2. Whenever possible, and reasonable, impairment ratings will be established strictly in accordance with the schedule attached as appendix A.

Transcription

1 Section Policy Section Title: Benefits Administration - Other Entitlements Subject: Permanent Impairment Rating Schedule Effective Date: For accidents on or after January 31, 2003 GENERAL INFORMATION The Workers Compensation Act deals with impairment awards. These awards are calculated by determining a rating that represents the percentage of impairment as it relates to the whole body. The award is not related to loss of earning capacity nor is it a proxy for loss of earning capacity. A. POLICY 1. The degree of impairment will be established by the Healthcare Services Department of the Workers Compensation Board in accordance with this policy. The degree of impairment established by this Department can only be altered on review and approval by the Executive or Senior Director responsible subject to the normal appeal process. 2. Whenever possible, and reasonable, impairment ratings will be established strictly in accordance with the schedule attached as appendix A. 3. In the event that the Healthcare Services Department feels that strict adherence would create an injustice, or if it is felt that an impairment exists that is not covered by the schedule, Healthcare Services may deem it just and fair to establish an impairment rating that is not specifically covered by the schedule. In such cases, it may use information other than the schedule, such as the American Medical Association's Guides to the Evaluation of Permanent Impairment established for a similar purpose. In such cases the award will not be official until it is reviewed and approved by the Director of Healthcare Services. The Healthcare Services Department will document the case and explain the justification for the non-scheduled award in full. Awards in excess of 20% must be reviewed and approved by the Director of Healthcare Services. 4. If a worker had a pre-existing condition, the worker is eligible for an impairment award based on the difference between the new combined rating and the rating assigned to the pre-existing condition. The Healthcare Services Department will assign a fair rating to the pre-existing condition based on the best information available. 5. Healthcare Services will assign an impairment rating based on file information, or information from the attending physician, if such information is available and the impairment rating is less than 20%. Impairment ratings of 20% or greater can be confirmed without an examination if it is apparent from objective evidence, such as an x-ray of an amputated limb, what the rating should Policy & Procedures Manual

2 WCB Policy , Permanent Impairment Rating Schedule Page 2 be. In other cases the worker will be asked to submit to an examination by a Healthcare Services physician or a physician chosen by the WCB. If the impairment rating has been appealed the rating will be performed by Healthcare Services or a physician ordered by the Appeal Commission. 6. The appropriate time to assess an injured worker for a permanent impairment award will be the subject of guidelines established by the Healthcare Services Department. B. REFERENCES The Workers Compensation Act, sections 4(9) and 38 Appendix A - Permanent Impairment Rating Schedule History: 1. Initial adoption of a permanent disability rating schedule in March, Permanent Impairment Rating Schedule approved by Board Order 152/86 as a compilation/recording of past policies, directives and practices, effective August 20, Board Order 152/86 revised by Board Order 42/89 on March 15, 1989, to incorporate "minimum awards". 4. Permanent Partial Disability Awards for Disfigurement adopted by Board Order 67/89 on April 24, Policy , Permanent Impairment Rating Schedule, approved by Board Order 12/92 on March 31, 1992, effective immediately for the rating of impairments after that date. Schedule revised to incorporate previously approved changes and recommendations of healthcare professionals. The majority of changes expand on and clarify the original schedule, and reflect amendments to The Workers Compensation Act, effective January 1, Policy re-numbered to on issue to Policy Manual. 7. Policy updated for current position and division titles, May 2, Permanent Impairment Rating Schedule amended by Board Order 32/96, on September 25, 1996, to correct specific omissions/errors and incorporate two amendments (partial loss of movement of finger, impairment of shoulder mobility) for all decisions (initial, reconsideration, and appeal) effective October 1, Permanent Impairment Rating Schedule amended by Board Order 6/2000 on February 22, 2000, which replaces the Hearing Impairment section for claims arising from accidents on or after April 1, Former policy re-issued as Permanent Impairment Rating Schedule Appendix A Impairment of Hearing section amended by Board Order 03/03, effective January 31, Former Policy reissued as and The degrees for plantar ankle flexion have been updated on Page 13 of the PPI Schedule to 40 degrees. Policy & Procedures Manual

3 WCB Policy , Permanent Impairment Rating Schedule Page June 1, 2009 Hand Chart The diagrams were replaced. 13. September 1, 2009, policy updated to clarify effective date. 14. Minor wording changes were made to the policy and departmental names were updated June 27, Policy & Procedures Manual

4 PERMANENT IMPAIRMENT RATING SCHEDULE THE WORKERS COMPENSATION BOARD OF MANITOBA A general summation of established practice, and scheduled ratings from various provincial jurisdictions, employed regularly by the Workers Compensation Board of Manitoba as guidelines for the evaluation of permanent impairment...

5 INDEX INTRODUCTION TO SCHEDULE...1 HAND (AMPUTATIONS AND LOSS OF MOBILITY)...4 UPPER EXTREMITY (AMPUTATION AND IMPAIRED FUNCTION)...10 LOWER EXTREMITY (AMPUTATION AND IMPAIRED FUNCTION)...14 SPINE...17 JAW...18 REPRODUCTIVE AND URINARY SYSTEM...18 HEMOPOIETIC AND LYMPHATIC SYSTEM...18 GASTRO-INTESTINAL SYSTEM...19 IMPAIRMENT OF SPECIAL SENSES...19 IMPAIRMENT OF HEARING...22 VIBRATION-INDUCED WHITE FINGER DISEASE...27 NERVOUS SYSTEM...27 BRAIN...29 DISFIGUREMENT...31 MYOCARDIAL INFARCTION...32 RESPIRATORY (INDUSTRIAL LUNG DISEASES)...33 PSYCHOLOGICAL...34 EVALUATION OF PSYCHIATRIC IMPAIRMENT...41 CANCER...42 COMBINED VALUES CHART...45

6 APPENDIX A

7 - 1 - GUIDELINES FOR PERMANENT IMPAIRMENT EVALUATION INTRODUCTION TO SCHEDULE: The rating schedule is designed to measure the degree of permanent physical impairment of body function following an injury for the purpose of calculating an award in accordance with Sections 4(9) and 38 of the Workers Compensation Act. Permanent impairment is evaluated by conducting a medical examination of the worker or by reviewing the medical history documented on file as described in the policy statement. Evaluation of permanent impairment is made when treatment has been completed, or when, in the opinion of the Board s physicians, the medical condition has stabilized and no further improvement is expected. The timing of the evaluation, therefore, varies according to the individual s circumstances. Permanent impairment is measured by the following factors: loss of a part of the body; loss of mobility in the joints; loss of function of any organs of the body identified in the schedule; and cosmetic deformity of the body. Currently for Manitoba Workers Compensation Board purposes, the permanent impairment evaluation is administratively converted into an impairment award according to the Permanent Impairment Rating Schedule.

8 - 2 - TYPES OF EVALUATIONS OR RATINGS: There are two types of evaluations for permanent impairment made by the physicians who work for the Workers Compensation Board: schedule ratings and judgement ratings. Schedule ratings refer to the percentage values shown in this book for specific injuries. Where the injury or impairment is straight forward, such as in cases of amputations, blindness, etc., it is assessed at the percentage value shown. Some types of impairment of function of the body do not lend themselves to exact measurement. These require judgement on part of the medical examiner. Judgement ratings are made to determine a percentage of impairment when the impairment does not fit into a specific category of the existing schedule, but must be within the parameters as outlined in the schedule. The figures outlined in the schedule are percentages of impairment of the total body. Multiple injuries, due to a single accident, resulting in more than one impairment are evaluated on the basis of the whole person, rather than by adding the individual values. This is done with the aid of a combined values chart, as established by the American Medical Association Guides to the Evaluation of Permanent Impairment. (See Combined Value Chart, page 54). As well, in the event of multiple injuries, the impairment rating may be enhanced in order to reflect the cumulative functional effect. Enhancement is particularly important in dealing with finger injuries, loss of vision, and loss of hearing; therefore, the enhancement factor has been considered in the development of the rating schedule, for these particular conditions. Enhancement is considered to be relevant in respect of injuries which involve mirror parts of bilateral structures; e.g., both wrists, both knees. In these instances, an enhancement factor of up to 50% of the lesser impairment is awarded. The ratings must not be disproportionate when applied to the whole person and are therefore subject to the combined values chart.

9 - 3 - Impairment rating for the loss of function of an extremity cannot exceed the rating allowed for amputation of that extremity. Multiple impairments affecting a single extremity, or part thereof, may be calculated on the basis of the combined values chart, or as a percentage loss of total function for the extremity.

10 - 4 - HAND (AMPUTATIONS AND LOSS OF MOBILITY) AMPUTATIONS: Finger amputations are rated in accordance with the detailed hand charts (see page 8); and partial amputations of a phalanx are rated on a judgement basis having regard to the whole value of the phalanx and the percentage affected by amputation. If a single finger is involved, the single finger chart is used. For multiple finger amputations, the corresponding multiple chart is used (refer to page 8). The charts are used by beginning at the DIP joint and assign values to the distal phalanx from the chart corresponding to the number of fingers having impairment at or proximal to the distal joint. Then proceeding to the PIP joint and assigning values to the middle phalanx from the chart corresponding to the number of fingers having impairment at or proximal to the middle phalanx. Then proceeding to the MP joint, and in a similar fashion assigning values to the proximal phalanges. PARTIAL LOSS OF MOVEMENT/FUNCTION: Impairment ratings for digit injuries take into consideration loss of joint movement as well as amputation, and the detailed hand charts are also used. When a finger joint is ankylosed in a position of function (or in an acceptable position), the rating is one-half of what it would be for an amputation at that level. If a joint is ankylosed in a position that is not functional, and there is some good reason why surgical correction will not be done, the rating could equal up to the rating for amputation of that joint.

11 - 5 - The impairment rating for partial loss of movement will be proportional to the amount of movement that is lost. In as much as there are great variations from person to person in ranges of when there is a completely normal digit to compare with, loss of movement can be determined by comparing the movement in the joint being examined with the movement in the normal joint on the opposite hand. When there is not a normal extremity with which to compare, the following will be considered to be normal ranges of movement for the digital joints: RANGE OF MOTION FINGERS D.I.P. P.I.P. M.P. Index Middle Ring Little I.P. M.P. C.M.C. Thumb For partial loss of movement at a joint, the lost range of movement, in degrees, is divided by the normal range of movement at that joint, and multiplied by either (i) one half the amputation rating at that joint if the remaining movement is in a position of function, or (ii) the full amputation value at that joint if the remaining movement is in a position that is not functional. If there has been an amputation at a point distal to the joint, only the values of the retained phalanx or phalanges are employed in the calculation for loss of movement. ENHANCEMENT OF MULTIPLE INJURIES: An enhancement factor has been included as part of the injury rating schedule in the event of multiple finger injuries to the same hand.

12 - 6 - As well, an enhancement factor of 50% of the lesser impairment is warranted in respect to injuries which involve identical parts of bilateral structures, although the ratings must not be disproportionate when applied to the whole person and are therefore subject to the combined values chart. METACARPALS: The detailed hand charts include rating guides for metacarpals; and, the function of the whole hand is assessed and rated by the combined value of the component parts which are impaired or amputated: Example: Thumb, including metacarpal Fingers, all four (combined values) Metacarpals TOTAL IMPAIRMENT (Combined Values)...49% AMPUTATIONS; (1) Thumb, including first metacarpal (2) Thumb, at MP joint (3) Thumb, at IP joint (4) Finger, index (5) Finger, index at PIP joint (6) Finger, index at Distal

13 - 7 - (7) Finger, middle (8) Finger, middle at PIP (9) Finger, middle at Distal (10)Finger, ring (11)Finger, ring at PIP (12)Finger, ring at Distal (13)Finger, little (14)Finger, little at PIP joint (15)Finger little at Distal (16)Fingers, index and middle (17)Fingers, index and ring (18)Fingers, index and little (19)Fingers, middle and ring (20)Fingers, middle and little (21)Fingers, ring and little (22)Fingers, index, middle and ring (combined value) (23)Fingers, index, middle, and little (combined value) (24)Fingers, index, ring, and little (combined value) (25)Fingers, middle, ring, and little (combined value) (26)Fingers, all four (combined value) (27)Fingers, four at Distal IMMOBILITY OF JOINTS: (1) Thumb, both joints (2) Thumb, distal joint

14 - 8 - Hand Chart Single Finger or Thumb Two Finger

15 - 9 - Hand Chart (con t) Three Finger Four Finger There is no enhancement factor between thumb and fingers. January 1982

16 UPPER EXTREMITY (AMPUTATION AND IMPAIRED FUNCTIONS) ENHANCEMENT OF MULTIPLE INJURIES: An enhancement factor of 50% of the lesser impairment is warranted in respect of injuries which involve identical parts of bilateral structures although the ratings must not be disproportionate when applied to the whole person and are therefore subject to the combined values chart. EXAMPLE: A worker, as a result of an occupational accident, suffers ankylosis of the left shoulder joint (without either articular or scapular movement) and disarticulation at the right shoulder. Total impairment is determined as follows: Ankylosis left shoulder % Disarticulation right shoulder % Enhancement (50% of 25) % Combined Value (Total Impairment)...81% LOSS OF MOVEMENT/FUNCTIONS: The impairment rating for partial loss of movement or function resulting from direct injury or related surgical procedures will be proportional to the amount of movement or function that is lost based on clinical findings, as a percentage of the assigned ratings for complete joint immobility. As there are great variations from person to person in ranges of movement, when there is a completely normal extremity to compare with, loss of movement can be determined by comparing the movement in the joint being examined with the movement of the normal joint on the opposite extremity.

17 When there is not a normal extremity with which to compare, the following will be considered as guidelines for normal ranges of movement for upper extremity joints: Shoulder: Forward Flexion Backward elevation 40 0 Abduction Adduction 30 0 Internal rotation 40 0 External rotation 90 0 Elbow: Flexion Extension 0 0 Pronation 90 0 Supination 90 0 Forearm: Pronation Supination Wrist Dorsiflexion 70 0 Palmarflexion 90 0 Radial deviation 20 0 Ulnar deviation 30 0

18 NOTE ON APPLYING RANGE OF MOTIONS: 1. Determine the expected range of motion (either the values shown or the range demonstrated by a completely normal extremity on the person being examined). 2. Determine the workers range of motion through observation/examination. 3. Add the elements of the expected range. 4. Add the elements of the observed range. 5. Determine the differences (the loss of range of motion). 6. Calculate the impairment as a portion of the impairment for a fully immobilized joint. NOTE: Range of motion will be calculated on the passive rather than the active range. EXAMPLE: RANGE OF MOTION WRIST (DEGREES) OBSERVED EXPECTED Palmar Flexion Dorsi Flexion Radial Deviation Ulnar Deviation TOTAL Residual impairment % i.e., Loss of total ROM Impairment - 100/210 x 12.5% = 5.95% (Rounded to 6.0%)

19 AMPUTATIONS: Proximal third of humerus or disarticulation at shoulder... 70% Middle third of humerus... 65% Distal third of humerus to biceps insertion... 60% Biceps insertion to wrist (depending on usefulness of stump)... 50% to 60% IMPAIRMENT OF MOBILITY: Shoulder, ankylosed in position of function % Shoulder, abduction limited to 90% but with good rotation and pivotal movement % Elbow, ankylosed in position of function % Forearm, complete loss of pronation and supination % Wrist, ankylosed in position of function % DENERVATION: Median nerve, complete at elbow % Median nerve, complete at wrist % Ulnar nerve, complete at elbow % Ulnar nerve, complete at wrist % MUSCULAR: Rupture of long head biceps brachii % VASCULAR IMPAIRMENTS: Thrombosis brachial artery...up to 25.0%

20 LOWER EXTREMITY (AMPUTATION AND IMPAIRED FUNCTION) ENHANCEMENT OF MULTIPLE INJURIES: An enhancement factor of 50% of the lesser impairment is warranted in respect of injuries which involve identical parts of bilateral structures (e.g., both ankles), although the ratings must not be disproportionate when applied to the whole person and are therefore subject to the combined values chart. LOSS OF MOVEMENT/FUNCTION: The impairment rating for partial loss of movement or function resulting from direct injury or related surgical procedures (including patellectomy and hip prosthesis) will be proportional to the amount of movement or function that is lost, based on clinical findings, as a percentage of the assigned ratings for complete joint immobility. Ankle: Dorsi flexion 20 0 Plantar 40 0 Inversion 30 0 Eversion 20 0 Knee: Flexion Extension 0 0 Hip: Forward flexion Backward flexion 30 0 Abduction 40 0 Adduction 20 0 Internal Rotation 40 0 External Rotation 50 0 AMPUTATIONS: Hip disarticulation or short stump requiring ischial bearing prothesis % Thigh, site of election %

21 End bearing or short below-knee stump not suitable for conventional B.K. prosthesis % Leg, suitable for B.K. prosthesis % Leg, at ankle, end bearing % Through foot... 10% to 25.0% Great toe, both phalanges % Great toe, one phalanx % All toes, total amputation % Toes, other than great, each % Patellectomy with no quadriceps repair necessary and/or no damage to femur (30% loss of knee joint function ) % Patellectomy with femoral damage plus quadriceps graft repair (50% loss of knee joint function) % LOSS OF MOBILITY: Hip, ankylosed in acceptable position % Knee, ankylosed in acceptable position % Knee, instability to 5.0% Ankle, ankylosed in acceptable position % Great toe, ankylosis both joints % Great toe, ankylosis distal joint % SHORTENING OF THE LEG: 1 (2.5 cm) % 1.5 (4 cm) % 2 (5 cm) % 3 (7.5 cm) %

22 DENERVATION: Peroneal nerve, complete % VASCULAR IMPAIRMENTS: Deep thrombosis of thigh and leg %

23 SPINE The criteria used for development of impairment ratings in regard to the spine, whether resultant from direct injury or related surgical procedures, essentially involves measurement of restricted motion. For this purpose, the spine is divided into the cervical and the lumbar/thoracic region. The impairment rating for partial loss of movement will be proportional to the amount of movement that is lost on clinical findings, as a percentage of the assigned ratings for complete immobility; taking into account flexion, extension, lateral flexion, and rotation. Cervical Region Combined Lumbar & Thoracic Regions Forward flexion 45 Forward flexion 90 Backward extension 45 Backward extension 30 Right lateral flexion 45 Right lateral flexion 30 Left lateral flexion 45 Left lateral flexion 30 Right rotation 80 Right rotation 30 Left rotation 80 Left rotation 30 SPINAL LOSS OF MOVEMENT: Total immobility of spine (usual distribution) % Immobility of the cervical spine, complete % Immobility of the lumbar and thoracic spine, complete % PELVIC REGION: The sequelae of fractures in the pelvic region (including rami, ilium, innominate, symphysis, sacrum, coccyx, and acetabulum) which result in a decreased range of movement, (primarily of the hip, may be rated in accordance with the relative loss of mobility.)

24 CAUDA-EQUINA LESION: Refer to impairment of the nervous system. JAW Impairment ratings in regard to injury of the temporo-mandibular joint are intended to reflect primarily loss of movement and/or function, but may include consideration for some degree of cosmetic deformity. Internal derangement, temporo-mandibular joint... up to 10.0% Loss of mandibular protrusion % Malocclusion, (improper bite) TPD % REPRODUCTIVE AND URINARY SYSTEM LOSS OF GONADS AND STERILITY: Gonad refers to testis or ovary. Loss of a gonad is considered as a disfigurement and rated at 2%. The loss of two gonads is rated at 10% and this includes an enhancement of 1%, and 5% for loss of fertility. a) Loss of one gonad % b) Loss of one gonad; and resultant sterility...(2% and 5%) 7.0% c) Loss of two gonads; and resultant sterility...(2%, 2%, 1% & 5%) 10.0% Direct Trauma or Neurological Damage Resulting in Impotence (following Urologists report)... up to 10.0% Loss of one kidney % HEMOPOIETIC AND LYMPHATIC SYSTEM Loss of Spleen %

25 GASTRO-INTESTINAL SYSTEM Partial Loss of Bowel % IMPAIRMENT OF SPECIAL SENSES SENSE OF SMELL: Loss of sense of smell (including impairment of sense of taste) % IMPAIRMENT OF VISION: Enucleation % Total loss of vision in one eye % Cataract (Impairment to be rated on visual acuity basis using the partial visual loss schedule) Aphakia of one eye (without correction) % Double aphakia (without correction) % Aphakia and double aphakia - following artificial lens implant or other corrective measures (impairment to be rated on visual acuity basis using the partial visual loss schedule with an appropriate allowance to cover loss of accommodation)...% of impairment as applicable Hemianopia, right field % Hemianopia, left field % Bitemporal hemianopia % Binasal hemianopia % Diplopia, all fields % Scotomata, depending on location and extent...up to 16.0% PARTIAL VISUAL LOSS: 20/ % 20/ % 20/ % 20/ % 20/ % 20/ % 20/ %

26 Less than 20/ % Note: Snellen s test for distance after correction with conventional lenses. Iridectomy with corrected vision...1 to 2.0% Dry eyes needing artificial tears % LOSS OF ACCOMMODATION:...up to 5.0% The disability allowance to cover loss of accommodation will be based on the age of the claimant. This adjustment accounts for the natural deterioration of the eyes ability to accommodate with age. 40 years & under 5.0% % % % %

27 TABLE OF PERMANENT IMPAIRMENT CONCERNING LOSS OF VISION IN ONE EYE OR BOTH FOLLOWING CORRECTION LOSS OF SIGHT IN ONE EYE... 16% ENUCLEATION... 18% LOSS OF SIGHT IN BOTH EYES % SNELLEN SCALE 20/30 20/40 20/50 20/60 20/80 20/100 20/200 20/400 Blind 6/9 6/12 6/15 6/18 6/24 6/30 6/60 6/120 20/ /9 20/ /12 20/ /15 20/ /18 20/ /24 20/ /30 20/ /60 20/ /120 Blind The permanent impairment shall always be determined following optical correction with spectacles. If one eye is enucleated, add 2% to the degree of permanent impairment obtained since the loss of sight in one eye is 16% and the enucleation is 18% When a one-eyed claimant loses his other eye, the degree of permanent impairment shall be rated at 100%.

28 IMPAIRMENT OF HEARING A. General Information Calculating impairment due to loss of hearing involves three steps: 1. Calculating the percentage of hearing loss in each ear. 2. Calculating the combined percentage of hearing loss. 3. Converting the loss of hearing to an impairment of the whole person. In most respects, the establishment of permanent hearing impairment is based on the 4 th edition (1993) of the American Medical Association s Guides to the Evaluation of Permanent Impairment. A change to the AMA guides would not result in an automatic change to this policy. B. Calculating the Percentage of Hearing Loss 1. When calculating impairment due to loss of hearing, the International Standard Organization (I.S.O.) audiometric calibration will be used. Test each ear and record the hearing levels at 500, 1000, 2000 and 3000 Hz. 2. Add the value of the hearing levels at 500, 1000, 2000 and 3000 Hz in each ear. 3. If the level of hearing loss is less than 100 db in the better ear, the percentage of hearing loss in that ear should be taken as 0%. 4. Consult Table 1 to determine the percentage of hearing loss in each ear. If the level of hearing loss falls between values on the chart, round the level to the nearest 5 db of hearing loss.

29 Table 1: Hearing Loss and Impairment Hearing Loss % in db Hearing Loss % in db Hearing Loss % in db Or greater 5. Use the following formula to determine binaural hearing impairment: Total % = ([5 x % hearing impairment in better ear] + % hearing impairment in poorer ear) /6. Example (significant hearing loss in both ears): A worker has the following test results in each ear: Right Ear: Hearing loss at 500 hertz = 30 db Hearing loss at 1,000 hertz = 45 db Hearing loss at 2,000 hertz = 60 db Hearing loss at 3,000 hertz = 60 db TOTAL = 195 db

30 Left Ear: Hearing loss at 500 hertz = 50 db Hearing loss at 1,000 hertz = 60 db Hearing loss at 2,000 hertz = 70 db Hearing loss at 3,000 hertz = 75 db TOTAL = 255 db Table 1 indicates that a combined hearing loss of 195 db is equivalent to a 35.6% hearing impairment in the right ear, and a combined hearing loss of 255 db is equivalent to a 58.1% hearing impairment in the left ear. The hearing impairment in the better ear (35.6%) is multiplied by 5. The product (178) is then added to the hearing impairment in the poorer ear (58.1%). The sum (236.1) is then divided by 6. The resulting hearing impairment in both ears is 39.4%. Example (significant hearing loss in one ear): A worker has the following test results in each ear: Right Ear: Left Ear: Hearing loss at 500 hertz = 35 db Hearing loss at 1,000 hertz = 35 db Hearing loss at 2,000 hertz = 40 db Hearing loss at 3,000 hertz = 55 db TOTAL = 165 db Hearing loss at 500 hertz = 10 db Hearing loss at 1,000 hertz = 10 db Hearing loss at 2,000 hertz = 15 db Hearing loss at 3,000 hertz = 20 db TOTAL = 55 db Table 1 indicates that a combined hearing loss of 165 db is equivalent to a 24.4% hearing impairment in the right ear, and a combined hearing loss of 55 db is equivalent to a 0% hearing impairment in the left ear. The hearing impairment in the better ear (0%) is multiplied by 5. The product (0) is then added to the hearing impairment in the poorer ear (24.4%). The sum (24.4) is then divided by 6. The resulting hearing impairment in both ears is 4.1%.

31 PRESBYCUSIS: One s ability to hear tends to lessen with age. The loss of hearing due to age is known as presbycusis. The WCB compensates workers for hearing loss caused by occupational noise, but not age. To compensate for hearing loss caused by occupational noise and not by age, multiply the number of the worker s years over the age of 60 by 2. Then deduct the product from the sum of the value of the hearing levels at 500, 1000, 2000 and 3000 Hz in each ear. Example: A sixty-six year old boiler-maker has the following test results in each ear: Right Ear: Left Ear: Hearing loss at 500 hertz = 20 db Hearing loss at 1,000 hertz = 25 db Hearing loss at 2,000 hertz = 30 db Hearing loss at 3,000 hertz = 45 db TOTAL 120 db Hearing loss at 500 hertz = 30 db Hearing loss at 1,000 hertz = 30 db Hearing loss at 2,000 hertz = 40 db Hearing loss at 3,000 hertz = 55 db TOTAL 155 db This worker is 6 years over the age of 60. Subtract 12 (6 years x 2) from 120 db and 155 db. This amounts to hearing loss of 108 db and 143 db. Table 1 indicates that a combined hearing loss of 108 db (rounded to 110 db) is equivalent to a 3.8% hearing impairment in the right ear, and a combined hearing loss of 143 db (rounded to 145 db) is equivalent to a 16.9% hearing impairment in the left ear. The hearing impairment in the better ear (3.8%) is multiplied by 5. The product (19) is then added to the hearing impairment in the poorer ear (16.9%). The sum (35.9) is then divided by 6. The resulting hearing impairment in both ears is 5.98%.

32 C. Calculating Whole-Person Impairment Percentage 7. Hearing loss is only one component of overall bodily function. Consult Table 2 to convert the impairment of hearing to impairment of the whole person. 8. Deafness, complete in both ears and the result of sudden and complete traumatic loss of hearing is rated as a 60% impairment of the whole person. Table 2: Converting Hearing Impairment to Whole Person Impairment % Hearing Impairment % Impairment of the Whole Person % Hearing Impairment % Impairment of the Whole Person D. Tinnitus 12. Tinnitus, when secondary to noise-induced occupational hearing loss, is rated as a 2% impairment of the whole person.

33 VIBRATION-INDUCED WHITE FINGER DISEASE The evaluation is performed by a Board Medical Officer and a judgement rating is assigned based on symptoms and objective findings as outlined by the examining specialist. The following is a simple classification system for percentage of impairment. The combined tables should be used to establish the total impairment when the condition is bilateral. 1. Confirmed diagnosis of Vibration Induced White Finger Disease. No clinical or investigative objective evidence of arterial occlusion as tested by either Allen's test, digital pressures, or angiography... 1% 2. Confirmed diagnosis of Vibration Induced White Finger Disease with clinical or investgative objective evidence of arterial occlusion as tested by either Allen's test, abnormal digital pressures, or angiography... 5% 3. Confirmed diagnosis of Vibration induced White Finger Disease of a severe nature with digital atrophic changes or gangrene. The rating will be judged in accordance with the Medical Officer's assessment based on a percentage of impairment of the whole hand.... up to 50% NERVOUS SYSTEM Determination of impairment is based on clinical findings indicative of brain or spinal cord damage, or peripheral nervous system injuries other than those specifically rated elsewhere in the Schedule. The percentages of multiple impairments are combined by using the Combined Values Chart, and the overall residual impairment rating resultant from a particular injury cannot exceed 100%. SPINAL CORD - BRAIN: Quadriplegia... up to 100% Paraplegia... up to 100% Hemiplegia... up to 100% Cauda Equina Lesion... up to 25% Paraparesis and hemiparesis may be rated on the combined values of associated loss of functions, as derived from the A.M.A. Guides to the Evaluation of Permanent Impairment.

34 STATION AND GAIT: Ability to stand and walk, but has difficulty with elevation, steps and distances 5 to 15% 2. Ability to stand, but walking limited to level surfaces 20 to 30% 3. Ability to stand but cannot walk 35 to 45 % 4. Ability to stand with difficulty, and cannot walk 50 to 60% 5. Cannot stand without prosthesis or help 65% UPPER EXTREMITIES: 1. Can use extremity for self care, grasping and holding; but has difficulty with finger dexterity 0 to 5% 2. Complete loss of digital dexterity 10 to 15% 3. Can use extremity with difficulty 20 to 25% 4. Cannot use extremity 30 to 40% URINARY BLADDER FUNCTION: 1. Impaired urgency 0 to 5% 2. Good reflex activity and no voluntary control 10 to 15% 3. No reflex or voluntary control 20 to 30% ANORECTAL FUNCTION: 1. Reflex regulation but no voluntary control 5 to 10% 2. No reflex regulation or voluntary control 10 to 15%

35 SEXUAL FUNCTION: 1. Sterility 5% 2. Impotence 10% POSTURAL VERTIGO: up to 10% BRAIN ORGANIC BRAIN SYNDROME: Defects may include defects in orientation; ability to understand concepts; memory; judgement; and decision process. 1. Impairment of complex integrated cerebral functions, ability to carry out activities of daily living...0 to 10% 2. Ability to carry out most activities of daily living with some difficulty...10 to 15% 3. Ability to carry out most activities but requires some supervision and/or direction to 25% 4. Ability to carry out most activities with continuous supervision...35 to 40% 5. Activities limited to directed care under confinement to 70% 6. Inability to care for self in any situation to 100% EPISODIC NEUROLOGICAL DISORDERS (SEIZURES): The criteria for evaluating such neurological disorders as syncope and epilepsy and based on the frequency, severity and duration of attacks as they affect performance of daily activities. 1. Slight severity and under control of medication... 0 to 5% 2. Slight severity and sufficiently under control to perform most activities... 5 to 10% -

36 Moderate severity and frequency, but can perform most activities to 15% 4. Sufficiently severe to interfere and restrict many daily activities to 30% 5. Such severity and constancy to limit activities to supervised or protected situations to 70% 6. Totally incapacitating in terms of daily activities to 100% DENERVATION: Peroneal nerve, complete... 12% Median nerve, complete at elbow... 40% Median nerve, complete at wrist... 20% Ulnar nerve, complete at elbow... 10% Ulnar nerve, complete at wrist... 8% HORNER S SYNDROME: % The syndrome is the result of a disruption of the sympathetic pathways of the brachial plexus at the C7 level, and the clinical features are: (a) partial ptosis (drooping of upper eyelid) (b) miosis (small pupil) (c) anhydrosis (lack of sweating) (d) apparent enophthalmos (depression of eyeball into socket)

37 DISFIGUREMENT When a worker is permanently disfigured as a result of an injury, the Board may determine that the disfigurement be considered a permanent impairment to which the claimant is entitled to an award. Disfigurement is an altered or abnormal appearance. This may be an alteration of color, shape, or structure, or a combination of these and can also include loss of function due to contractures as a result of scarring. The rating for disfigurement is done by the Board s Medical Department and the degree of disfigurement is determined on a judgemental basis. The maximum rating for disfigurement, in extreme cases, is 25%. Typical awards for disfigurement are between 1 and 5%. In order to maintain consistency in awards for disfigurement, and to make the awards as objective as possible, Medical staff will make reference to the folio of previous disfigurement awards established as policy by Board Order No. 67/89 and maintained by the Director of the Benefits Division as prescribed in Board Order 67/89. Contractures resulting in loss of function should be considered as for any other cause, and are applied using the combined values chart.

38 MYOCARDIAL INFARCTION - IMPAIRMENT RATING SCALE OFSEVERITY 1 TO 3 4 TO 6 7 TO 9 10 A. SUBJECTIVE 1. Angina 0 per day 2 to 3 per day 4 per day At rest 2. Dyspnea Running or carrying weights On stairs Level walk At rest 3. Orthopnea 1 pillow 2 pillows 3 or more Paroxysmal nocturnal dyspnca or slceps on chair 4. Edema In PM occasionally Frequent in PM Trace to 1+ at the time Fixed 5. Cough None On running & on stairs Frequent At night 6. Palpitation Never Only at fast walk or work Occasionally at rest Frequent even at rest B. OBJECTIVE 1. Stress Test Negative Mild ST or extra Systole Severe ST & PVC Resting EKG, ischemia or PVC 2. Muga Scan a) Ejection fraction 50% 40 to 50% 30 to 40% 30% b) Akinesis c) Dyskinesis d) Hypokinesis Thallium a) Infarction b) Ischemia 0 0 Small Large 4. Holter No PVC or APC No ST-T changes Occasional PVC No ST-T changes Frequent PVC & occasional ST-T Multifocal or coupled ST-T changes MAXIMUM IMPAIRMENT % SUBJECTIVE - 60 to be weighted as half the value, i.e., if obtained grade is 10, it will be reduced to 5 OBJECTIVE - 80 (Objective 24 = 24/34) EXAMPLE - Claimant showed subjective 20 = 10 RATING - 34/140 = 24%

39 RESPIRATORY (INDUSTRIAL LUNG DISEASES ) - IMPAIRMENT RATING CRITERIA CLASS 1 0% CLASS II 25% CLASS III 25-45% CLASS IV > 45.<65% CLASS V >65-100% A. SUBJECTIVE OBST REST OBST REST OBST REST OBST REST 1. Cough / / /- 2. Sputum < 15cc +/ cc +/- >60cc +/- 3. Dyspnea Wheeze 0 +/ /- 5. Edema Orthopnea B. OBJECTIVE 1. Volumes % >110<130% >70<80% >130<150% >60<70% >150>170% >50<60% >170% <50% (TLC, R.V., V.C.) 2. FEV,/FVC >80% 70-80% 70-80% 60-70% >80% 50-60% 70-80% <40% 70-80% 3. Peak Flow N >80% >80% 60-80% >80% 40-60% >80% <40% >80% 4. Phase III N <115% N % % >300% 5. DLCO N N % >60<80% >60<80% >40<60% >40<60% <40% <40% 6. PO N N N by 10 by 10 by 20 by 20 by 30 by PCO N N N N N N N N 8. A-A Gradient <10 <10 <20 <30 <30 <40 <40 >40 >40 9. VD/VT <25% <35% <35% <45% <40% <50% <45% >50% > METS N >5 METS >5 METS 3-5 METS 3-5 METS <3 METS <3 METS Sat. % N N N by 5% by 5% by 10% by 10% 12. Heart Rate N 13. Vent. Rate N SCALE OF SEVERITY 0 to 2 2 to 4 4 to 6 6 to 8 8 to 10 LEGEND: OBST - Obstructive EXAMPLE: TOTAL POINTS OBTAINABLE CLAIMANT: -SUBJECTIVE - 50: WEIGHTED 25 REST - Restrictive - SUBJECTIVE: 6 X 10 = 60 - OBJECTIVE - 100: TOTAL OBJECTIVE: 13 X 10 = 130 TOTAL = IMPAIRMENT - 125/190 X 100 = 65.7%

40 PSYCHOLOGICAL INTRODUCTION: The psychic functions (mental, affective, adaptive, behavioral) of certain accident victims may be permanently damaged. a) General Impairment Producing Mechanisms Such impairments are sometimes the direct consequence of a lesion in the central nervous system and therefore entail psychiatric or psychiatric or psychological evaluation which goes beyond the sole assessment of a neurological impairment. In other cases, the impairment reflects a permanent affective dysfunction revealing chronic psychological maladaptation to trauma having temporarily or permanently damaged another part of the body. Impairments of this nature may sometimes result from the interaction of the two impairment producing mechanisms. b) General Evaluation Criteria Impairment is assessed by means of a clinical psychiatric or psychological examination. Adequate knowledge of the accident victim s personality prior to the accident, his complete background and his usual mode of adaptation is necessary for the conducting of a clinical evaluation. The victim s premorbid level of personal adaptation must be considered in order to determine the degree of functional damage stemming from mental illness caused by an accident. A detailed objective mental examination is essential. The symptomatology must establish a credible, total and coherent syndrome. Impairment of psychic functions must be manifested by changes in the patient s daily activities and interpersonal relationships and in certain cases must be accompanied by physiopathological signs. Symptoms must be present during a sufficiently long period and, as a rule, must persist despite constant, standard therapy. Additional objective information on the patient s abnormal mental condition is usually provided by his family and friends and those treating him. A purely subjective syndrome that is difficult to verify rarely indicates severe permanent partial impairment.

41 The clinical evaluation may sometimes be supplemented with a social or psychometric evaluation. Unfavourable social circumstances may influence that accident victim s rehabilitation and overall prognosis but do not in themselves constitute an impairment of psychic functions. The evaluation must take his motivational aspect into account. Lastly, an impairment assessed by such psychiatric or psychological evaluation is different in its very nature from an impairment caused by the loss of enjoyment of life or of a mutilated organ. (c) Groups and Classes of Impairment Permanent impairment of the accident victim s psychic functions may result from: chronic brain syndromes psychoses neuroses personality disorders The history of psychiatric or psychological sequelae, the specific results of the mental examination and supplementary examinations usually allow only one nostologic category to be determined. However, organic brain syndromes may, in particular, be accompanied by and thus include in their clinical picture and evaluation psychotic or neurotic signs or deterioration of the personality. Symptomatic severity is accompanied by repercussions going beyond the accident victim s mere experience to change his usual activities of daily living and his personal or social efficiency. The accident victim requires constant supervision or therapy, assistance or a particular milieu, and in certain cases even needs to be looked after on a full-time basis for the fulfilment of his basic needs. The diagnosis as to the degree of severity of the impairment affecting the whole person must be specified by applying the general evaluation criteria, by taking the objective effects of the assessed syndrome into consideration, and by referring to the following clauses: Class I: Minor impairment... 0 to 15% Class II: Serious impairment to 45% Class III: Extremely serious impairment... 45% and over

42 Precise quantification in one class may be difficult to achieve, thus the necessity for a comparison with similar cases whose development was followed by the evaluating physician. It may be necessary to wait some time before the final evaluation of the impairment can be carried out. A standard clinical psychiatric or psychological evaluation may not necessarily determine an additional impairment and may be useful only for evaluating the motivation of a patient with an impairment in another system or for establishing that the patient s potential for a more complete rehabilitation requires further scrutiny before the degree of impairment in the other system is established. 1. CHRONIC BRAIN SYNDROMES: The syndrome is directly associated with organic brain injury resulting from trauma. Above all, it consists of disturbances of the higher cognitive functions. It is essentially characterized by impairment of orientation, comprehension, memory and of the abilities to learn, anticipate, make decisions and exercise judgement: A supplementary psychometric evaluation may be useful in this case. In addition to these essential signs, the subject may show signs of instability, puerilism, erosion of the importance of moral values, or character disorders. The syndrome is sometimes complicated by psychotic or neurotic reactions in which case they are included in the evaluation. Psychoses or neuroses without organic brain injury will be evaluated separately in their own class. a) Class I The patient has impairment of the higher cognitive functions but is able to perform most of the activities of daily living, as prior to the accident...0 to 15% b) Class II The patient has impairment of the higher cognitive functions and in some cases exhibits constant or intermittent but recurring psychotic or neurotic symptoms, to such an extent that he requires supervision and direction for several or most of his daily activities to 45%

43 c) Class III The impairment of the higher cognitive functions and the psychological adaptation to the impairment itself are such that the performance of daily activities requires more or less constant care in a protective milieu (home or similar establishment). Patients with extremely severe impairments require help even in meeting their most elementary needs... 45% and over 2. PSYCHOSES: Psychosis is a severe disturbance of mental function likely to cause more or less considerable impairment, depending on its nature, severity, duration, repercussions, the patient s history and his reaction to therapeutic measures. It is often advisable to wait two or three years before making the final evaluation of the impairment. The clinical picture may then stabilize and show evidence of permanent impairment. In certain cases basic impairment may be only the more or less strong possibility of relapse. The syndrome is essentially manifested by disturbances in perception, thinking (process, form, content) and behaviour and by abnormalities in emotional control. It is usually accompanied by a lack of self-criticism and often involves abnormal behaviour discernible by those around him. a) Class I An impairment in this class is manifested by minor and discrete disturbances in perception, thinking, emotional behaviour, but it has little effect on how the patient functions in comparison to his adaptation prior to the accident. Patients who are well controlled by constant psychotropic medication, which alleviates the necessity for rehospitalization, are placed in this class... 0 to 15% b) Class II A psychosis in this class is evident upon mental examination, easily discernible by those around the patient and is reflected in difficulty in social behaviour, odd behaviour and a fairly noticeable reduction in social and personal efficiency. Nevertheless, disorders are not too serious, so the patient can be tolerated in this milieu. The patient s collaboration is

44 inconstant, the possibility of intermittent hospitalization is likely and the syndrome is poorly controlled by medication. The patient may require occasional supervision and direction in leading his daily life...15 to 45% c) Class III A psychosis in this class is so severe that the patient manifests disturbances in perception and thinking, and an inability to control his emotions that leads him to behave in a way that is socially intolerable or dangerous to his own well-being. The patient always requires at least part-time supervision and direction so that he can lead his daily life. In more serious cases, he may require a protective milieu or constant care in an establishment, with recurrent hospitalization... 45% and over 3. NEUROSES: Individuals react differently to life s problems. Some accident victims are prone to adapt neurotically to trauma and its sequelae. Neuroses have no known organic cause. The patient remains lucid and is able to distinguish between external reality and his own subjective experiences. He does not show personality disorganization, but his behaviour may be disturbed within the limits of what is generally acceptable. Neuroses may entail excessive anxiety and phobic, hysterical, obsessive-compulsive, depressive and sometimes even psychosomatic symptoms. Given the strictly subjective nature of neurosis, its great variability, its natural tendency to subside and the motivational context (secondary gains), it is necessary to wait long enough to ensure a strict application of the following general clinical evaluation criteria; previous manner of adaptation, objective repercussions on daily life and relationships, the psychosomatic element, regular continuation of treatment, and social context. a) Class I i. The neurosis is above all subjective but credible, complete and coherent. It is attended with minor changes and does not render the victim incapable of adaptive behaviour. There is no reduction in daily activities or in social or personal efficiency... 0 to 15%