorders.
8.4 Classes 2, 3 and 4 in table 5-12 (p107) list ranges of WPI. The assessor should
nominate the nearest whole percentage based on the complete clinical circumstances
when selecting within the range.
Asthma (AMA5 section 5.5)
8.5 In assessing permanent impairment arising from occupational asthma, the assessor
will require evidence from the treating physician that:
 At least three lung function tests have been performed over a six month period
and that the results were consistent and repeatable over that period;
 the worker has received maximal treatment and is compliant with his/her
medication regimen.
8.6 Bronchial challenge testing should not be performed as part of the impairment
assessment, therefore in AMA5 table 5-9 (p 104) ignore column four (PC20 mg/mol
or equivalent, etc.).

8.7 Permanent impairment due to asthma is rated by the score for the best post-
bronchodilator forced expiratory volume in one second (FEV1) (score in column 2,
AMA5 table 5-9) plus per cent of FEV1 (score in column 3) plus minimum
medication required (score in column 5). The total score derived is then used to assess
the percent impairment in AMA5 table 5-10 (p 104).
Obstructive sleep apnoea (AMA5 section 5.6)
8.8 This section needs to be read in conjunction with AMA5 section 11.4 (p 259) and
section 13.3c (p 317).
8.9 Before permanent impairment can be assessed, the person must have appropriate
assessment and treatment by an ear, nose and throat surgeon and a respiratory
physician who specialises in sleep disorders.
8.10 Degree of permanent impairment due to sleep apnoea should be calculated with
reference to AMA5 table 13-4 (p 317).
Hypersensitivity pneumonitis (AMA5 section 5.7)
8.11 Permanent impairment arising from disorders included in this section are assessed
according to the impairment classification in AMA5 table 5-12 (p107).
Pneumoconiosis (AMA5 section 5.8)
8.12 Permanent impairment due to pneumoconiosis is assessed according to the

impairment classification in AMA5 Table 5–12.
Lung cancer (AMA5 section 5.9)
8.13 Permanent impairment due to lung cancer should be assessed at least six months after
surgery. Table 5-12 (AMA5 p107) (not table 5-11) should be used for assessment of
permanent impairment.
8.14 Persons with residual lung cancer after treatment are classified in respiratory
impairment class 4 (table 5-12) (AMA5 p107).
Permanent impairment due to respiratory disorders (AMA5 section 5.10)
8.15 Table 5-12 (p 107 AMA5) should be used to assess permanent impairment for
respiratory disorders. The pulmonary function tests listed in table 5-12 must be
performed under standard conditions. Exercise testing is not required on a routine
basis.
8.16 An isolated abnormal diffusing capacity for carbon monoxide (DCO) in the presence
of otherwise normal results of lung function testing should be interpreted with
caution and its aetiology should be clarified.

9. Hearing
Chapter 11, AMA5 (page 245) applies to the assessment of permanent impairment of
hearing, subject to the modifications set out below. Before undertaking an impairment
assessment, users of the Guide must be familiar with the following:
 The Introduction in the Guide
 The appropriate chapter/s of the Guide for the body system they are assessing.
 The National Acoustic Laboratory Report No. 118 Improved procedure for
determining percentage loss of hearing (January 1988) and its associated tables.
Assessment of hearing impairment (hearing loss)
9.1 A worker requiring assessment of permanent impairment resulting from a hearing

injury must undergo an audiometric test for hearing conducted by an audiologist for
the purposes of assessment.
In accordance with section 179 of the Workers’ Compensation and Rehabilitation

Act 2003 (the Act), audiologists who have undertaken the required training in this
Guide can assess a worker’s degree of permanent impairment arising from an
industrial deafness injury. For all other hearing injuries, the assessor should be an
appropriately qualified medical specialist who has undertaken the required training
in this Guide.
A worker may present for assessment of hearing loss for compensation purposes
before having undergone all or any of the health investigations that generally occur
before assessment of permanent impairment. For this reason and to ensure that
conditions other than “occupational hearing impairment” are precluded, an
audiologist who assesses a worker for impairment due to industrial deafness should
alert the referring insurer or body if there is evidence (e.g. audiogram, history) of
another possible cause to the worker’s hearing impairment other than industrial
deafness. In such cases, a further assessment by a specialist may be undertaken.
9.2 The worker’s hearing levels must be determined separately for the left and right ears
at audiometric test frequencies 500, 1000, 1500, 2000, 3000 and 4000Hz with an
audiometer complying with AS IEC 60645.3-2002 (Electroacoustics – Audiological
equipment – Auditory test signals of short duration for audiometric and neuro-
ontological purposes). The test must be preceded by a period of quiet of at least 8
hours. For air conduction testing, the test must comply with AS/NZS 1269.4:2005
(Occupational noise management – Auditory assessment).
9.3 The assessment needs to be undertaken in accordance with the hearing impairment
section of Table 11-10 in AMA5 (pp 272-275). The assessment must be based on a
medical history and an examination of the worker, evaluation of relevant audiological
tests and evaluation of other relevant investigations available to the assessor.
Some of the relevant tests are discussed in the AMA5 hearing impairment evaluation
summary table 11-10 (pp 272-275). The relevant row is the one headed 'hearing
impairment' with the exception of the last column headed 'degree of impairment'. The
degree of impairment is determined according to this Guide.

9.4 Disregard AMA5 sections 11.1b and 11.2 (pp 246-255), but retain section 11.1a
(interpretation of symptoms and signs, p 246).
9.5 The level of hearing impairment caused by non-work-related conditions is assessed

by the assessor and considered when determining the level of work-related hearing
impairment. This requires clinical judgement on the part of the assessor and any non-
work-related deductions should be recorded in their report.
9.6 Disregard AMA5 tables 11-1, 11-2, and 11-3 (pp 247-250). For the purposes of this
Guide, National Acoustic Laboratory (NAL) tables from the NAL report No. 118,
'improved procedure for determining percentage loss of hearing' (January 1988) are
adopted as follows:
 Tables RB 500–4000 (pp 11–16)

 Tables RM 500–4000 (pp 18–23)
 Appendix 1 and 2 (pp 8–9)
 Appendix 5 and 6 (pp 24–26)
 Tables EB 4000–8000 (pp 28–30) (The extension tables)
 Table EM 4000–8000 (pp 32–34) (The extension tables)
Where an assessor uses the extension tables, they must provide an explanation of the
worker's "special requirement to be able to hear at frequencies above 4000Hz."
(NAL Report no.118, p6).
In the presence of significant conduction hearing loss, the extension tables do not
apply.
AMA5 table 11-3 is replaced by table 9.1 at the end of this chapter.
Hearing impairment
9.7 Impairment of a worker's hearing is determined according to evaluation of the

individual's binaural hearing impairment.
9.8 Permanent hearing impairment should be evaluated when the condition is stable.
Prosthetic devices (that is, hearing aids) must not be worn during the evaluation of
hearing sensitivity.
9.9 Hearing threshold level for pure tones is defined as the number of decibels above
standard audiometric zero for a given frequency at which the listener's threshold of
hearing lies when tested in a suitable sound attenuated environment. It is the reading
on the hearing level dial of an audiometer that is calibrated according to Australian
Standard AS 2586-1983.
9.10 Evaluation of binaural hearing impairment is determined by using the tables in the
1988 NAL publication with allowance for presbyacusis according to the presbyacusis
correction table, if applicable, in the same publication.
The binaural tables RB 500-4000 (NAL no 118, pp11-16) are to be used. The
extension tables EB 4000-8000 (pp28-30) may be used when the worker has a
"special requirement to be able to hear at frequencies above 4000Hz" (NAL report
no.118, p6). Where an assessor uses the extension tables, they must provide an

explanation of the worker's special requirement to be able to hear at frequencies
above 4000Hz. For the purposes of calculating binaural hearing impairment, the
better and worse ear may vary as between frequencies.
Where it is necessary to use the monaural tables, the binaural hearing impairment
(BHI) is determined by the formula:
BHI = [4 x (better ear hearing loss)] + worse ear hearing loss

5
9.11 Presbyacusis correction (NAL publication, p 24) only applies to occupational hearing
loss contracted by gradual process (e.g. occupational noise induced hearing loss
and/or occupational solvent induced hearing loss). Please note when calculating by
formula for presbyacusis correction (e.g. when the worker is above 81 years), use the
formula at appendix 6 at line 160 (NAL publication, p 26) which uses the correct
number of 1.79059. Note: there is a typographical error at Table P on p 25 of the
NAL publication, with the number 1.79509 incorrectly used.
9.12 Addition for severe tinnitus: Once binaural hearing loss has been assessed, up to 5
percent may be added to the work-related binaural hearing impairment for severe
tinnitus caused by a work-related injury:
 after legislated deduction of the first 5 percent of binaural hearing loss (if
applicable);
 after presbyacusis correction (if applicable);
 before proportion for time worked outside of Queensland (if applicable); and
 before determining the worker’s WPI%.
If an audiologist is assessing a worker with industrial deafness and is unable to

determine the severity of the worker’s tinnitus or an appropriate addition for it, the
worker may have a further assessment by another specialist.
9.13 Only hearing ear: A worker has an 'only hearing ear' if he or she has suffered a non-
work-related severe or profound sensorineural hearing loss in the other ear. If a
worker suffers a work-related injury causing a hearing loss in the only hearing ear of
x dBHL at a relevant frequency, the worker's work-related binaural hearing
impairment at that frequency is calculated from the binaural tables using x dB as the
hearing threshold level in both ears. If applicable, any other adjustments to the
assessed hearing loss (e.g. for presbyacusis, severe tinnitus or any other legislated
adjustments) are undertaken according to this Guide.
9.14 When necessary, binaural hearing impairment figures should be rounded to the
nearest 0.1 per cent. Rounding up should occur if equal to or greater than 0.05 per
cent, and rounding down should occur if less than 0.05 per cent.
9.15 Table 9.1 is used to convert the worker’s final binaural hearing impairment, after any
applicable adjustments for presbyacusis, severe tinnitus or pre-existing hearing loss,
to their WPI.
In accordance with section 125 of the Act, for cases of industrial deafness the assessor
must also:

 deduct the first 5 percent of the worker’s current binaural hearing impairment
before adjusting for presbyacusis and tinnitus; and
 as a final adjustment, apportion the worker’s binaural hearing impairment for
any work-related noise exposure not occurring in Queensland.
9.16 Pre-existing hearing loss: Where a worker previously has been compensated for a
degree of work-related hearing impairment or there is objective evidence of a degree
of binaural hearing impairment prior to their current injury, this percentage of prior
hearing impairment is to be deducted by the assessor from their current assessed
binaural hearing impairment. This deduction is to be done with other applicable
adjustments but in assessments of industrial deafness, before apportioning for work-
related noise exposure not incurred in Queensland.
This Guide’s method of determining a worker’s compensable binaural hearing

impairment is consistent with the legislated method that preceded this Guide.
Although where a previous hearing impairment was not assessed in accordance with
the method outlined in this Guide, the applicable method is set out in the following
example:
 The current level of binaural hearing impairment is established by the relevant

specialist.
 Convert this to WPI from Table 9.1 in this Guide.
 Calculate the proportion of the current binaural hearing impairment that was
accounted for by the earlier assessment and express it as a percentage of the
current hearing impairment.
 The percentage of current hearing impairment that remains is the amount to be
compensated.
 This needs to be expressed in terms of WPI for calculation of compensation
entitlement.
Example:
 The current binaural hearing loss is eight per cent.
 The WPI is four per cent.
 The binaural hearing impairment for which compensation was paid previously
is six per cent, which is 75 per cent of the current binaural hearing impairment
of eight per cent.
 The remaining percentage, 25 per cent, is the percentage of WPI to be
compensated.
 25 percent of the WPI of four per cent is one per cent WPI.

Table 9.1: Relationship of binaural hearing impairment to whole person impairment
% Binaural % WPI % Binaural % WPI

hearing hearing
impairment impairment
0.0–1.1 0 50.1–52.7 21
1.2–2.5 1 52.8–55.0 22
2.6–4.7 2 55.1–57.7 23
4.8–7.6 3 57.8–60.0 24
7.7–9.7 4 60.1–62.5 25
9.8–12.6 5 62.6–65.0 26
12.7–15.0 6 65.1–67.7 27
15.1–17.6 7 67.8–70.0 28
17.7–19.8 8 70.1–72.8 29
19.9–22.6 9 72.9–75.0 30
22.7–24.8 10 75.1–77.8 31
24.9–27.4 11 77.9–80.0 32
27.5–29.9 12 80.1–82.8 33
30.0–32.6 13 82.9–85.1 34
32.7–34.9 14 85.2–87.8 35
35.0–37.7 15 87.9–90.2 36
37.8–39.9 16 90.3–92.7 37
40.0–42.7 17 92.8–95.1 38
42.8–44.9 18 95.2–97.6 39
45.0–47.7 19 97.7–100 40
47.8–50.0 20
9.17 AMA5 examples 11.1, 11.2, 11.3 (pp 250-251) are replaced by the following
examples 9.1-9.7. Table 9.2 gives a summary of the different elements of assessment
addressed in each of these examples.

Table 9.2: Element of assessment in examples
Element Example No.

General use of binaural table — NAL 1,2
1988
“Better ear”–“worse ear” crossover 1,2
Assessable audiometric frequencies 7 — also
1,2,4,5,6
Tinnitus 1,2,3,4
Presbyacusis All examples
Binaural hearing impairment All examples
Conversion to WPI All examples
Gradual process injury 3
Noise-induced hearing loss 1,2,3,5,6,7
Solvent-induced hearing loss 3
Acute occupational hearing loss 4,5
Acute acoustic trauma 5
Pre-existing non-occupational hearing 6
loss
Only hearing ear 6
NAL 1988 Extension Table Use 7
Multiple Causes of Hearing Loss 3,5,6
Head injury 4

Example 9.1: Occupational noise-induced hearing loss and severe tinnitus
A 55-year-old man, who has worked as a boilermaker in Mackay for 30 years, gave a history
of progressive hearing loss and tinnitus. He has previously seen a medical specialist about his
tinnitus, who assessed it as severe. The external auditory canals and tympanic membranes
were normal. Rinne test was positive bilaterally and the Weber test result was central. Clinical
assessment of hearing was consistent with results of pure tone audiometry, which showed a
bilateral sensorineural hearing loss. The medical specialist diagnosed noise induced hearing
loss.
Presbycusis deduction 0
Severe tinnitus addition 4
Previously compensated NA
BHI
Duration of noise 30
exposure (years)
exposure in
Queensland (years)
Frequency Left Ear Right Ear Binaural Hearing Occupational %BHI
(Hz) (dB HL) (dB HL) Impairment
(%BHI)
500 15 10 0 0
1000 20 20 0.8 0.8
1500 25 25 1.4 1.4
2000 35 35 3.4 3.4
3000 60 60 6.3 6.3
4000 75 75 8.2 8.2
Total Occupational BHI 20.1
Discount first 5% of total BHI 20.1 – 5 = 15.1
Presbycusis deduction Nil
Addition for severe tinnitus 15.1 + 4 = 19.1
Less previously compensated BHI Nil
Work-related noise exposure in Qld (30/30)*19.1 = 19.1
Compensable BHI % 19.1%

The current compensable BHI converts to 8% WPI according to Table 9.1
NB: In this example, the worker’s tinnitus was assessed as severe and a value given purely
for the purposes of demonstrating how this is included in the calculation.

Example 9.2: Occupational noise-induced hearing loss and mild tinnitus
A 55-year-old man who has worked as a steelworker for 30 years (including 10 years in
Northern England), gave a history of increasing difficulties with hearing and tinnitus. A
medical specialist diagnosed occupational noise-induced hearing loss with mild tinnitus.
BHI
exposure (years)
exposure in Queensland
(years)
Frequency Left Ear Right Ear Binaural Hearing Occupational
(Hz) (dB HL) (dB HL) Impairment %BHI
(%BHI)
500 15 15 0.0 0.0
1000 15 15 0.0 0.0
1500 20 25 1.0 1.0
2000 30 35 2.5 2.5
3000 50 45 4.2 4.2
4000 55 55 5.2 5.2
Presbycusis deduction 7.9 – 0 = 7.9
Less previously compensated BHI 7.9 – 0 = 7.9
The current compensable BHI converts to 3% WPI according to Table 9.1.

Example 9.3: Multiple gradual process occupational hearing loss
A 63-year-old retired man who worked as a boat builder and printer over a total of 35 years
gave a history of hearing difficulties and tinnitus. There has been marked chronic exposure to
noise and solvents in both occupations. A medical specialist diagnosed bilateral noise-induced
hearing loss and bilateral solvent-induced hearing loss with severe tinnitus, opining that the
solvent exposure contributed to the hearing impairment as a gradual process injury. He has
never had any other otological issues but the referral material states that in 1995 he was
compensated for 4% binaural hearing loss due to industrial deafness.
Presbycusis deduction 1.7

Previously compensated 4
BHI
exposure (years)
(years)
Frequency Left Ear Right Ear Binaural Hearing Occupational
(%BHI)
500 15 15 0.0 0.0
1000 15 15 0.0 0.0
1500 25 25 1.4 1.4
2000 35 40 3.8 3.8
3000 60 60 6.3 6.3
4000 60 60 6.0 6.0
Presbycusis deduction 12.5 – 1.7 = 10.8

Example 9.4: Occupational hearing loss from head injury
A 62-year-old housepainter sustained a head injury after falling from a ladder. He suffered
left hearing loss and tinnitus unaccompanied by vertigo. A specialist has already assessed his
tinnitus as severe. External auditory canals and tympanic membranes are normal. Rinne test
is positive bilaterally and Weber test lateralises to the right. The CT scan of the temporal bones
shows a fracture on the left. Clinical assessment of hearing is consistent with pure tone
audiometry, which shows a flat left sensorineural hearing loss and mild right sensorineural
hearing loss. He has no history of hearing difficulties or tinnitus prior to the accident.
Presbycusis deduction NA
BHI
Duration of noise NA
exposure (years)
Duration of noise NA
(years)
Frequency Left Ear Right Ear Binaural Hearing Occupational %BHI
(Hz) (dB HL) (dB HL) Impairment
(%BHI)
500 50 15 2.3 2.3
1000 55 15 3.1 3.1
1500 60 20 3.4 3.4
2000 65 20 2.6 2.6
3000 65 25 2.2 2.2
4000 65 30 2.1 2.1
6000 65 20 - -
8000 65 20 - -
Discount first 5% of total BHI NA – not industrial deafness
Presbycusis deduction NA – not gradual hearing loss
Work-related noise exposure in Qld NA – not industrial deafness
NB: This example demonstrates how the table may still be used to calculate the final BHI
for cases where the worker does not have gradual noise-induced hearing loss.

Example 9.5a: Occupational noise-induced hearing loss with acute hearing loss
A 65-year-old male production worker with 10 years in his current job was injured in an
explosion at work. He reported immediate post injury otalgia and acute hearing loss in the left
ear. His medical specialist diagnosed occupational noise-induced hearing loss and left acute
acoustic trauma. The medical history provided in the referral does not mention any other
hearing complaints or prior claims made by the worker. The worker’s medical specialist also
had no evidence that immediately before the explosion the hearing in the left ear was
significantly different from that in the right ear.

BHI
exposure (years)
(years)
Frequency Left Ear Right Ear Binaural Hearing Noise induced
(%BHI)
500 30 15 1.0 0.0
1000 45 15 2.5 0.0
1500 55 15 2.5 0.0
2000 70 15 2.2 0.0
3000 80 25 2.4 0.7
4000 80 30 2.3 0.8
Total BHI 12.9
Noise induced BHI 1.5
Acute acoustic trauma BHI 12.9 – 1.5 = 11.4
Addition for severe tinnitus 0
Less previously compensated BHI 0
Noise induced BHI calculation – 1.5 – 5 = -3.5
Discount first 5% (equating to 0)
Work-related noise exposure in Qld 0
Total Compensable BHI % 11.4 + 0 = 11.4%
NB: This example demonstrates how the table may be altered to calculate the final BHI for
cases where the worker has two different work-related causes of hearing loss. Assessors

should note the differences in the adjustments that need to be made to the BHI% before
converting to WPI%.
Example 9.5b: Occupational noise-induced hearing loss with acute hearing loss
A 65-year-old male production worker has reported gradual hearing loss over the last 10 years
he has been employed in his current job. He also reports that he was injured in an explosion
while on a camping holiday about a year ago. He reported immediate post injury otalgia and
acute hearing loss in the left ear as a result of this explosion. However, his medical specialist
diagnosed occupational noise-induced hearing loss in addition to left acute acoustic trauma.
The medical history provided in the referral does not mention any other hearing complaints
or prior claims made by the worker. The worker’s medical specialist also had no evidence that
immediately before the camping explosion the hearing in the left ear was significantly
different from that in the right ear.

BHI
exposure (years)
(years)
(%BHI)
500 30 15 1.0 0.0
1000 45 15 2.5 0.0
1500 55 15 2.5 0.0
2000 70 15 2.2 0.0
3000 80 25 2.4 0.7
4000 80 30 2.3 0.8
Total BHI 12.9
Noise induced BHI 1.5
Discount first 5% of total BHI 1.5 – 5 = -3.5 (0)
Addition for severe tinnitus 0
Less previously compensated BHI 0
Work-related noise exposure in Qld 0
Total Compensable BHI % 0%

As the worker currently has no compensable BHI%, he is assessed as having
no permanent impairment according to the Guide (0% BHI = 0% WPI)
NB: This example is intended to illustrate how the assessor is to assess industrial deafness or
gradual work-related hearing loss when there is a history of traumatic/acute hearing loss that
is not work-related. This example also shows that if a worker’s current BHI resulting from the
gradual hearing loss does not exceed the necessary deductions, they are assessed as having
0% BHI for the purposes of this Guide.

Example 9.6: Occupational noise-induced hearing loss in an only hearing ear
A 66-year-old woman has been a textile worker in Brisbane for 30 years. Childhood mumps
had left her with profound hearing loss in the left ear. She gave a history of progressive hearing
loss in her only hearing ear unaccompanied by tinnitus or vertigo. External auditory canals
and tympanic membranes appeared normal. Rinne test was positive on the right and was false
negative on the left. Weber test lateralised to the right. Clinical assessment of hearing is
consistent with pure tone audiogram showing a profound left sensorineural hearing loss and a
partial right sensorineural hearing loss.
BHI
exposure (years)
(years)
(%BHI)
500 >95 10 3.4 0.0
1000 >95 15 4.3 0.0
1500 >95 20 4.2 0.6
2000 >95 25 3.8 1.1
3000 >95 50 5.4 4.8
4000 >95 70 8.0 7.5
Total BHI 29.1
Occupational (noise induced) BHI 14.0
Discount first 5% of total BHI 14 – 5 = 9
Presbycusis deduction 9–0=9
Addition for severe tinnitus 9+0=9
Less previously compensated BHI 9–0=9
Work-related noise exposure in Qld (30/30)*9 = 9
Total Compensable BHI % 9%
NB: This example demonstrates how the table may be used to calculate the final BHI for cases
where the worker has an only hearing ear or one ear affected by something other than work.
This demonstrates the process outlined in paragraph 9.14 of how to equate the non-hearing or
affected ear with the hearing or non-affected ear.

Example 9.7: Occupational noise-induced hearing loss where there is a special
requirement for ability to hear at frequencies above 4000 Hz
A 56-year-old female electronics technician who worked in a noisy factory for 20 years had
increasing hearing difficulty. The diagnosis made was bilateral occupational noise-induced
hearing loss extending to 6000 Hz or 8000 Hz. Her treating medical specialist was of the
opinion that there was a special requirement for hearing above 4000 Hz. There was no
conductive hearing loss.
Severe tinnitus addition NA
BHI
exposure (years)
(years)
Frequency Left Ear Right Ear %BHI using the %BHI not using
(Hz) (dB HL) (dB HL) extension tables extension tables
500 - - 0.0 0.0
1000 15 15 0.0 0.0
1500 20 25 1.0 1.0
2000 30 35 2.5 2.5
3000 45 45 4.1 4.1
4000 45 50 2.2 3.6
6000 60 55 1.6 –
8000 50 20 0.2 –
Total Occupational BHI 11.6 11.2
The assessing medical specialist is of the opinion that the binaural hearing
impairment in this matter is 11.6% rather than 11.2%
Presbycusis deduction 6.6 + 0 = 6.6
Less previously compensated BHI 6.6 - 0 = 6.6

10. The visual system
visual system, subject to the modifications set out below. Before undertaking an
impairment assessment, users of the Guide must be familiar with the following:
The provisions of this Guide take precedence over AMA4 and AMA5.
Introduction and approach to assessment
10.1 The visual system must be assessed by an ophthalmologist.
10.2 Chapter 8 (pp 209-222) of AMA4 are adopted for this Guide without significant
change.
10.3 AMA4 is used rather than AMA5 for the assessment of permanent impairment of the
visual system because:
 the equipment recommended for use in AMA5 is expensive and not owned by
most privately practising ophthalmologists (e.g. the Goldman apparatus for
measuring visual fields);
 the assessments recommended in AMA5 are considered too complex, raising a
risk that resulting assessments may be of a lower standard than if the AMA4
method was used.
 there is little emphasis on diplopia in AMA5, yet this is a relatively frequent
problem.
 many ophthalmologists are familiar with the Royal Australian College of
Ophthalmologists’ impairment guide, which is similar to AMA4.
10.4 Impairment of vision should be measured with the injured worker wearing their
prescribed corrective spectacles and/or contact lenses, if that was normal for the
injured worker before the workplace injury. If, as a result of the workplace injury,
the injured worker has been prescribed corrective spectacles and/or contact lenses for
the first time, or different spectacles and/or contact lenses than those prescribed
before injury, the difference should be accounted for in the assessment of permanent
impairment.
10.5 The ophthalmologist should perform, or review, all tests necessary for the assessment
of permanent impairment rather than relying on tests, or interpretations of tests, done
by the orthoptist or optometrist.
10.6 An ophthalmologist should assess visual field impairment in all cases.
10.7 In AMA4 Section 8.5, 'other conditions' (p 222), the 'additional10 per cent
impairment' referred to means 10 per cent WPI, not 10 per cent impairment of the
visual system.

11. Psychiatric and psychological disorders
AMA5 Chapter 14 is excluded and replaced by this chapter. Before undertaking an
impairment assessment, users of this Guide must be familiar with the following (in this
order):
This Guide replace the Psychiatric and Psychological chapter in AMA5.
Introduction
11.1 This chapter lays out the method for assessing psychiatric impairment. The
evaluation of impairment requires a medical examination.
11.2 Evaluation of psychiatric impairment is conducted by a Medical Assessment

Tribunal.
11.3 Psychiatric and psychological disorders may be a primary impairment or secondary

to a physical impairment and are assessed in the same way.
Diagnosis
11.4 The impairment rating must be based upon a psychiatric diagnosis (according to a
recognised diagnostic system) and the report must specify the diagnostic criteria upon
which the diagnosis is based. Impairment arising from any of the somatoform
disorders (DSM IV TR, pp 485-511) are excluded from this chapter.
11.5 If pain is present as the result of an organic impairment, it should be assessed as part
of the organic condition under the relevant table. This does not constitute part of the
assessment of impairment relating to the psychiatric condition. The impairment
ratings in the body organ system chapters in AMA5 make allowance for any
accompanying pain.
11.6 It is expected that the psychiatrist will provide a rationale for the rating based on the
injured worker's psychiatric symptoms. The diagnosis is among the factors to be
considered in assessing the severity and possible duration of the impairment, but is
not the sole criterion to be used. Clinical assessment of the person may include
information from the injured worker's own description of his or her functioning and
limitations, from family members and others who may have knowledge of the person.
Medical reports, feedback from treating professionals, results of standardised tests,
including appropriate psychometric testing performed by a qualified clinical
psychologist, and work evaluations may provide useful information to assist with the
assessment. Evaluation of impairment will need to take into account variations in the
level of functioning over time. Percentage impairment refers to 'whole person
impairment'.

Permanent impairment
11.7 A psychiatric disorder is permanent, if in your clinical opinion, it is likely to continue

indefinitely. Regard should be given to:
 the duration of impairment;
 the likelihood of improvement in the injured workers’ condition;
 whether the injured worker has undertaken reasonable rehabilitative treatment;
 any other relevant matters.
Effects of treatment
11.8 Consider the effects of medication, treatment and rehabilitation to date. Is the
condition stable? Is treatment likely to change? Are symptoms likely to improve? If
the injured worker declines treatment, this should not affect the estimate of
permanent impairment. The psychiatrist may make a comment in the report about the
likely effect of treatment or the reasons for refusal of treatment.
Co-morbidity
11.9 Consider co-morbid features (e.g. bi-polar disorder, personality disorder, substance
abuse) and determine whether they are directly linked to the work-related injury or
whether they were pre-existing or unrelated conditions.
Pre-existing impairment
11.10 To measure the impairment caused by a work-related injury or incident, the

psychiatrist must measure the proportion of WPI due to a pre-existing condition. Pre-
existing impairment is calculated using the same method for calculating current
impairment level. The assessing psychiatrist uses all available information to rate the
injured worker's pre-injury level of functioning in each of the areas of function. The
percentage impairment is calculated using the aggregate score and median class score
using the conversion table below. The injured worker's current level of impairment
is then assessed, and the pre-existing impairment level (%) is then subtracted from
their current level to obtain the percentage of permanent impairment directly
attributable to the work-related injury. If the percentage of pre-existing impairment
cannot be assessed, the deduction is 1/10th of the assessed WPI.
Psychiatric impairment rating scale (PIRS)
11.11 Behavioural consequences of psychiatric disorder are assessed on six scales, each of
which evaluates an area of functional impairment:
}
1. Self-care and personal hygiene (Table 11.1)
2. Social and recreational activities (Table 11.2) Activities of daily living
3. Travel (Table 11.3)
4. Social functioning (relationships) (Table 11.4)
5. Concentration, persistence and pace (table 11.5)
6. Employability (Table 11.6)
11.12 Impairment in each area is rated using class descriptors. Classes range from 1 to 5,
in accordance with severity. The standard form must be used when scoring the PIRS.
The examples of activities are examples only. The assessing psychiatrist should take

account of the person's cultural background. Consider activities that are usual for the
person's age, sex and cultural norms.
Table 11.1: Psychiatric impairment rating scale — Self-care and personal hygiene
Class 1 No deficit, or minor deficit attributable to the normal variation in the general
population
Class 2 Mild impairment: able to live independently; looks after self adequately, although
may look unkempt occasionally; sometimes misses a meal or relies on take-away
food.
Class 3 Moderate impairment: Can’t live independently without regular support. Needs
prompting to shower daily and wear clean clothes. Does not prepare own meals,
frequently misses meals. Family member or community nurse visits (or should
visit) 2–3 times per week to ensure minimum level of hygiene and nutrition.
Class 4 Severe impairment: Needs supervised residential care. If unsupervised, may
accidentally or purposefully hurt self.
Class 5 Totally impaired: Needs assistance with basic functions, such as feeding and
toileting.
Table 11.2: Psychiatric impairment rating scale — Social and recreational activities
population: regularly participates in social activities that are age, sex and
culturally appropriate. May belong to clubs or associations and is actively
involved with these.
Class 2 Mild impairment: occasionally goes out to such events without needing a support
person, but does not become actively involved (e.g., dancing, cheering favourite
team).
Class 3 Moderate impairment: rarely goes out to such events, and mostly when prompted
by family or close friend. Will not go out without a support person. Not actively
involved, remains quiet and withdrawn.
Class 4 Severe impairment: never leaves place of residence. Tolerates the company of
family member or close friend, but will go to a different room or garden when
others come to visit family or flat mate.
Class 5 Totally impaired. Cannot tolerate living with anybody, extremely uncomfortable
when visited by close family member.
Table 11.3: Psychiatric impairment rating scale— Travel

population: Can travel to new environments without supervision.
Class 2 Mild impairment: can travel without support person, but only in a familiar area
such as local shops, visiting a neighbour.
Class 3 Moderate impairment: cannot travel away from own residence without support
person. Problems may be due to excessive anxiety or cognitive impairment.
Class 4 Severe impairment: finds it extremely uncomfortable to leave own residence even
with trusted person.
Class 5 Totally impaired: may require two or more persons to supervise when travelling.

Table 11.4: Psychiatric impairment rating scale — Social functioning
population: No difficulty in forming and sustaining relationships (e.g., partner,
close friendships lasting years).
Class 2 Mild impairment: existing relationships strained. Tension and arguments with
partner or close family member, loss of some friendships.
Class 3 Moderate impairment: previously established relationships severely strained,
evidenced by periods of separation or domestic violence. Spouse, relatives or
community services looking after children.
Class 4 Severe impairment: unable to form or sustain long term relationships. Pre-existing
relationships ended (e.g., lost partner, close friends). Unable to care for
dependants (e.g., own children, elderly parent).
Class 5 Totally impaired: unable to function within society. Living away from populated
areas, actively avoiding social contact.
Table 11.5: Psychiatric impairment rating scale — Concentration, persistence and pace
population. Able to pass a TAFE or university course within normal time frame.
Class 2 Mild impairment: can undertake a basic retraining course, or a standard course at
a slower pace. Can focus on intellectually demanding tasks for periods of up to 30
minutes, then feels fatigued or develops headache.
Class 3 Moderate impairment: unable to read more than newspaper articles. Finds it
difficult to follow complex instructions (e.g., operating manuals, building plans),
make significant repairs to motor vehicle, type long documents, follow a pattern
for making clothes, tapestry or knitting.
Class 4 Severe impairment: can only read a few lines before losing concentration.
Difficulties following simple instructions. Concentration deficits obvious even
during brief conversation. Unable to live alone, or needs regular assistance from
relatives or community services.
Class 5 Totally impaired: needs constant supervision and assistance within institutional
setting.

Table 11.6: Psychiatric impairment rating scale — Employability
population. Able to work full time. Duties and performance are consistent with
the injured worker’s education and training. The person is able to cope with the
normal demands of the job.
Class 2 Mild impairment. Able to work full time but in a different environment from that
of the pre-injury job. The duties require comparable skill and intellect as those of
the pre-injury job. Can work in the same position, but no more than 20 hours per
week (e.g., no longer happy to work with specific persons, or work in a specific
location due to travel required).
Class 3 Moderate impairment: cannot work at all in same position. Can perform less than
20 hours per week in a different position, which requires less skill or is
qualitatively different (e.g., less stressful).
Class 4 Severe impairment: cannot work more than one or two days at a time, less than 20
hours per fortnight. Pace is reduced, attendance is erratic.
Class 5 Totally impaired. Cannot work at all.
Using the PIRS to measure impairment
11.13 Rating psychiatric impairment using the PIRS is a two-step procedure:
1. Determine the median class score.
2. Calculate the aggregate score.
Determining the median class score
11.14 Each area of function described in the PIRS is given an impairment rating which
ranges from Class 1 to 5. The six scores are arranged in ascending order, using the
standard form. The median is then calculated by averaging the two middle scores
e.g.:
Example A: 1, 2, 3, 3, 4, 5 Median Class = 3

Example B: 1, 2, 2, 3, 3, 4 Median Class = 2.5 = 3*
Example C: 1, 2, 3, 5, 5, 5 Median Class = 4
*If a score falls between two classes, it is rounded up to the next class. A median
class score of 2.5 thus becomes 3.
11.15 The median class score method was chosen, as it is not influenced by extremes. Each
area of function is assessed separately. While impairment in one area is neither
equivalent nor interchangeable with impairment in other areas, the median seems the
fairest way to translate different impairments onto a linear scale.
Median class score and percentage impairment
11.16 Each median class score represents a range of impairment, as shown below:
 Class 1 = 0–3%
 Class 2 = 4–10%

 Class 3 = 11–30%
 Class 4 = 31–60%
 Class 5 = 61–100%
Calculation of the aggregate score
11.17 The aggregate score is used to determine an exact percentage of impairment within a
particular median class range. The six class scores are added to give the aggregate
score.
Use of the conversion table to arrive at percentage impairment
11.18 The aggregate score is converted to a percentage score using the conversion table
(table 11.7 below).
11.19 The conversion table was developed to calculate the percentage impairment based on
the aggregate and median scores.
11.20 The scores within the conversion table are spread in such a way to ensure that the
final percentage rating is consistent with the measurement of permanent impairment
percentages for other body systems.
Table 11.7: Conversion table
Aggregate score
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
% Impairment
Class 1 0 0 1 1 02 2 2 3 3
Class 2 4 5 5 6 7 7 8 9 9 10
Class 3 11 13 15 17 19 22 24 26 28 30
Class 4 31 34 37 41 44 47 50 54 57 60
Class 5 61 65 70 74 78 83 87 91 96 10
Conversion table — explanatory notes 0
a. Distribution of aggregate scores
 The lowest aggregate score that can be obtained is: 1+1+1+1+1+1=6.
 The highest aggregate score is 5+5+5+5+5+5= 30.
 The table therefore has aggregate scores ranging from six to 30.
 Each median class score has an impairment range, and a range of possible
aggregate scores (e.g. class 3 = 11-30 per cent).
 The lowest aggregate score for class 3 is 13 (1 + 1 + 2 + 3 + 3 + 3 = 13).
 The highest aggregate score for class 3 is 22 (3 + 3 + 3 + 3 + 5 + 5 = 22).
 The conversion table distributes the impairment percentages across aggregate
scores.
b. Same aggregate score in different classes

 The conversion table shows that the same aggregate score leads to different
percentages of impairment in different median classes.
 For example, an aggregate score of 18 is equivalent to an impairment rating of
o 10% in Class 2,
o 22% in Class 3,
o 34% in Class 4.

 This is due to the fact that an injured worker whose impairment is in median class
2 is likely to have a lower score across most areas of function. They may be
significantly impaired in one aspect of their life, such as travel, yet have low
impairment in social function, self-care or concentration.
 Someone whose impairment reaches median class 4 will experience significant
impairment across most aspects of his or her life.
Examples: (Using the previous cases)
Example A
PIRS scores Median class

1 2 3 3 4 5 =3
Aggregate score Total % Impairment

1+ 2+ 3+ 3+ 4+ 5= 18 22%
Example B

1 2 2 3 3 4 =3

1+ 2+ 2+ 3+ 3+ 4= 15 15%
Example C

1 2 3 5 5 5 =4

1+ 2+ 3+ 5+ 5+ 5= 21 44%

Table 11.8: PIRS rating form
Name Claim reference number
D.O.B. Age at time of injury
Date of injury Occupation before
injury
Date of Marital status before
assessment injury
Psychiatric diagnoses 1. 2.
3. 4.
Psychiatric treatment
Is impairment permanent? Yes No (Circle one)
PIRS category Class Reason for decision
Self-care and personal
hygiene
Social and recreational

activities
Travel
Social functioning
Concentration, persistence
and pace
Employability
Score Class Median

=
Aggregate Score
Total %
+ + + + + + =
Impairment (%WPI) from table 11.7

Less pre-existing impairment (if any)
Final Impairment (%WPI)

12. Haematopoietic system
haematopoietic system, subject to the modifications set out below. Before undertaking
an impairment assessment, users of this Guide must be familiar with the following:
Introduction
12.1 AMA5 chapter 9 (pp 191-210) provides guidelines on the method of assessing
permanent impairment of the haematopoietic system. Overall, that chapter should be
followed when conducting the assessment, with variations indicated below.
12.2 Impairment of end organ function due to haematopoietic disorder should be assessed
separately, using the relevant chapter of this Guide. The percentage WPI due to end
organ impairment should be combined with any percentage WPI due to
haematopoietic disorder, using the combined values table (pp 604-606 AMA5).
Anaemia
12.3 Table 12.1 (below) replaces AMA5 Table 9–2 (p 193).
Table 12.1: Classes of anaemia and percentage whole person impairment

Class 1: 0–10% Class 2: 11–30% Class 3: 31–70% Class 4: 71–100%
WPI WPI WPI WPI
No symptoms Minimal symptoms Moderate to marked Moderate to marked
and and symptoms symptoms
haemoglobin 100– haemoglobin 80– and and
120g/L 100g/L haemoglobin 50– haemoglobin 50–
and and 80g/L before 80g/L before
no transfusion no transfusion transfusion transfusion
required required and and
transfusion of 2 to 3 transfusion of 2 to 3
units required, every units required, every
4 to 6 weeks 2 weeks
12.4 The assessor should exercise clinical judgement in determining WPI, using the
criteria in table 12.1. For example, if comorbidities exist which preclude transfusion,
the assessor may assign class 3 or class 4, on the understanding that transfusion would
under other circumstances be indicated. Similarly, there may be some claimants with
class 2 impairment who, because of comorbidity, may undergo transfusion.
12.5 Pre-transfusion haemoglobin levels in table 12.1 are to be used as indications only.
It is acknowledged that for some claimants, it would not be medically advisable to

permit the claimant's haemoglobin levels to be as low as indicated in the criteria of
table 12.1.
12.6 The assessor should indicate a percentage WPI, as well as the class.
Polycythaemia and myelofibrosis
12.7 The level of symptoms (as in table 12.1) should be used a guide for the assessor in
cases where non-anaemic tissue iron deficiency results from venesection.
White blood cell diseases
12.8 In cases of functional asplenia, the assessor should assign three per cent WPI. This
should be combined with any other impairment rating, using the combined values
table (pp 604-606 AMA5).
Haemorrhagic and platelet disorders
12.9 AMA5 table 9-4 (p 203) is to be used as the basis for assessing haemorrhagic and
platelet disorders
12.10 For the purposes of this Guide, the criteria for inclusion in class 3 of AMA5 table 9-
4 (p 203) is:
 Symptoms and signs of haemorrhagic and platelet abnormality

 Requires continuous treatment
 Interference with daily activities; requires occasional assistance.
12.11 For the purposes of this Guide, the criteria for inclusion in class 4 of AMA5 table 9-
4 (p 203) is:
 Symptoms and signs of haemorrhagic and platelet abnormality

 Requires continuous treatment
 Difficulty performing daily activities; requires continuous care.
Thrombotic disorders
12.12 AMA5 table 9-4 (p 203) is used as the basis for determining impairment due to
thrombotic disorder.

13. The endocrine system
endocrine system, subject to the modifications set out below. Before undertaking an
Introduction
13.1 AMA5 chapter 10 provides a useful summary of the methods for assessing permanent
impairment arising from disorders of the endocrine system.
13.2 Refer to other chapters in AMA5 for related structural changes - the skin
(e.g. pigmentation in Chapter 8), the central and peripheral nervous system
(e.g. memory, in Chapter 13), the urinary and reproductive system (e.g. infertility,
renal impairment, in Chapter 7), the digestive system (e.g. dyspepsia, in Chapter 6),
the cardiovascular system (in Chapters 3 and 4) and the visual system (Chapter 8
AMA4).
13.3 The clinical findings to support the impairment assessment are to be reported in the
units recommended by the Royal College of Pathologists of Australia. (See Appendix
13.1).
13.4 Westergren erythrocyte sedimentation rate (WSR) is equivalent to ESR.
Adrenal cortex
13.5 AMA5 (p 222) first paragraph: disregard the last sentence, 'they also affect
inflammatory response, cell membrane permeability, and immunologic responses,
and they play a role in the development and maintenance of secondary sexual
characteristics'. Replace with: 'immunological and inflammatory responses are
reduced by these hormones and they play a role in the development and maintenance
of secondary sexual characteristics'.
13.6 AMA5 example 10-18 (pp 224-225): see reference to ESR (13.4 above).
13.7 AMA5 example 10-20 (p 225): History: for 'hypnotic bladder' read 'hypotonic
bladder'.
Diabetes mellitus
13.8 AMA5 (p 231): refer to the Australian Diabetes Association Guidelines with regard
to levels of fasting glucose. (Position statement from the Australian Diabetes Society,
reprinted in Appendix 13.2).

13.9 AMA5 (p 231): insert at the end of the second paragraph: 'the goal of treatment is to
maintain haemoglobin A lc within one per cent of the normal range (four to 6.3 per
cent)'.
Mammary glands
13.10 AMA5 example 10-45 (p 239), current symptoms: disregard the last sentence, 'both
bromocriptine and cabergoline cause nausea, precluding use of either drug' and
replace with: 'routine use of bromocriptine and cabergoline is normal in Australia. It
is rare that nausea precludes their use'.
Criteria for rating permanent impairment due to metabolic bone disease
13.11 AMA5 (p 240): impairment due to a metabolic bone disease itself is unlikely to be
associated with a work injury and would usually represent a pre-existing condition.
13.12 Impairment from fracture, spinal collapse or other complications may arise as a result
of a work injury associated with these underlying conditions (as noted in AMA5,
section 10.10c) and would be assessed using the other chapters indicated, with the
exception of chapter 18 (pain) which is excluded by this Guide.
Appendix 13 .1: Interpretation of pathology tests
From Manual of use and interpretation of pathology tests, third edition. Reprinted with kind
permission of the Royal College of Pathologists of Australasia.
Reference ranges, plasma or serum, unless otherwise indicated

Alanine aminotransferase (ALT) (adult) < 35 U/L
Albumin (adult) 32–45 g/L
Alkaline phosphatase (ALP) (adult, non-pregnant) 25–100 U/L
Alpha fetoprotein (adult, non-pregnant) < 10 g/L
Alpha-1-antitrypsin 1.7–3.4 g/L
Anion gap 8–16 mmol/L
Aspartate aminotransferase (AST) < 40 U/L
Bicarbonate (total CO2) 22–32 mmol/L
Bilirubin (total) (adult) < 20 µmol/L
Calcium (total) 2.10–2.60 mmol/L
(ionised) 1.17–1.30 mmol/L
Chloride 95–110 mmol/L
Cholesterol (HDL) (male) 0.9–2.0 mmol/L
(female) 1.0–2.2 mmol/L
Cholesterol (total) < 5.5 mmol/L
(National Heart Foundation [Australia] recommendation)
Copper 13–22 µmol/L
Creatine kinase (CK) (male) 60–220 U/L
(female) 30–180 U/L

Creatinine (adult male) 0.06–0.12 mmol/L
(adult female) 0.05–0.11 mmol/L
Gamma glutamyl transferase (male) < 50 U/L
(GGT)
(female) < 30 U/L
Globulin adult 25–35g/L
Glucose (venous plasma) - 3.0–5.4 mmol/L
(fasting)
(venous plasma) - 3.0–7.7 mmol/L
(random)
Lactate dehydrogenase (LD) (adult) 110–230 U/L
Magnesium (adult) 0.8–1.0 mmol/L
Osmolality (adult) 280–300 m.osmoll/kg
water
pCO2 (arterial blood) 4.6–6.0 kPa (35–45
mmHg)
pH (arterial blood) 7.36–7.44 (36–44
nmol/L)
Phosphate 0.8–1.5 mmol/L
pO2 (arterial blood) 11.0–13.5 kPa (80–100
mmHg)
Potassium (plasma) 3.4–4.5 mmol/L
(serum) 3.8–4.9 mmol/L
Prolactin (male) 150–500 mU/L
(female) 0–750 mU/L
Protein, total (adult) 62–80 g/L
Sodium 135–145 mmol/L
Testosterone and related androgens See Table A (below)
Therapeutic intervals
Amitriptyline 150–900 nmol/L 60–250 µg/L
Carbamazepine 20–40 µmol/L 6–12 mg/L
Digoxin 0.6–2.3 nmol/L 0.5–1.8 µg/L
Lithium 0.6–1.2 mmol/L
Nortriptyline 200–650 nmol/L 50–170 µg/L
Phenobarbitone 65–170 µmol/L 15–40 mg/L
Phenytoin 40–80 µmol/L 10–20 mg/L
Primidone 22–50 µmol/L 4.8–11.0 mg/L
Procainamide 17–42 µmol/L 4–10 mg/L

Therapeutic intervals
Quinidine 7–15 µmol/L 2.3–4.8 mg/L
Salicylate 1.0–2.5 mmol/L 140–350 mg/L
Theophylline 55–110 µmol/L 10–20 mg/L
Valproate 350–700 µmol/L 50–100 mg/L
Thyroid stimulating 0.4–5.0 mIU/L
hormone (TSH)
Thyroxine (free) 10–25 pmol/L
Triglycerides (fasting) < 2.0 mmol/L
Triiodothyronine (free) 4.0–8.0 pmol/L
Urate (male) 0.20–0.45 mmol/L
(female) 0.15–0.40 mmol/L
Urea (adult) 3.0–8.0 mmol/L
Zinc 12–20 µmol/L
Table A: Reference intervals for testosterone and related androgens (serum)

Male Female
Pre- Adult (age Pre- Adult (age
pubertal related) pubertal related)
Free testosterone (pmol/L) 170–510 < 4.0
Total testosterone (nmol/L) < 0.5 8–35 < 0.5 < 4.0
SHBG (nmol/L) 55–100 10–50 55–100 30–90 (250–
500 in the 3rd
trimester)
Dihydrotestosterone 1–2.5
(nmol/L)
Reference ranges, urine

Calcium 2.5–7.5 mmol/24 hours
Chloride (depends on intake, 100–250 mmol/24 hours
plasma levels)
Cortisol (free) 100–300 nmol/24 hours
Creatinine (child) 0.07–0.19 mmol/24
hours/kg
(male) 9–18 mmol/24 hours
(female) 5–16 mmol/24 hours
HMMA (infant) < 10 mmol/mol
creatinine
(adult) < 35 µmol/24 hours
Magnesium 2.5–8.0 mmol/24 hours

Reference ranges, urine
Osmolality (depends on hydration) 50–1200 m.osmol/kg
water
Phosphate (depends on intake, 10–40 mmol/24 hours
plasma levels)
Potassium (depends on intake, 40–100 mmol/24 hours
plasma levels)
Protein, total < 150 mg/24 hours
(pregnancy) < 250 mg/24 hours
Sodium (depends on intake, 75–300 mmol/24 hours
plasma levels)
Urate (male) 2.2–6.6 mmol/24 hours
(female) 1.6–5.6 mmol/24 hours
Urea (depends on protein intake) 420–720 mmol/24 hours
Reference ranges, whole blood

Haemoglobin (Hb) (adult male) 130–180 g/L
(adult female) 115–165 g/L
Red cell count (RCC) (adult male) 4.5–6.5 x 1012/L
(adult female) 3.8–5.8 x 1012/L
Packed cell volume (PCV) (adult male) 0.40–0.54
(adult female) 0.37–0.47
Mean cell volume (MCV) 80–100 fL
Mean cell haemoglobin (MCH) 27–32 pg
Mean cell haemoglobin concentration 300–350 g/L
(MCHC)
Leucocyte (White Cell) Count (WCC) 4.0–11.0 x 109/L
Leucocyte differential count
– Neutrophils 2.0–7.5 x 109/L
– Eosinophils 0.04–0.4 x 109/L
– Basophils
< 0.1 x 109/L
– Monocytes
– Lymphocytes 0.2–0.8 x 109/L
Platelet count 1.5–4.0 x 109/L
150–400 x 109/L
Erythrocyte sedimentation rate (ESR) male 17–50 yrs 1–10 mm/hour
male >50 yrs 2–14 mm/hour
female 17–50 yrs 3–12 mm/hour
female >50 yrs 5–20 mm/hour
Reticulocyte count 10–100 x 109/L
(0.2–2.0%)

Iron (adult) 10–30 µmol/L
Iron (total) binding capacity (TIBC) 45–80 µmol/L
Transferrin 1.7–3.0 g/L
Transferrin saturation 0.15–0.45 (15–
45%)
Ferritin (male) 30–300 µg/L
(female) 15–200 µg/L
Vitamin B12 120–680 pmol/L
Folate (red cell) 360–1400 nmol/L
(serum) 7–45 nmol/L
Reference ranges, citrated plasma

Activated partial thromboplastin time (APTT) 25–35 seconds
– Therapeutic range for continuous infusion heparin 1.5–2.5 x baseline
Prothrombin time (PT) 11–15 seconds
International normalised ratio (INR)
– Therapeutic range for oral anticoagulant therapy 2.0–4.5
Fibrinogen 1.5–4.0 g/L
Reference ranges, serum

Rheumatoid factor (nephelometry) < 30 IU/L
C3 0.9–1.8 g/L
C4 0.16–0.50 g/L
C-reactive protein < 5.0 mg/L
Immunoglobulins:
IgG 6.5–16.0g/L
IgA 0.6–4.0g/L
IgM 0.5–3.0g/L
Reference intervals for lymphocyte subsets

Adult
Total lymphocytes 1.5–4.0
CD3 0.6–2.4
CD4 (T4) 0.5–1.4
CD8 (T8) 0.2–0.7
CD19 0.04–0.5
CD16 0.2–0.4
CD4/CD8 ratio 1.0–3.2

Appendix 13.2: New classification and criteria for diagnosis of diabetes mellitus
Position Statement from the Australian Diabetes Society,* New Zealand Society for the
Study of Diabetes,† Royal College of Pathologists of Australasia‡ and Australasian
Association of Clinical Biochemists§
Peter G Colman,* David W Thomas,‡ Paul Z Zimmet,* Timothy A Welborn,* Peter Garcia-Webb§
and M Peter Moore†
First published in the Medical Journal of Australia (MJA 1999; 170: 375–378). Reprinted with
permission.
Introduction
Recently, there has been major growth in knowledge about the aetiology and pathogenesis of
different types of diabetes and about the predictive value of different blood glucose levels for
development of complications. In response, both the American Diabetes Association (ADA)
and the World Health Organization (WHO) have re-examined, redefined and updated the
classification of and criteria for diabetes, which have been
unchanged since 1985. While the two working parties had
cross-representation, they met separately, and Key messages
differences have emerged between their Diagnosis of diabetes is not in doubt when
recommendations. there are classical symptoms of thirst and
polyuria and a random venous plasma
glucose level ≥ 11.1 mmol/L.
The ADA published its final recommendations in 1997,1 The Australasian Working Party on
while the WHO group published its provisional Diagnostic Criteria for Diabetes Mellitus
conclusions for consultation and comment in June 1998.2 recommends:
 Immediate adoption of the new criterion
The WHO process called for comments on the proposal by for diagnosis of diabetes as proposed by
the end of September 1998, with the intention of finalising the American Diabetes Association
(ADA) and the World Health
definitive classification and criteria by the end of Organization (WHO) — fasting venous
December 1998 and of publishing these soon thereafter. plasma glucose level ≥ 7.0 mmol/L;
However, WHO publications need to go through an  Immediate adoption of the new
internal approval process and it may be up to 12 months classification for diabetes mellitus
before the final WHO document appears. proposed by the ADA and WHO, which
comprises four aetiological types — type
1, type 2, other specific types, and
A combined working party of the Australian Diabetes gestational diabetes — with impaired
Society, New Zealand Society for the Study of Diabetes, glucose tolerance and impaired fasting
Royal College of Pathologists of Australasia and glycaemia as stages in the natural
Australasian Association of Clinical Biochemists was history of disordered carbohydrate
metabolism.
formed to formulate an Australasian position on the two
 Awareness that some cases of diabetes
sets of recommendations and, in particular, on the will be missed unless an oral glucose
differences between them. This is an interim statement tolerance test (OGTT) is performed. If
pending the final WHO report, which will include there is any suspicion or other risk factor
recommendations on diabetes classification as well as suggesting glucose intolerance, the
OGTT should continue to be used
criteria for diagnosis. We see it as very important to pending the final WHO recommendation.
inform Australasian health professionals treating patients
with diabetes about these changes.
What are the new diagnostic criteria?

The new WHO criteria for diagnosis of diabetes mellitus and hyperglycaemia are shown in
Box 1. The major change from the previous WHO recommendation3 is the lowering of the
diagnostic level of fasting plasma glucose to ≥7.0 mmol/L, from the former level of ≥7.8
mmol/L. For whole blood, the proposed new level is ≥6.1 mmol/L, from the former ≥6.7
mmol/L.
This change is based primarily on cross-sectional studies demonstrating the presence of

microvascular4 and macrovascular complications5 at these lower glucose concentrations. In
addition, the 1985 WHO diagnostic criterion for diabetes based on fasting plasma glucose level
(≥7.8 mmol/L) represents a greater degree of hyperglycaemia than the criterion based on
plasma glucose level two hours after a 75 g glucose load (≥11.1 mmol/L).6 A fasting plasma
glucose level of ≥7 mmol/L accords more closely with this 2 h post-glucose level.
Recommendation: The ADA and the WHO committee are unanimous in adopting the changed
diagnostic level, and the Australasian Working Party on Diagnostic Criteria recommends that
healthcare providers in Australia and New Zealand should adopt it immediately.
Clinicians should note that the diagnostic criteria differ between clinical and epidemiological
settings. In clinical practice, when symptoms are typical of diabetes, a single fasting plasma
glucose level of ≥7.0 mmol/L or 2 h post-glucose or casual postprandial plasma glucose level
of ≥11.1 mmol/L suffices for diagnosis. If there are no symptoms, or symptoms are equivocal,
at least one additional glucose measurement (preferably fasting) on a different day with a
value in the diabetic range is necessary to confirm the diagnosis. Furthermore, severe
hyperglycaemia detected under conditions of acute infective, traumatic, circulatory or other
stress may be transitory and should not be regarded as diagnostic of diabetes. The situation
should be reviewed when the primary condition has stabilised.
In epidemiological settings, for study of high-prevalence populations or selective screening of

high-risk individuals, a single measure — the glucose-level 2 h post-glucose load — will
suffice to describe prevalence of impaired glucose tolerance (IGT).
1: Values for diagnosis of diabetes mellitus and other categories of hyperglycaemia2

Glucose concentration (mmol/L [mg/dL])
Whole blood Plasma
Venous Capillary Venous Capillary
Diabetes mellitus fasting ≥6.1 (≥110) ≥6.1 (≥110) ≥7.0 (≥126) ≥7.0 (≥126)
or 2 h post-glucose load ≥10.0 (≥180) ≥11.1 (≥200) ≥11.1 (≥200) ≥12.2 (≥220)
or both
Impaired glucose tolerance (IGT) < 6.1 (< 110) < 6.1 (< 110) < 7.0 (< 126) < 7.0 (< 126)
Fasting (if measured) and 2 h post- ≥6.7 (≥120) and ≥7.8 (≥140) and < ≥7.8 (≥140) and < ≥8.9 (≥160) and
glucose load < 10.0 (< 180) 11.1 (< 200) 11.1 (< 200) < 12.2 (< 220)
Impaired fasting glycaemia (IFG) ≥5.6 (≥100) and ≥5.6 (≥100) and ≥6.1 (≥110) and ≥6.1 (≥110) and
Fasting < 6.1 (< 110) < 6.1 (< 110) < 7.0 (< 126) < 7.0 (< 126)
2 h post-glucose load < 6.7 (< 120) < 7.8 (< 140) < 7.8 (< 140) < 8.9 (< 160)
(if measured)
For epidemiological or population screening purposes, the fasting or 2 h value after 75 g oral glucose may be used alone. For clinical purposes, the diagnosis of
diabetes should always be confirmed by repeating the test on another day, unless there is unequivocal hyperglycaemia with acute metabolic decompensation or
obvious symptoms. Glucose concentrations should not be determined on serum unless red cells are immediately removed, otherwise glycolysis will result in an
unpredictable underestimation of the true concentrations. It should be stressed that glucose preservatives do not totally prevent glycolysis. If whole blood is
used, the sample should be kept at 0–4oC or centrifuged immediately, or assayed immediately. Table reproduced with permission from Alberti KGMM, Zimmet
PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus. Provisional Report
of a WHO Consultation. Diabet Med 1998; 15: 539–553. Copyright John Wiley & Sons Limited.

What about the oral glucose tolerance test?
Previously, the oral glucose tolerance test (OGTT) 2: Aetiological classification of

was recommended in people with a fasting plasma disorders of glycaemia*
glucose level of 5.5–7.7 mmol/L or random Type 1 (-cell destruction, usually leading to
plasma glucose level of 7.8–11.0 mmol/L. After a absolute insulin deficiency)
 Autoimmune
75 g glucose load, those with a 2 h plasma glucose
 Idiopathic
level of < 7.8 mmol/L were classified as
Type 2 (may range from predominantly insulin
normoglycaemic, of 7.8–11.0 mmol/L as having resistance with relative insulin deficiency to a
IGT and of ≥11.1 mmol/L as having diabetes. predominantly secretory defect with or without
insulin resistance)
The new diagnostic criteria proposed by the ADA Other specific types
and WHO differ in their recommendations on use  Genetic defects of -cell function
of the OGTT. The ADA makes a strong  Genetic defects in insulin action
recommendation that fasting plasma glucose level  Diseases of the exocrine pancreas
can be used on its own and that, in general, the  Endocrinopathies
OGTT need not be used.1 The WHO group2 argues  Drug or chemical induced
strongly for the retention of the OGTT and  Infections
suggests using fasting plasma glucose level alone  Uncommon forms of immune-
mediated diabetes
only when circumstances prevent the

performance of the OGTT. Other genetic syndromes sometimes
associated with diabetes
Gestational diabetes
There are concerns that many people with a * As additional subtypes are discovered, it is anticipated they will
fasting plasma glucose level < 7.0 mmol/L will be reclassified within their own specific category. Includes the
have manifestly abnormal results on the OGTT former categories of gestational impaired glucose tolerance and
gestational diabetes. Table reproduced with permission from
and are at risk of microvascular and Alberti KGMM, Zimmet PZ. Definition, diagnosis and classification
macrovascular complications. This has major

of diabetes mellitus and its complications. Part 1: diagnosis and
classification of diabetes mellitus. Provisional Report of a WHO
ramifications for the approach to diabetes Consultation. Diabet Med 1998; 15: 539-553. Copyright John Wiley
& Sons Limited.
screening, particularly when the Australian
National Diabetes Strategy proposal,7 launched in
June 1998 by Dr Michael Wooldridge, then Federal
Minister for Health and Aged Care, has early
detection of type 2 diabetes as a key priority.
Recommendation: The Australasian Working Party on Diagnostic Criteria has major

concerns about discontinuing use of the OGTT and recommends that a formal
recommendation on its use in diabetes screening be withheld until the final WHO
recommendation is made. However, in the interim, the OGTT should continue to be used.
Diabetes in pregnancy
The ADA has retained its old criteria for diagnosis of gestational diabetes.1 These differ
from those recommended by both WHO2 and the Australian Working Party on Diabetes in
Pregnancy8 and are generally not recognised outside the United States. The new WHO
statement retains the 1985 WHO recommendation that both IGT and diabetes should be
classified as gestational diabetes. This is consistent with the recommendations of the
Australasian Diabetes in Pregnancy Society, which recommended a diagnostic 2 h venous
plasma glucose level on the OGTT of ≥8.0 mmol/L. In New Zealand, a cut-off level of ≥ 9.0
mmol/L has been applied.8
How has the classification of diabetes changed?

The proposed new classification encompasses both clinical stages and aetiological types of
hyperglycaemia and is supported by numerous epidemiological studies. The classification
by aetiological type (box 2) results from new knowledge of the causes of hyperglycaemia,
including diabetes. The terms insulin-dependent and non-insulin- dependent diabetes
(lOOM and NIDDM) are eliminated and the terms type 1 and type 2 diabetes retained. Other
aetiological types, such as diabetes arising from genetic defects of -cell function or insulin
action, are grouped as 'other specific types', with gestational diabetes as a fourth category.
The proposed staging (box 3) reflects the fact that any aetiological type of diabetes can pass
or progress through several clinical phases (both asymptomatic and symptomatic) during
its natural history. Moreover, individuals may move in either direction between stages.
Impaired glucose tolerance and impaired fasting glycaemia
Impaired glucose tolerance (IGT).a discrete class in the previous classification, is now
categorised as a stage in the natural history of disordered carbohydrate metabolism.
Individuals with IGT are at increased risk of cardiovascular disease, and not all will be
identified by fasting glucose level.
In reducing the use of the OGTT. the ADA recommended a new category- impaired fasting
glycaemia (IFG)- when fasting plasma glucose level is lower than that required to diagnose
diabetes but higher than the reference range (< 7.0 mmoi/L but ≥ 6.1 mmoi/U. Limited
data on this category show that it increases both risk of progressing to diabetes9 and
cardiovascular risk5 . However, data are as yet insufficient to determine whether IFG has
the same status as IGT as a risk factor for developing diabetes and cardiovascular disease
and as strong an association with the metabolic syndrome (insulin resistance syndrome)
IFG can be diagnosed by fasting glucose level alone, but if 2 h glucose level is also measured
some individuals with IFG will have IGT and some may have diabetes. In addition, the
number of people with OGTT results indicating diabetes but fasting plasma glucose level <
7.0 mmol/L is unknown, but early data suggest there may be major variation across
different populations.10

A number of studies, including the DECODE initiative of the European Diabetes
Epidemiology Group, have reported that individuals classified with IFG are not the same as
the IGT group.11-15 The European Group believes that, on available European evidence, the
ADA decision to rely solely on fasting glucose level would be unwise.
Recommendation: The Australasian Working Party on Diagnostic Criteria recommends

immediate adoption of the new classification. However, clinicians should be aware that
some cases of diabetes will be missed unless an OGTT is performed. Thus, if there is any
suspicion or other risk factor suggesting glucose intolerance, the working party continues
to recommend use of an OGTT pending the final WHO recommendation.
References
1. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care
1997; 20: 1183-1197.
2. Alberti KGMM, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its
complications. Part 1: diagnosis and classification of diabetes mellitus. Provisional Report of
a WHO Consultation. Diabet Med 1998; 15: 539-553.
3. World Health Organization. Diabetes mellitus. Report of a WHO study group. Technical report
series 727. Geneva: WHO, 1985.
4. McCance DR, Hanson RL, Charles MA, et al. Comparison of tests for glycated haemoglobin and
fasting and two hour plasma glucose concentrations as diagnostic methods for diabetes.
BMJ 1994; 308: 1323-1328.
5. Charles MA, Balkau B, Vauzelle-Kervoeden F, et al. Revision of diagnostic criteria for diabetes
[letter]. Lancet 1996; 348: 1657-1658.
6. Finch CF, Zimmet PZ, Alberti KGMM. Determining diabetes prevalence: a rational basis for the
use of fasting plasma glucose concentrations? Diabet Med 1990; 7: 603-610.
7. Colagiuri S, Colagiuri R, Ward J. National diabetes strategy and implementation plan.
Canberra: Diabetes Australia, 1998.
8. Hoffman L, Nolan C, Wilson D, et al. Gestational diabetes mellitus -- management guidelines.
The Australasian Diabetes in Pregnancy Society. Med J Aust 1998; 169: 93-97.
9. Charles MA, Fontbonne A, Thibult N, et al. Risk factors for NIDDM in white population.
Diabetes 1991; 40: 796-799.
10. Keen H. Impact of new criteria for diabetes on pattern of disease. Lancet 1998; 352: 1000-
1001.
11. DECODE Study Group on behalf of the European Diabetes Epidemiology Study Group. Will
new diagnostic criteria for diabetes mellitus change phenotype of patients with diabetes?
Reanalysis of European epidemiological data. BMJ 1998; 317: 371-375.
12. De Vegt F, Dekker JM, Stehouwer CDA, et al. The 1997 American Diabetes Association criteria
versus the 1985 World Health Organization criteria for the diagnosis of abnormal glucose
tolerance. Diabetes Care 1998; 21: 1686-1690.
13. Harris MI, Eastman RC, Cowie CC, et al. Comparison of diabetes diagnostic categories in the
US population according to 1997 American Diabetes Association and 1980-1985 World
Health Organization diagnostic criteria. Diabetes Care 1997; 20: 1859-1862.
14. Unwin N, Alberti KGMM, Bhopal R, et al. Comparison of the current WHO and new ADA
criteria for the diagnosis of diabetes mellitus in three ethnic groups in the UK. Diabet Med
1998; 15: 554-557.
15. Chang C-J, Wu J-S, Lu F-H, Lee H-L, et al. Fasting plasma glucose in screening for diabetes in
the Taiwanese population. Diabetes Care 1998; 21: 1856-1860.

14. The skin
Chapter 8, AMA5 (page 173) applies to the assessment of permanent impairment of the skin,
subject to the modifications set out below. Before undertaking an impairment assessment, users of
this Guide must be familiar with the following:
Introduction
14.1 AMA5 chapter 8 (pp 173-190) refers to skin diseases generally rather than work-related skin
diseases alone. This chapter has been adopted for measuring impairment of the skin system,
with the following variations.
14.2 Disfigurement, scars and skin grafts may be assessed as causing significant permanent
impairment when the skin condition causes limitation in the performance of ADL
14.3 For cases of facial disfigurement, refer to table 6.1 in this Guide.
14.4 AMA5 table 8-2 (p 178) provides the method of classification of impairment due to skin
disorders. Three components - signs and symptoms of skin disorder, limitations in ADL and
requirements for treatment - define five classes of permanent impairment. The assessing
specialist should derive a specific percentage impairment within the range for the class that best
describes the clinical status of the claimant.
14.5 The skin is regarded as a single organ and all non-facial scarring is measured together as one
overall impairment rather than assessing individual scars separately and combining the results.
14.6 A scar may be present and rated as zero per cent WPI.
Note that uncomplicated scars for standard surgical procedures do not of themselves rate an
impairment.
14.7 The table tor the evaluation of minor skin impairment (TEMSKI) (see table 14.1) is an extension
of table 8-2 in AMA5. The TEMSKI divides class 1 of permanent impairment (zero to nine per
cent) due to skin disorders into five categories of impairment. The TEMSKI may be used by
trained assessors (who are not trained in the skin body system), for determining impairment
from zero to four per cent in the class 1 category, that has been caused by minor scarring
following surgery. Impairment greater than tour per cent must be assessed by a specialist who
has undertaken the requisite training in the assessment of the skin body system.
14.8 The TEMSKI is to be used in accordance with the principle of 'best fit'. The assessor must be
satisfied that the criteria within the chosen category of impairment best reflect the skin disorder
being assessed. If the skin disorder does not meet all of the criteria within the impairment
category, the assessor must provide detailed reasons as to why this category has been chosen
over other categories.
14.9 Where there is a range of values in the TEMSKI categories, the assessor should use clinical
judgement to determine the exact impairment value.

14.10 The case examples provided in AMA5 chapter 8 do not, in most cases, relate to permanent
impairment that results from a work-related injury. Reference should be made to similar cases
previously determined or provided in training, in addition to following examples and AMA5
examples 8.1-8.22 (pp 178-187).

Table 14.1 Table for the Evaluation of Minor Skin Impairment (TEMSKI)
Criteria 0% WPI 1% WPI 2% WPI 3 - 4% WPI 5 - 9% WPI*
Description of the scar(s) Claimant is not conscious or is Claimant is conscious of the Claimant is conscious of the Claimant is conscious of the Claimant is conscious of the scar(s)
and/or skin condition(s) barely conscious of the scar(s) scar(s) or skin condition scar(s) or skin condition scar(s) or skin condition or skin condition
or skin condition
(shape, texture, colour) Some parts of the scar(s) or Noticeable colour contrast of Easily identifiable colour Distinct colour contrast of scar(s) of
Good colour match with skin condition colour contrast scar(s) or skin condition with contrast of scar(s) or skin skin condition with surrounding
surrounding skin and the scar(s) with the surrounding skin as a surrounding skin as a result of condition with surrounding skin skin as a result of pigmentary or
or skin condition is barely result of pigmentary or other pigmentary or other changes. as a result of pigmentary or other changes
distinguishable. Claimant is changes. other changes.
unable to easily locate the Claimant is able to easily Claimant is able to easily locate the
scar(s) or skin condition Claimant is able to locate the locate the scar(s) or skin Claimant is able to easily locate scar(s) or skin condition
scar(s) or skin condition condition the scar(s) or skin condition.
No trophic changes Trophic changes are visible
Minimal trophic changes Trophic changes evident to Trophic changes evident to
Any staple or suture marks are touch touch Any staple or suture marks are
barely visible Any staple or suture marks are clearly visible
visible Any staple or suture marks are Any staple or suture marks are
clearly visible clearly visible
Location Anatomic location of the scar(s) Anatomic location of the Anatomic location of the Anatomic location of the scar(s) Anatomic location of the scar(s) or
or skin condition scar(s) or skin condition scar(s) or skin condition or skin condition skin condition is usually and clearly
not clearly visible with usual is not usually visible with usual is usually visible with usual is visible with usual visible with usual clothing/hairstyle
clothing/hairstyle clothing/hairstyle. clothing/hairstyle. clothing/hairstyle.
Contour No contour defect Minor contour defect Contour defect visible Contour defect easily visible Contour defect easily visible
ADL / Treatment No effect on any ADL. Negligible effect on any ADL. Minor limitation in the Minor limitation in the Limitation in the performance of
performance of few ADL. performance of few ADL AND few ADL (INCLUDING restriction
exposure to chemical or physical in grooming or dressing) AND
agents (for example, sunlight, exposure to chemical or physical
heat, cold etc.) agents (for example, sunlight, heat,
may temporarily increase cold etc.) may temporarily increase
limitation. limitation or restriction.
No treatment, or intermittent No treatment, or intermittent No treatment, or intermittent No treatment, or intermittent No treatment, or intermittent
treatment only, required treatment only, required treatment only, required treatment only, required treatment only, required
Adherence to underlying No adherence No adherence No adherence Some adherence Some adherence

structures
This table uses the principle of ‘best fit’. You should assess the impairment to the whole skin system against each criteria and then determine which impairment category best fits (or
describes) the impairment. Refer to 14.8 regarding application of this table .

Example 14.1: Cumulative irritant dermatitis
Subject: 42-year-old man.
History: Spray painter working on ships in dry dock. Not required to prepare
surface but required to mix paints (including epoxy and polyurethane)
with 'thinners' (solvents) and spray metal ships' surface. At end of each
session, required to clean equipment with solvent. Not supplied with
gloves or other personal protective equipment until after onset of
symptoms. Gradual increase in severity in spite of commencing to wear
gloves. Off work two months leading to clearance, but frequent
recurrence, especially if the subject attempted prolonged work wearing
latex or PVC gloves or wet work without gloves.
Current: Returned to dry duties only at work. Mostly clear of dermatitis, but flares.
Physical examination: Varies between no abnormality detected to mild dermatitis of the dorsum
of hands.
Investigations: Patch test standard + epoxy + isocyanates (polyurethanes). No reactions.
Impairment: Zero per cent.
Comment: No interference with ADL.
Example 14.2: Allergic contact dermatitis to hair dye
Subject: 30-year-old woman.
History: Hairdresser 15 years, with six month history of hand dermatitis,

increasing despite beginning to wear latex gloves after onset. Dermatitis
settled to very mild after four weeks off work, but not clear. As the
condition flared whenever the subject returned to hairdressing, she
ceased and is now a computer operator.
Current: Mild continuing dermatitis of the hands which flares when doing wet
work (without gloves) or when wears latex or PVC gloves. Has three
young children and impossible to avoid wet work.
Investigation: Patch test standard + hairdressing series. Possible reaction to

paraphenylene diamine.
Impairment: Five per cent.
Comment: Able to carry out ADL with difficulty, therefore limited performance of
some ADL
Guidelines for evaluation of permanent impairment, 2nd edition Page 90 of 103

Example 14.3: “Cement dermatitis” due to chromate in cement
Subject: 43-year-old man.
History: Concreter since age 16. Eighteen month history of increasing hand
dermatitis eventually on dorsal and palmar surface of hands and fingers.
Off work and treatment led to limited improvement only.
Physical examination: Fissured skin, hyperkeratotic chronic dermatitis.
Investigation: Patch test. Positive reaction to dichromate.
Current: Intractable, chronic, fissured dermatitis.
Impairment: 12 per cent.
Comment: Unable to obtain any employment because has chronic dermatitis and on
disability support pension. Difficulty gripping items including steering
wheel, hammer and other tools. Unable to do any wet work (e.g.
painting). Former home handyman, now calls in tradesman to do any
repairs and maintenance. Limited performance in some ADL
Example 14.4: Latex contact urticaria/angioedema with cross reactions
Subject: Female nurse, age 40.
History: Six month history of itchy hands minutes after applying latex gloves at
work. Later swelling and redness associated with itchy hands and wrists
and subsequently widespread urticaria. One week off led to immediate
clearance. On return to work wearing PVC gloves, developed
anaphylaxis on first day back.
Physical examination: No abnormality detected or generalised urticaria/angioedema.
Investigation: Latex radioallergosorbent test, strong positive response.
Current: The subject experiences urticaria and mild anaphylaxis if she enters a
hospital, some supermarkets or other stores (especially if latex items are
stocked), at children's parties or in other situations where balloons are
present, or on inadvertent contact with latex items including sport goods
handles, some clothing, and many shoes (latex based glues). Also has
restricted diet (must avoid bananas, avocados and kiwi fruit).
Impairment: 17 per cent.
Comment: Severe limitation in some ADL in spite of intermittent activity.

Example 14.5: Non-melanoma skin cancer
Subject: 53-year-old married man.
History: Road worker since 17 years of age. Has had a basal cell carcinoma on the
left forehead, squamous cell carcinoma on the right forehead (graft),
basal cell carcinoma on the left ear (wedge resection) and squamous cell
carcinoma on the lower lip (wedge resection) excised since 45 years of
age. No history of loco-regional recurrences. Multiple actinic keratoses
treated with cryotherapy or Efudix over 20 years (forearms, dorsum of
hands, head and neck).
Current: New lesion right preauricular area. Concerned over appearance 'I look a
mess.'
Physical examination: Multiple actinic keratoses forearms, dorsum of hands, head and neck.
Five millimetre diameter nodular basal cell carcinoma right preauricular
area, hypertrophic red scar 3cm length left forehead, 2cm diameter graft
site (hypopigmented with 2mm contour deformity) right temple, non-
hypertrophic scar left lower lip (vermilion) with slight step deformity and
non-hypertrophic pale wedge resection scar left pinna leading to 30 per
cent reduction in size of the pinna. Graft sites taken from right post
auricular area. No regional lymphadenopathy.
Impairment rating: Six per cent.
Comment: Refer to table 6.1 (facial disfigurement)
Example 14.6: Non-melanoma skin cancer
Subject: 35-year-old single female professional surf life-saver.
History: Occupational outdoor exposure since 19 years of age. Basal cell

carcinoma on tip of nose excised three years ago with full thickness graft
following failed intralesional interferon treatment.
Current: Poor self-esteem because of cosmetic result of surgery.
Physical examination: One centimetre diameter graft site on the tip of nose (hypopigmented
with 2mm depth contour deformity, cartilage not involved). Graft site
taken from right post-auricular area.
Impairment rating: 10 per cent.
Comment: Refer to table 6.1 (facial disfigurement)

15. Cardiovascular system
Chapters 3 and 4 AMA5 (page 23 and 65) apply to the assessment of permanent impairment
of the cardiovascular system, subject to the modifications set out below. Before undertaking
an impairment assessment, users of this Guide must be familiar with the following:
Introduction
15.1 The cardiovascular system is discussed in AMA5 chapters 3 (Heart and Aorta) and 4
(Systemic and Pulmonary Arteries) (pp 25-85). These chapters can be used to assess
permanent impairment of the cardiovascular system with the following minor
modifications.
15.2 It is noted that in this chapter there are wide ranges for the impairment values in each
category. When conducting an assessment, assessors should use their clinical judgement to
express a specific percentage within the range suggested.
Exercise stress testing
15.3 As with other investigations, it is not the role of a medical assessor to order exercise stress
tests purely for the purpose of evaluating the extent of permanent impairment.
15.4 If exercise stress testing is available, then it is a useful piece of information in arriving at
the overall percentage impairment.
15.5 If previous investigations are inadequate for a proper assessment to be made, the Medical
Assessor should consider the value of proceeding with the evaluation of permanent
impairment without adequate investigations and data (see chapter 1 of this Guide -ordering
of additional investigations).
Permanent impairment — maximum medical improvement
15.6 As for all assessments, maximal medical improvement is considered to have occurred when
the worker's condition is well stabilised and unlikely to change substantially in the next
year with or without medical treatment.
Vascular diseases affecting the extremities
15.7 Note that in this section, AMA5 table 4-4 and table 4-5 (p 76) refer to percentage
impairment of the upper or lower extremity. Therefore, an assessment of impairment
concerning vascular impairment of the arm or leg requires that the percentages identified
in tables 4-4 and 4-5 be converted to WPI. The table for conversion of the upper extremity
is AMA5 table 16-3 (p 439) and the table for conversion of the lower extremity is AMA5
table 17-3 (p 527).
Thoracic outlet syndrome
15.8 Impairment due to thoracic outlet syndrome is assessed according to Chapter 2 in this
Guide and AMA5 chapter 16, the upper extremities.

16. Digestive system
Chapter 6, AMA5 (page 117) applies to the management of permanent impairment of the
digestive system. Before undertaking an impairment assessment, users of this Guide must be
familiar with the following:
Introduction
16.1 The digestive system is discussed in AMA5 chapter 6 (pp117-142).This chapter can be
used to assess permanent impairment of the digestive system.
16.2 AMA5, p 136: section 6.6 hernias. Occasionally in regard to inguinal hernias there is
damage to the ilio-inguinal nerve following surgical repair. Where there is loss of sensation
in the distribution of the ilio-inguinal nerve involving the upper anterior medial aspect of
the thigh, a one per cent WPI should be assessed as per Table 5.1 of this Guide. This
assessment should not be made unless the symptoms have persisted for 12 months.
16.3 Where, following repair, there is severe dysaesthesia in the distribution of the ilio-inguinal
nerve, a maximum of a five per cent WPI may be assessed as per Table 5.1. This assessment
should not be made unless the symptoms have persisted for 12 months.
16.4 Where, following repair of a hernia of the abdominal wall, there is residual persistent
excessive induration at the site, which is associated with significant discomfort, this should
be assessed as a class 1 herniation (AMA5, Table 6-9, p 136). This assessment should not
be made unless the symptoms have persisted for 12 months.
16.5 Impairments due to nerve injury and induration cannot be combined. The higher
impairment should be chosen.
16.6 A person who has suffered more than one work related hernia recurrence at the same site
and who now has limitation of ADL’s should be assessed as herniation class 1 (AMA5,
Table 6-9, p 136).
16.7 A diagnosis of a hernia should not be made on the findings of an ultrasound examination
alone. For the diagnosis of a hernia to be made there must be a palpable defect in the
supporting structures of the abdominal wall and either a palpable lump or a history of a
lump when straining.
16.8 A divarication of the rectus abdominus muscles in the upper abdomen is not a hernia,
although the supporting structures have been weakened, they are still intact.

16.9 Effects of analgesics on the digestive tract:
 Table 6-3 AMA5 (p 121) class 1 is to be amended to read 'there are symptoms and
signs of digestive tract disease'.
 Nonsteroidal anti-inflammatory agents including Aspirin taken for prolonged periods

can cause symptoms in the upper digestive tract. In the absence of clinical signs or
other objective evidence of upper digestive tract disease, anatomic loss or alteration a
zero per cent WPI is to be assessed.
 Effects of analgesics on the lower digestive tract:
o Constipation is a symptom, not a sign and is generally reversible. A WPI

assessment of zero per cent applies to constipation.
o Irritable bowel syndrome without objective evidence of colon or rectal disease is

to be assessed at zero per cent WPI.
 Assessment of colorectal disease and anal disorders requires the report of a treating
doctor or family doctor which includes a proper physical examination with rectal
examination if appropriate and/or a full endoscopy report.
 Failure to provide such reports may result in a zero per cent WPI.
16.10 Splenectomy. Post-traumatic splenectomy or functional asplenia following abdominal

trauma should be assessed as a three per cent WPI.
16.11 Abdominal adhesions:
 Intra-abdominal adhesions following trauma requiring further laparotomy should be

assessed under AMA5 Table 6-3, p121.

17. Evaluation of permanent impairment arising from chronic pain
(Exclusion of Chapter 18, AMA5)
17.1. The International Association for the Study of Pain (IASP) has defined pain as:
“An unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage”.
17.2. For chronic pain assessment using this Guide and AMA5, chapter 18 of AMA5, on pain,
(p 565-591) is excluded.
17.3. The reasons for excluding chronic pain, as a separate condition from this Guide are:
 It is a subjective experience and is therefore open to exaggeration or fabrication in the
compensation setting. Assessment depends on the credibility of the subject being
assessed. In order to provide reliability, applicants undergoing pain assessments require
more than one examiner at different times, concordance with the established conditions,
consistency over time, anatomical and physiological consistency, agreement between
the examiners and exclusion of inappropriate illness behaviour.
 Pain cannot be measured and no objective assessment can be made.
 Tools to measure pain are based on self-reports and may be inherently unreliable.
 Some impairment ratings take symptoms into account and some of the ranges of
impairment e.g. WPI spine, may reflect the effect of the injury and pain on ADL. This
is not so for impairment assessment of the upper and lower limb which is based on
range of movement and diagnosis based estimates, other than for peripheral nerve
injury.
17.4. Where there is a peripheral nerve injury and there is sensory loss, some of the sensory nerve
impairment categories permit pain to be included (categories 1-5, table 16.10 p 482
AMA5).
17.5 The AMA5 section 17.2m, 'causalgia and complex regional pain syndrome (reflex
sympathetic dystrophy)' (p 553 AMA5) should not be used. Table 16-16 AMA5 p 496 has
been replaced by table 17.1 in this Guide. The table is used to determine if complex regional
pain syndrome (CRPS) is a rateable diagnosis. It is important to exclude diagnoses that
may mimic CRPS, such as disuse atrophy, unrecognised general medical problems,
somatoform disorders, and factitious disorder. Once the diagnosis is established, assess
impairment as in AMA5.
Complex Regional Pain Syndrome (CRPS) Type 1
17.6 For CRPS1 to be present for the purposes of assessment:

 The diagnosis is to be confirmed by criteria in Table 17.1
 The diagnosis has been present for at least one year (to ensure accuracy of the diagnosis
and to permit adequate time to achieve MMI)
 The diagnosis has been verified by more than one examining physician
 Other possible diagnoses have been excluded

CRPS1 is to be assessed as follows:
 Apply the diagnostic criteria for complex regional pain syndrome type 1 (Table 17.1).
Table 17.1 Diagnostic Criteria for Complex Regional Pain Syndrome (CRPS) types 1 and 2
1. Continuing pain, which is disproportionate to any causal event.
2. Must report at least 1 symptom in each of the 4 following categories:
 Sensory: Reports of hyperaesthesiae and/or allodynia
 Vasomotor: Reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry
 Sudomotor/oedema: Reports of oedema and/or sweating increase or decrease and/or sweating asymmetry
 Motor/trophic: Reports of decreased range of joint motion and/or motor dysfunction ( tremor, dystonia) and/or
trophic changes (hair, nail, skin)
3. Must display at least 1 sign* at time of evaluation in all of the following 4 categories:
 Sensory: Evidence of hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure
and/or joint movement)
 Vasomotor: Evidence of temperature asymmetry and/or asymmetric skin colour changes
 Sudomotor/oedema: Evidence of oedema and/or sweating asymmetry
 Motor/trophic: Evidence of decreased active joint range of motion and/or motor dysfunction ( tremor, dystonia)
and/or trophic changes (hair, nail, skin)
4. There is no other diagnosis that better explains the signs and symptoms.
*A sign is included only if it is observed and documented at time of the impairment evaluation.
 If the criteria in each of the sections 1, 2, 3 and 4 in table 17.1 are satisfied, the diagnosis
of CRPS1 may be made.
 Rate the extremity impairment resulting from loss of motion of each individual joint
involved.
 Rate the extremity impairment resulting from sensory deficits and pain, according to
the grade that best fits the degree or amount of interference with ADL described in
AMA5 table 16.10a (p 482) . Use clinical judgement to select the appropriate severity
grade and the appropriate percentage from within the range shown in each grade. The
maximum value is not automatically applied. The value selected represents the
extremity impairment. A nerve value multiplier is not used.
 Combine the extremity impairment for loss of joint motion with the impairment for
pain or sensory deficit using the combined values chart (AMA5, p 604) to obtain the
final extremity impairment.
 Convert the final extremity impairment to WPI using table 16.3 p 439 for the upper
extremity and table 17.3 p 527 for the lower extremity in AMA5.
Complex Regional Pain Syndrome (CRPS) type 2, causalgia
17.7 For CRPS2, the mechanism is an injury to a specific nerve. The methodology in AMA5 pp
496-497 is to be followed:
 If the criteria in each of the sections 1, 2, 3 and 4 in table 17.1 are satisfied and there is
objective evidence of an injury to a specific nerve, the diagnosis of CRPS2 may be
made.
 Rate the extremity impairment due to loss of motion of each individual joint involved.
 Rate the extremity impairment resulting from sensory deficits and pain of the injured
nerves according to the determination methods described in section 16.5b and table 16-

10a (chapter 16) AMA5. Use clinical judgement to select the appropriate severity grade
and the appropriate percentage from within each range shown in the grade.
 Rate the extremity impairment resulting from motor deficits and loss of power of the
injured nerve according to the determination method in section 16.5b and table 16-11a
(chapter 16) AMA 5.
 Combine the extremity impairment percents for loss of range of motion of the joints
involved, pain or sensory deficits and motor deficits, if present, to determine the final
extremity impairment, using the combined values chart (AMA5, p 604).
 Convert the final extremity impairment to WPI using table 16.3 p 439 for the upper
extremity and table 17.3 p 527 for the lower extremity in AMA5

Appendix 1: Key definitions
AMA5
Means the Fifth Edition of the American Medical Association’s (AMA) Guides to the
Evaluation of Permanent Impairment and any published errata.
AMA4
Means the Fourth Edition of the American Medical Association’s (AMA) Guides to the
Evaluation of Permanent Impairment and any published errata.
Assessor
A medical practitioner with qualifications, training and experience relevant to the body system
being assessed who has undertaken the requisite training in use of this Guide. For the purpose of
industrial deafness assessments, the assessor may be a registered audiologist who has undertaken
the requisite training in the use of this Guide.
The Act
The Act refers to the Workers’ Compensation and Rehabilitation Act 2003.
Combine
Any direction in this Guide or the AMA4 or AMA5 to combine impairment values should be
taken as a reference to use the Combined Values Chart.
Degree of permanent impairment (DPI)

The Act defines degree of permanent impairment as “an estimate expressed as a percentage, of the
degree of the worker’s permanent impairment assessed and decided in accordance with the GEPI”.
Section 1.49 of this Guide states that a worker’s DPI is to be expressed as a percentage of whole
person impairment (% WPI).
Stable and Stationary

The point at which a worker’s injury can be assessed for DPI and the DPI decided. According to
both the Act and section 1.15 of this Guide, a worker’s injury or condition is considered to be
stable and stationary when it is well stabilised and is unlikely to change substantially in the next
year with or without medical treatment.
This concept is referred to as maximum medical improvement in the template national guide.
NSW Guide
The WorkCover Guides for the Evaluation of Permanent Impairment, published by New South
Wales’ State Insurance Regulatory Authority. The fourth edition of the NSW Guide is the basis
for the template national guide.
Template national guide

The template guide developed by Safe Work Australia for jurisdictions to adapt and use according
to their own legislation to achieve a nationally consistent approach to assessing permanent
impairment across all Australian workers’ compensation schemes.

Appendix 2: Working groups on permanent impairment
Permanent Impairment Co-ordinating Group 2001
Name Position
Dr Jim Stewart Chair
Ms Kate McKenzie WorkCover
Mr John Robertson Labor Council of NSW
Ms Mary Yaager Labor Council of NSW
Dr Ian Gardner Medical Representative to Workers Compensation and
Workplace Occupational Health and Safety Council of NSW
Dr Stephen Buckley Rehabilitation Physician
Prof Michael Fearnside Professor of Neurosurgery
Dr John Harrison Orthopaedic Surgeon
Dr Jonathan Phillips Psychiatrist
Professor Bill Marsden Professor of Orthopaedic Surgery
Dr Dwight Dowda Occupational Physician
Associate Professor Ian Assoc Professor of Rehabilitation Medicine
Cameron
Dr Robin Chase Australian Medical Association
2005 Revisions
Dr Roger Pillemer Orthopaedic Surgeon
Dr John Dixon Hughes General Surgeon
Dr Yvonne Skinner Psychiatrist
Permanent Impairment Co-ordinating Committee 2008

Name Position
Mr Rob Thomson Chair
Ms Mary Yaager Unions NSW
Dr Ian Gardner Workers Compensation and Workplace Occupational Health
and Safety Council of NSW
Associate Professor Associate Professor of Neurosurgery, Neurosurgical Society of
Michael Fearnside Australasia
Dr John Harrison Orthopaedic Surgeon, Australian Orthopaedic Association,
Australian Society of Orthopaedic Surgeons
Dr Yvonne Skinner Psychiatrist, Royal Australian and New Zealand College of
Psychiatrists
Professor Ian Cameron Professor of Rehabilitation Medicine, Australasian Faculty of
Rehabilitation Medicine
Dr Roger Pillemer Approved Medical Specialist
Dr Michael Gliksman Australian Medical Association
Dr Neil Berry Royal Australasian College of Surgeons
Permanent Impairment Co-ordinating Committee 2013
Name Position
Mr Gary Jeffery Chair
Mr Kim Garling WorkCover Independent Review Officer
Ms Alisha Wilde/Mr Shay Unions NSW
Degaura
Dr Mark Burns Australian Faculty of Occupational and Environmental
Medicine
Associate Professor Associate Professor of Neurosurgery, Neurosurgical Society of
Michael Fearnside Australasia
Dr John Harrison Orthopaedic Surgeon, Australian Orthopaedic Association,
Australian Society of Orthopaedic Surgeons
Dr Yvonne Skinner Psychiatrist, Royal Australian and New Zealand College of
Psychiatrists
Professor Ian Cameron Professor of Rehabilitation Medicine, Australasian Faculty of
Rehabilitation Medicine
Dr Roger Pillemer Workers Compensation Commission, Senior Approved
Medical Specialist
Dr Michael Gliksman Australian Medical Association
Dr Neil Berry Australasian College of Surgeons
Mr Kevin Gillingham WorkCover WA
Mr David Caulfield/ Mr WorkCover SA
Phil Waddas
Ms Meg Brighton WorkSafe ACT
Working Groups
Psychiatric and Psychological Spine Upper Limb
Dr Julian Parmegiani Prof Michael Fearnside Dr Dwight Dowda
Dr Derek Lovell Dr John Cummine Assoc Prof Ian Cameron
Dr Rod Milton Prof Michael Ryan Prof Bill Marsden
Dr Yvonne Skinner Dr Dwight Dowda Assoc Prof Bruce Connelly
Dr Jonathan Phillips Assoc Prof Ian Cameron Dr David Crocker
Dr Chris Blackwell Dr Hugh Dickson Dr Richard Honner
Dr Bruce Westmore Dr Conrad Winer Dr Jim Ellis
Dr Susan Ballinger Dr Mario Benanzio Dr Conrad Winer
Ms Lyn Shumack Dr Jim Ellis Dr David Duckworth
Dr Jack White Dr Jim Bodel 2005 Revisions
Ms Sandra Dunn Dr William Wolfenden Dr Roger Pillemer
Dr Tim Hannon Dr Kevin BleaseL Dr Graham Mcdougall
Dr John Harrison Dr Brian Noll
Prof Sydney Nade Dr Bruce Connelly
2005 Revisions 2012 Revisions
Dr Roger Pillemer Dr Roger Pillemer
Dr John Harrison
Dr Brian Noll
2008 Revisions
Dr James Bodel
Dr Phillipa Harvey-Sutton Dr John Cross
Cassock Prof Michael Fearnside Dr Mark Burns
Dr Jim Bodel Dr Michael Gliksman
Assoc Prof Michael Ryan Dr Robert Breit
Dr Roger Pillemer Prof Ian Cameron
Prof Ian Cameron

2012 Revisions
Assoc Prof Michael Fearnside
Dr Phillipa Harvey-Sutton
Dr Jim Bodel
Associate Professor Michael Ryan
Dr Roger pillemer
Professor Ian Cameron
Hearing Urinary and Reproductive Respiratory, Ear, Nose and
Throat
Dr Brian Williams Prof Richard Millard Dr Julian Lee
Dr Joseph Scoppa Dr Kim Boo Kuah Prof David Bryant
Dr Stanley Stylis Associate Professor Ian Cameron Dr Joseph Scoppa
Dr Paul Niall Dr Michael Burns
Associate Professor Ian Cameron Dr Frank Maccioni
Dr Peter Corte
Dr Brian Williams
Associate Professor Ian Cameron
Skin Vision Lower Limb
Dr Victor Zielinski Dr Michael Delaney Dr Dwight Dowda
Dr Scott Menzies Dr Peter Duke Associate Professor Ian
Cameron
Dr Edmund Lobel Dr Peter Anderson Professor Bill Marsden
Associate Professor Ian Cameron Dr John Kennedy Dr Peter Holman
Dr Neville Banks Dr Jay Govind
Associate Professor Ian Dr Jim Bodel
Cameron
Dr Mario Benanzio
Dr Jim Ellis
Cardiovascular Digestive Dr Conrad Winer
Dr Thomas Nash Prof Philip Barnes Dr Cecil Cass
Dr John Gunning Dr David De Carle Dr John Harrison
Dr George Michell Dr Dwight Dowda Dr John Korber
Dr Stephen Buckley 2012 Revisions 2008 Revisions
Dr Melissa Doohan Dr Neil Berry Dr Roger Pillemer
Dr Charles Fisher Dr John Garvey Dr John Harrison
Dr John Duggan Professor Ian Cameron
Dr Nick Talley Dr Michael Gliksman
Dr David Johnson Dr Jim Bodel
Dr John Dixon-Hughes Dr Robert Breit
Dr Ian Meakin
Endocrine Nervous System
Dr Alfred Steinbeck Dr Stephen Buckley 2012 Revisions
Prof Peter Hall Associate Professor Ian Dr Roger Pillemer
Dr Stephen Buckley Cameron
Dr John Harrison
Dr Dwight Dowda
Dr Brian Noll
Dr Ivan Lorentz
Dr James Bodel
Dr Keith Lethlean
Dr John Cross
Dr Peter BLUM
Dr Mark Burns
Professor Michael Fearnside
Dr Michael Gliksman
Dr Tim Hannon
Dr Robert Breit
2012 Revisions Professor Ian Cameron
Associate Professor Michael
Fearnside Haematopoietic
Dr Mark Burns Prof John Gibson
Dr Ross Mellick Dr Stephen Flecknoe
Professor Ian Cameron Dr Peter Slezak
Prof John Dwyer
Associate Professor Ian
Cameron
Evaluation of permanent
impairment arising from
chronic pain
Associate Professor Michael
Fearnside

Guidelines For Evaluation of Permanent Impairment

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Queensland’s Guidelines for evaluation

of permanent impairment, 2nd edition

Current as of 1 July 2016

Questions about this publication should be directed to:

Workers’ Compensation Regulator

Phone: 1300 362 128

© The State of Queensland (Queensland Treasury) 2016.

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 1 of 103

1.1 Queensland’s Guidelines for Evaluation of Permanent Impairment (the Queensland

When conducting a permanent impairment assessment in accordance with the

Development of this Guide

PART 2 – PRINCIPLES OF ASSESSMENT

(a) Assessing permanent impairment involves clinical assessment of the claimant as

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 2 of 103

(b) Assessors are required to exercise their clinical judgement in determining a

Body systems covered by this Guide

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 3 of 103

Stable and stationary

Psychiatric/ psychological injuries

1.22 As referenced in paragraph 1.19, impairments arising from psychological and

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The assessor’s judgment, based upon experience, training, skill, thoroughness in

Activities of Daily Living

Deductions for pre-existing impairment

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 5 of 103

Adjustment for the effects of orthoses and prostheses

1.29 Assessments of permanent impairment are to be conducted without assistive devices,

Adjustment for the effects of treatment

1.31 In circumstances where the treatment of a condition leads to a further, secondary

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 6 of 103

Future deterioration of a condition

Ordering of additional investigations

PART 3 – ADMINISTRATIVE PROCESS

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Information required for assessments

1.42 Information for claimants regarding independent medical examinations and

1.46 A report of the evaluation of permanent impairment should be accurate,

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 8 of 103

1.49 The assessed degree of permanent impairment is to be expressed as a % WPI.

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1.57 Complaints received in relation to the behaviour of an assessor during an evaluation

Disputes over assessed degree of permanent impairment

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The provisions in this Guide take precedence over AMA5.

The approach to assessment of the upper extremity and hand

2.5 Range of motion is assessed as follows:

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 11 of 103

Specific Interpretation of the AMA5 – The Hand and Upper Extremity

Impairment of the upper extremity due to peripheral nerve disorders

The assessment of carpal tunnel syndrome post-operatively is undertaken in the same

Impairment due to other disorders of the upper extremity

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 12 of 103

2.13 Strength evaluation, as a method of upper extremity impairment assessment, should

Conditions affecting the shoulder region

2.16 Diagnosis of impingement is made on the basis of positive findings on appropriate

Guidelines for Evaluation of Permanent Impairment, 2nd Edition Page 13 of 103

Epicondylitis of the elbow

2.19 No additional impairment is to be awarded for resurfacing procedures used in the

Calculating motion impairment