1996 FL Impairment Rating Schedule
1996 FL Impairment Rating Schedule
1996 FL Impairment Rating Schedule
Florida
Uniform
Permanent
Impairment
Rating
Schedule
ii
DYSARTHRIA ............................................................................................................................................................................... 97
TEMPOROMANDIBULAR JOINT DISORDERS ................................................................................................................................. 100
as age, sex, education, economic and social environment, in addition to the definite medical factorpermanent impairment. The first group of factors has proved extremely difficult to measure. For this
reason, permanent impairment is in fact the sole or real criterion of permanent disability far more
often than is readily acknowledged. In actual practice, however, the final determination of permanent
disability is an administrative decision as to the patients entitlement. Under no circumstances shall
this guide be used to determine disability. This guide is intended to be used solely for the purpose of
rating impairments. Competent evaluation of permanent impairment requires an adequate and
complete medical examination, and the avoidance of subjective impressions and such factors, as age,
sex, or employability.
(5) Maximum Medical Improvement or Date of Maximum Medical Improvementthe date after which
further recovery from, or lasting improvement to, an injury or disease can no longer reasonably be
anticipated, based upon reasonable medical probability.
EVALUATION PROCESS
An evaluation for permanent impairment shall be performed by a physician as defined in Section
440.13(l)(r), Florida Statutes. Physician means a physician licensed under Chapter 458 an osteopath
licensed under Chapters 458 and 459, a chiropractor licensed under Chapter 460, a podiatrist licensed
under Chapter 461, an optometrist licensed under Chapter 463, or a dentist licensed under Chapter 466. In
no case, however, may a physician as defined above give a permanent impairment rating for a condition
for which that physician cannot professionally treat.
The evaluation for permanent impairment, including the assignment of any rating, shall not be
determined before the date of maximum medical improvement. Furthermore, pursuant to Section
440.15(3)(a)4, Florida Statutes, an evaluation may occur up to six weeks before the end of temporary
indemnity benefits.
The evaluation should be inclusive of a complete history of the condition under evaluation, including
reference to treatment, response to treatment, and pre- existing conditions or aggravating factors when
present. The evaluation shall include a thorough physical examination of the body system or systems
involved. Objective findings (appropriate to the specific organ involved) should include observation,
palpation, auscultation, and measurements where indicated for neuromusculoskeletal conditions. This
should include observation of postural and structural abnormalities, palpation of neuromuscular structures
and note of tender areas found in consistent clinical distribution corresponding to subjective complaint.
Rigidity, spasm or loss of range-of-motion of joints should be noted if present.
Range of motion should be determined by using a measuring device such as a goniometer or
inclinometer for extremities. Consistency and validity are necessary for determining the values obtained
in joint range-of-motion evaluation. Joint measurements should be performed twice and produce
comparable figures varying less than ten percent of the maximum value for the involved part.
In order for an opinion of no impairment for joint range of motion, the evaluator must record the
specified ranges of motion of the involved joint.
40 combined with 35 = 61
61 combined with 10 = 65
6. Pre-existing conditions may not be rated unless there is objectively documented evidence of an
increased loss of function to the affected area as a result of the industrial injury.
7. For those permanent impairments that are subject to confirmation only through the administration of
diagnostic tests and procedures that although characterized as subjective in nature, are generally
accepted and used in the medical discipline involved, the injured employee is entitled to an
impairment rating of 2% of the body as a whole. This rating cannot be added or combined to another
impairment for a condition provided for in other sections of this Guide. For example, if an injured
worker has a back injury and in addition has headaches as determined by subjective complaints, the
headaches are not ratable since they are included in the rating allowed for the back injury and the
impairment rating is only as determined by evaluating the back injury alone.
8. Employees shall be rated for a permanent impairment, if any, as of the date of maximum medical
improvement or six weeks before the expiration of 104 weeks of temporary benefits, whichever
occurs first, as provided for in Section 440.15(3)(a)4.
FRACTURES
Disorder
1.
T=2%
T=3%
T=5%
L=5%
L=7%
L=12%
Fracture of the Posterior Elements of the Vertebra (pedicles, laminae, or articular processes)
Cervical ................................................................................................................................................................4%
Thoracic ...............................................................................................................................................................2%
Lumbar.................................................................................................................................................................5%
This may include nonunion or mal-union.
Values given are the same whether it is a single or multiple fracture in the SAME vertebra. Fractures of the body
and the posterior elements in the same vertebra are to be COMBINED.
At MMI if the fracture is healed and causes no functional impairment, it is not ratable.
3.
4.
Dislocation
Dislocation reduced without fusion.......................................................................................................................5%
Dislocation reduced with surgical fusion ............................................................................................................10%
Dislocation unreduced ................................................................................................................................... 5-15%
Additional segments: Combine with value from appropriate section of the spine where applicable.
Pain associated with rigidity (loss of motion or postural abnormality) and chronic muscle spasm. The chronic
muscle spasm and rigidity is substantiated by objective clinical findings but without associated demonstrable
degenerative changes
Cervical ................................................................................................................................................................3%
Thoracic ...............................................................................................................................................................3%
Lumbar.................................................................................................................................................................3%
3.
Unoperated, with medically documented* injury and associated with minimal post traumatic changes on
diagnostic tests (including disc lesions with the exception of HNP)
Cervical ................................................................................................................................................................4%
Thoracic ...............................................................................................................................................................3%
Lumbar.................................................................................................................................................................5%
4.
5.
6.
7.
8.
With surgically treated disc lesion including a surgical spinal fusion, increase the impairment by 1% per vertebral
level fused.
1.
2.
Grade III (51%75% slippage) or Grade IV (76%100% slippage) Spondylolisthesis, accompanied by objective
studies documenting injury
Cervical ................................................................................................................................................................9%
Thoracic ...............................................................................................................................................................5%
Lumbar...............................................................................................................................................................10%
2.
2.
3.
Multiple levels, operated, with or without residual objective signs of injury .......................................... Add 1%/level
4.
Ankylosis secondary to surgery or injury in the spinal area (see Ankylosis table).
b.
Spinal cord or spinal nerve root injuries, with neurologic impairment (see neurological section).
c.
ANKYLOSIS
The following techniques for determining impairment ratings for Ankylosis and the use of the
goniometer is for the purpose of determining the degree of Ankylosis clinically rather than
radiographically. In determining the impairment for this condition, loss of motion shall not be used. An
alternate method for determining impairment can be based on radiographic methods as hereinafter
provided. Diagrams for performing testing to determine impairment ratings are as follows:
1. Cervical RegionFlexion-Extension Technique of Measurement
a. Place goniometer base as if measuring the neutral position (Figure 1). Measure the deviation from
neutral position with the goniometer arm and record the reading.
b. Consult the table below to determine the impairment of the whole person.
Example: Cervical region with ankylosed at 30 degrees flexion is equivalent to 23% impairment of
the whole person.
OR
c. Determine number and position of ankylosed vertebrae by appropriate x-ray methods. (Consult
Table 1)
Figure 1 Placement of Goniometer in Neutral
Position of Cervical Spine: Flexion/Extension
% Impairment
of Whole Person
14%
19%
23%
35%
14%
19%
23%
60%
% Impairment
of Whole
Person
15%
20%
25%
30%
% Impairment
of Whole Person
14%
17%
21%
25%
28%
% Impairment
of Whole Person
20%
22%
24%
27%
29%
31%
34%
36%
38%
40%
20%
27%
34%
40%
Ankylosis in the lumbosacral spine has significance only if immobility occurs in both the hips and the
lumbar spine region, so that the neutral position cannot be attained in the sagittal plane. This is a very rare
event. Isolated fusions of either a hip or two to three spinal levels place additional stresses on adjacent
segments, but do not lead to biomechanical failure of the functional unit. Thus, impairment related to
fusion of part of the lumbar/hip motion complex are treated only by radiographic methods Table.
6. Dorsolumbar RegionRotation Technique of Measurement
Determine number and position of ankylosed vertebrae by appropriate x-ray methods.
(Consult Table 1)
Impairment Due To Ankylosis Of The Thoracic Region Rotation
% Impairment of Whole
Person
Region ankylosed at:
0 (neutral position)
20%
10
27%
20
30 (full right/left rotation)
34%
40%
The largest ankylosis impairment value is 33%; therefore, the whole person is 33% impaired by
ankylosed cervical region.
TABLE 1
IMPAIRMENT OF CERVICAL, THORACIC AND LUMBAR REGIONS DUE TO ANKYLOSIS,
DETERMINED BY RADIOGRAPHIC METHODS
Favorable (Neutral)
Position
Any 2 cervical
Any 3 cervical
Any 4 cervical
Any 5 cervical
Any 6 cervical
Any 7 cervical
C7 and T1
Any 2 thoracic
Any 3 thoracic
Any 4 thoracic
Any 5 thoracic
Any 6 thoracic
Any 7 thoracic
Any 8 thoracic
Any 9 thoracic
Any 10 thoracic
Any 11 thoracic
Any 12 thoracic
T12 and L1
Any 2 lumbar
Any 3 lumbar
Any 4 lumbar
Any 5 lumbar
C1-C7
T1-T12
L1-L5
C1-T12
L1-L5
C1-L5
% Impairment of Whole
Person
2
5
7
9
12
14
2
1
2
3
4
5
5
6
7
8
9
12
3
3
6
9
12
14
10
12
23
21
32
Unfavorable Position
Any 2 cervical
Any 3 cervical
Any 4 cervical
Any 5 cervical
Any 6 cervical
Any 7 cervical
C7 and T1
Any 2 thoracic
Any 3 thoracic
Any 4 thoracic
Any 5 thoracic
Any 6 thoracic
Any 7 thoracic
Any 8 thoracic
Any 9 thoracic
Any 10 thoracic
Any 11 thoracic
Any l2 thoracic
T12 and L1
Any 2 lumbar
Any 3 lumbar
Any 4 lumbar
Any 5 lumbar
C1-C7
T1-T12
L1-L5
C1-T12
T1-L5
C1-L5
%Impairment of Whole
Person
4
10
14
18
24
28
4
2
4
5
7
9
11
13
15
16
18
20
6
6
12
18
24
28
20
24
28
39
56
This table should not be used if there are specific disorders of the spine that already have been used to
determine an impairment.
PELVIS
The following shows impairment values associated with conditions of the pelvis.
Disorder
1.
2.
3.
SPECIFIC DISORDERS
Upper extremitySpecific disorders of the upper extremity (i.e., persistent joint subluxation, joint
swelling, etc.) are converted to impairment of upper extremity and then combined with all other upperextremity values.
Lower extremitySpecific disorders of the lower extremity (i.e., hip disorders, specific disorders of
the knee, etc.) are combined with all other lower- extremity values.
Using the specific guidelines for motor and sensory impairment, these values will also be determined
separately and combined with all other values of the involved extremity.
The evaluator is cautioned to combine all the values of one extremity before conversion to whole
person. (Only one conversion to whole person should be done per extremity.)
When both upper and lower extremities are involved, each extremity should be evaluated separately
and converted to whole person. Then the two whole-person values (both the upper and lower extremities)
should be combined to produce a single whole-person rating.
There is no dominant or preferred lower extremity. Most conditions of the lower extremity relative to
the dominant side refer to the employability of the patient and determine disability, not physical
impairment.
Ankylosis
Ankylosis is defined as absence of joint motion. Since no joint motion can be measured, ankylosis
cannot be considered range of motion. Therefore ankylosis values are combined with all other values of
the extremity. Since there can be many planes of movement of a joint, there can be multiple ankyloses.
When multiple ankyloses occur in the same joint, the evaluator should utilize the largest value for
impairment rating.
Example:
Wrist joint ankyloses at 20 degrees palmar flexion and 10 degrees ulnar deviation.
20 degrees palmar flexion ankylosed = 47% upper-extremity impairment
10 degrees ulnar deviation ankylosed = 50% upper-extremity impairment
Shoulder.............................. 3% U E
Elbow .................................. 3% U E
Wrist/Hand .......................... 3% U E
Lower Extremity
Hip........................................4% L E
Knee.....................................4% L E
Ankle/Foot ............................4% L E
This condition must not be rated for at least one year after onset and should not be explained by any
other ratable diagnoses.
These conditions (P.O.S. and R.S.D.) should not be rated until MMI and should not be secondary to
any other ratable diagnosis.
These values must be combined with all other values.
% Impairment
of Thumb
0 .................................80....................................... 0..................................................................45
10 .................................70...................................... 10.................................................................39
20 ................................60...................................... 20.................................................................34
30 .................................50...................................... 30.................................................................28
40 .................................40...................................... 40.................................................................23
50 .................................30...................................... 50.................................................................17
60 .................................20...................................... 60.................................................................11
70 .................................10...................................... 70...................................................................6
80 ..................................0....................................... 80...................................................................0
Ankylosis
Joint ankylosed at:
0.(neutral position) ....................................................................................................................45
10................................................................................................................................................43
20................................................................................................................................................40
30................................................................................................................................................38
*40................................................................................................................................................35
50................................................................................................................................................45
60................................................................................................................................................55
70................................................................................................................................................65
80.(full flexion).............................................................................................................................75
*position of function
TABLE 2
IMPAIRMENT DUE TO
ABNORMAL MOTION AND ANKYLOSIS OF THE
METACARPOPHALANGEAL JOINT OF THE THUMB
Abnormal Motion
Average range of FLEXION-EXTENSION is 60 degrees
Value to total range of joint motion is 100%
Flexion from neutral
position ( 0) to:
% Impairment
of Thumb
0 .................................60....................................... 0..................................................................55
10 .................................50...................................... 10.................................................................46
20 .................................40...................................... 20.................................................................37
30 .................................30...................................... 30.................................................................27
40 .................................20...................................... 40.................................................................18
40 .................................10...................................... 50...................................................................9
60 ..................................0....................................... 60...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................55
10................................................................................................................................................49
*20................................................................................................................................................43
30................................................................................................................................................52
40................................................................................................................................................61
50................................................................................................................................................70
60 (full flexion).............................................................................................................................80
*position of function
TABLE 3
IMPAIRMENT DUE TO
ABNORMAL MOTION AND ANKYLOSIS OF THE
CARPOMETACARPAL JOINT OF THE THUMB
Abnormal Motion
Average range of FLEXION-EXTENSION is 45 degrees
Flexion from neutral
position ( 0) to:
% Impairment
of Thumb
0 .................................15....................................... 0..................................................................15
10 ..................................5....................................... 10...................................................................5
15 ..................................0....................................... 15...................................................................0
Extension From Neutral
Position (0) to:
0 .................................30....................................... 0..................................................................15
10 .................................20...................................... 10.................................................................10
20 .................................10...................................... 20...................................................................5
30 ..................................0....................................... 30...................................................................0
Ankylosis
Joint Ankylosed At:
0 (neutral position) ....................................................................................................................30
10................................................................................................................................................55
15(full Extension) ........................................................................................................................80
Joint Ankylosed At:
0 (neutral Position)....................................................................................................................30
10................................................................................................................................................47
20................................................................................................................................................63
30 (full Extension) .......................................................................................................................80
TABLE 4
RELATIONSHIP OF IMPAIRMENT OF
THE THUMB TO IMPAIRMENT OF THE HAND*
% Impairment of
Thumb
Hand
01
0
23
1
46
2
78
3
911
4
1213
5
1416
6
1718
7
1921
8
2223
9
2426
10
2728
11
2931
12
3233
13
3436
14
3738
15
3941
16
4243
17
4446
18
4748
19
% Impairment of
Thumb
Hand
4951
20
5253
21
5456
22
5758
23
5961
24
6263
25
6466
26
6768
27
6971
28
7273
29
7476
30
7778
31
7981
32
8283
33
8486
34
8788
35
8991
36
9293
37
9496
38
9798
39
99100
40
*Impairment of the hand contributed by the thumb may be rounded to the nearest 5 percent only when it is the sole
impairment involved.
Consult Table 18 for converting hand impairment to upper-extremity impairment.
FINGERS
TABLE 5
IMPAIRMENT DUE TO ABNORMAL
MOTION AND ANKYLOSIS OF THE DISTAL
INTERPHALANGEAL JOINT OF ANY FINGER
Abnormal Motion
Average range of FLEXION-EXTENSION is 70 degrees
Value to total range of joint motion is 100%
Flexion from neutral
position ( 0) to:
% Impairment
of Finger
0 .................................70....................................... 0..................................................................45
10 .................................60...................................... 10.................................................................38
20 .................................50...................................... 20.................................................................32
30 .................................40...................................... 30.................................................................26
40 .................................30...................................... 40.................................................................19
50 .................................20...................................... 50.................................................................13
60 .................................10...................................... 60...................................................................6
70 ..................................0....................................... 70...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................45
10................................................................................................................................................41
20................................................................................................................................................38
30................................................................................................................................................34
*40................................................................................................................................................30
50................................................................................................................................................35
60................................................................................................................................................40
70 (full flexion).............................................................................................................................45
*position of function
TABLE 6
IMPAIRMENT DUE TO ABNORMAL
MOTION AND ANKYLOSIS OF THE PROXIMAL
INTERPHALANGEAL JOINT OF ANY FINGER
Abnormal Motion
Average range of FLEXION-EXTENSION is 100 degrees
Value to total range of joint motion is 100%
Flexion from neutral
position ( 0) to:
% Impairment
of Finger
0 ................................100...................................... 0..................................................................60
10 .................................90...................................... 10.................................................................54
20 .................................80...................................... 20.................................................................48
30 .................................70...................................... 30.................................................................42
40 .................................60...................................... 40.................................................................36
50 .................................50...................................... 50.................................................................30
60 .................................40...................................... 60.................................................................24
70 .................................30...................................... 70.................................................................18
80 .................................20...................................... 80.................................................................12
90 .................................10...................................... 90...................................................................6
100 ..................................0...................................... 100..................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................58
20................................................................................................................................................55
30................................................................................................................................................53
*40................................................................................................................................................50
50................................................................................................................................................55
60................................................................................................................................................60
70................................................................................................................................................65
80................................................................................................................................................70
90................................................................................................................................................75
100 (full flexion).............................................................................................................................80
*position of function
TABLE 7
IMPAIRMENT DUE TO ABNORMAL
MOTION AND ANKYLOSIS OF THE
METACARPOPHALANGEAL JOINT OF ANY FINGER
Abnormal Motion
Average range of FLEXION-EXTENSION is 90 degrees
Value to total range of joint motion is 100%
Flexion from neutral
position ( 0) to:
% Impairment
of Finger
0 .................................90....................................... 0..................................................................55
10 .................................80...................................... 10.................................................................49
20 .................................70...................................... 20.................................................................43
30 .................................60...................................... 30.................................................................37
40 .................................50...................................... 40.................................................................31
50 .................................40...................................... 50.................................................................24
60 .................................30...................................... 60.................................................................18
70 .................................20...................................... 70.................................................................12
80 .................................10...................................... 80...................................................................6
90 ..................................0....................................... 90...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................55
10................................................................................................................................................52
20................................................................................................................................................48
30................................................................................................................................................45
*40................................................................................................................................................54
50................................................................................................................................................63
60................................................................................................................................................72
70................................................................................................................................................82
80................................................................................................................................................91
90 (full flexion)........................................................................................................................... 100
*position of function
TABLE 8
RELATIONSHIP OF IMPAIRMENT OF THE DIGITS
TO IMPAIRMENT OF THE HAND
% Impairment of
Thumb
Hand
% Impairment of
Index or Middle
Finger
Hand
01
23
46
79
9 11
12 13
14 16
17 18
19 21
22 23
24 26
27 28
29 31
32 33
=
=
=
=
=
=
=
=
=
=
=
=
=
=
0
1
2
3
4
5
6
7
8
9
10
11
12
13
02
37
8 12
13 17
18 22
23 27
28 32
33 37
38 42
43 47
48 52
53 57
58 62
63 67
=
=
=
=
=
=
=
=
=
=
=
=
=
=
0
1
2
3
4
5
6
7
8
9
10
11
12
13
34 36
37 38
39 41
42 43
44 46
47 48
49 51
52 53
54 56
57 58
59 61
62 63
64 66
67 68
69 71
72 73
74 76
77 78
79 81
82 83
84 86
87 88
89 91
92 93
94 96
97 98
99 100
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
68 72
73 77
78 82
83 87
88 92
93 97
98 100
=
=
=
=
=
=
=
14
15
16
17
18
19
20
% Impairment of
Ring or Little
Finger
Hand
0-4
5 - 14
15 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75 - 84
85 - 94
95 - 100
=
=
=
=
=
=
=
=
=
=
=
0
1
2
3
4
5
6
7
8
9
10
Note: Impairment of the hand contributed by a digit may be rounded to the nearest 5 percent only when it is the sole
impairment involved.
WRIST JOINT
TABLE 9
IMPAIRMENT DUE TO ABNORMAL MOTION AND
ANKYLOSIS OF THE WRIST JOINTEXTENSION
Abnormal Motion
Average range of EXTENSION-FLEXION is 130 degrees
Value to total range of joint motion is 70%
Extension from neutral
position ( 0) to:
% Impairment of
Upper Extremity
0 .................................60....................................... 0..................................................................10
10 .................................50...................................... 10...................................................................8
20 .................................40...................................... 20...................................................................6
30 .................................30...................................... 30...................................................................5
40 .................................20...................................... 40...................................................................3
50 .................................10...................................... 50...................................................................2
60 ..................................0....................................... 60...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................30
100 .................................................................................................................................................28
20................................................................................................................................................27
*30................................................................................................................................................25
40................................................................................................................................................47
50................................................................................................................................................68
60 (full extension)........................................................................................................................90
*position of function
TABLE 10
IMPAIRMENT DUE TO ABNORMAL MOTION
AND ANKYLOSIS OF THE WRIST JOINTFLEXION
Abnormal Motion
Average range of EXTENSION-FLEXION is 130 degrees
Value to total range of joint motion is 70%
Flexion from neutral
position ( 0) to:
% Impairment of
Upper Extremity
0 .................................70....................................... 0..................................................................11
10 .................................60...................................... 10.................................................................10
20 .................................50...................................... 20...................................................................8
30 .................................40...................................... 30...................................................................6
40 .................................30...................................... 40...................................................................5
50 .................................20...................................... 50...................................................................3
60 .................................10...................................... 60...................................................................2
70 ..................................0....................................... 70...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................30
10................................................................................................................................................39
20................................................................................................................................................47
30................................................................................................................................................56
40................................................................................................................................................64
50................................................................................................................................................73
60................................................................................................................................................81
70 (full flexion).............................................................................................................................90
TABLE 11
IMPAIRMENT DUE TO ABNORMAL MOTION
AND ANKYLOSIS OF THE WRIST JOINTRADIAL/ULNAR DEVIATION
Abnormal Motion
Average range of RADIAL-ULNAR DEVIATION (adduction-abduction) is 50 degrees
Value to total range of joint motion is 30%
Radial deviation from
neutral position ( 0) to:
% Impairment of
Upper Extremity
0 .................................20....................................... 0....................................................................4
10 .................................10...................................... 10...................................................................2
20 ..................................0....................................... 20...................................................................0
Ulnar deviation from
neutral position (0) to:
0 .................................30....................................... 0....................................................................5
10 .................................20...................................... 10...................................................................4
20 .................................10...................................... 20...................................................................2
30 ..................................0....................................... 30...................................................................0
Ankylosis
Joint ankylosed at:
*0 (neutral position)......................................................................................................................30
10................................................................................................................................................60
20 (full radial deviation) ...............................................................................................................90
Joint ankylosed at:
*0 (neutral position) ....................................................................................................................30
10................................................................................................................................................50
20................................................................................................................................................70
30 (full ulnar deviation)................................................................................................................90
*position of function
ELBOW JOINT
TABLE 12
IMPAIRMENT DUE TO ABNORMAL MOTION AND ANKYLOSIS
OF THE ELBOW JOINTFLEXION/EXTENSION
Abnormal Motion
Average range of FLEXION-EXTENSION is 150 degrees
Value to total range of joint motion is 60%
Retained Active
Flexion of:
% Impairment of
Upper Extremity
0 ...............................................................................................................39
10 ...............................................................................................................36
20 ...............................................................................................................34
30 ...............................................................................................................31
40 ...............................................................................................................29
50 ...............................................................................................................26
60 ...............................................................................................................23
70 ...............................................................................................................21
80 ...............................................................................................................18
90 ...............................................................................................................16
100 ...............................................................................................................13
110 ...............................................................................................................10
120 .................................................................................................................8
130 .................................................................................................................5
140 .................................................................................................................3
150 .................................................................................................................0
Extension to:
0 (neutral position).......................................................................................0
10 .................................................................................................................2
20 .................................................................................................................4
30 .................................................................................................................6
40 .................................................................................................................8
50 ...............................................................................................................10
60 ...............................................................................................................12
70 ...............................................................................................................14
80 ...............................................................................................................16
90 ...............................................................................................................18
100 ...............................................................................................................20
110 ...............................................................................................................22
120 ...............................................................................................................24
130 ...............................................................................................................26
140 ...............................................................................................................28
150 ...............................................................................................................30
Ankylosis
Joint ankylosed at:
0 (neutral position).....................................................................................65
10 ...............................................................................................................64
20 ...............................................................................................................62
30 ...............................................................................................................61
40 ...............................................................................................................59
50 ...............................................................................................................58
60 ...............................................................................................................56
70 ...............................................................................................................55
80 ...............................................................................................................53
90 ...............................................................................................................52
100 ...............................................................................................................50
110 ...............................................................................................................59
120 ...............................................................................................................68
130 ...............................................................................................................77
140 ...............................................................................................................86
150 (full flexion) .............................................................................................95
*position of function
In the case of bilateral ankylosis of the elbows, position of function would not necessarily be the same for
both elbows; however, the corresponding impairment of the whole person can be computed by using the
above figures and the conversion figures on UPPER EXTREMITY Conversion Tables.
TABLE 13
IMPAIRMENT DUE TO ABNORMAL MOTION AND ANKYLOSIS
OF THE ELBOW JOINTPRONATION/SUPINATION
Abnormal Motion
Average range of ROTATION is 160 degrees
Value to total range of joint motion is 40%
Pronation from
neutral position ( 0) to:
% Impairment of
Upper Extremity
0 .................................80....................................... 0..................................................................13
10 .................................70...................................... 10.................................................................11
20 .................................60...................................... 20.................................................................10
30 .................................50...................................... 30...................................................................8
40 .................................40...................................... 40...................................................................7
50 .................................30...................................... 50...................................................................5
60 .................................20...................................... 60...................................................................3
70 .................................10...................................... 70...................................................................2
80 ..................................0....................................... 80...................................................................0
Supination from
neutral position (0) to:
0 .................................80....................................... 0..................................................................13
10 .................................70...................................... 10.................................................................11
20 .................................60...................................... 20.................................................................10
30 .................................50...................................... 30...................................................................8
40 .................................40...................................... 40...................................................................7
50 .................................30...................................... 50...................................................................5
60 .................................20...................................... 60...................................................................3
70 .................................10...................................... 70...................................................................2
80 ..................................0....................................... 80...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................65
10................................................................................................................................................69
20................................................................................................................................................73
30................................................................................................................................................76
40................................................................................................................................................80
50................................................................................................................................................84
60................................................................................................................................................88
70................................................................................................................................................91
80 (full pronation/supination).......................................................................................................95
SHOULDER JOINT
Flexion/Extension
TABLE 14
IMPAIRMENT DUE TO ABNORMAL MOTION AND ANKYLOSIS OF THE
SHOULDER JOINTFLEXION
Abnormal Motion
Average range of FLEXION/EXTENSION is 190 degrees
Value to total range of joint motion is 33%
Flexion from neutral
position ( 0) to:
% Impairment of
Upper Extremity
0 ................................150...................................... 0..................................................................16
10 ................................140..................................... 10.................................................................15
20 ................................130..................................... 20.................................................................14
30 ................................120..................................... 30.................................................................13
40 ................................110..................................... 40.................................................................12
50 ................................100..................................... 50.................................................................11
60 .................................90...................................... 60...................................................................9
70 .................................80...................................... 70...................................................................8
80 .................................70...................................... 80...................................................................7
90 .................................60...................................... 90...................................................................6
100 .................................50..................................... 100..................................................................5
110 .................................40..................................... 110..................................................................4
120 .................................30..................................... 120..................................................................3
130 .................................20..................................... 130..................................................................2
140 .................................10..................................... 140..................................................................1
150 ..................................0...................................... 150..................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................53
20................................................................................................................................................47
*30................................................................................................................................................40
40................................................................................................................................................45
50................................................................................................................................................50
60................................................................................................................................................55
70................................................................................................................................................60
80................................................................................................................................................65
90................................................................................................................................................70
100................................................................................................................................................75
110................................................................................................................................................80
120................................................................................................................................................85
130................................................................................................................................................90
140................................................................................................................................................95
150 (full flexion)........................................................................................................................... 100
*position of function
TABLE 15
IMPAIRMENT DUE TO ABNORMAL MOTION
AND ANKYLOSIS OF THE SHOULDER JOINTEXTENSION
Abnormal Motion
Average range of FLEXION/EXTENSION is 190 degrees
Value to total range of joint motion is 33%
Flexion from neutral
position ( 0) to:
% Impairment of
Upper Extremity
0 .................................40....................................... 0....................................................................4
10 .................................30...................................... 10...................................................................3
20 .................................20...................................... 20...................................................................2
30 .................................10...................................... 30...................................................................1
40 ..................................0....................................... 40...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................70
20................................................................................................................................................80
30................................................................................................................................................90
40 (full extension)...................................................................................................................... 100
TABLE 16
IMPAIRMENT DUE TO ABNORMAL MOTION AND ANKYLOSIS
OF THE SHOULDER JOINTABDUCTION-ADDUCTION
Abnormal Motion
Average range of ABDUCTION-ADDUCTION is 180 degrees
Value to total range of joint motion is 33%
Abduction from neutral
position ( 0) to:
% Impairment of
Upper Extremity
0 ................................150...................................... 0..................................................................17
10 ................................140..................................... 10.................................................................16
20 ................................130..................................... 20.................................................................14
30 ................................120..................................... 30.................................................................13
40 ................................110..................................... 40.................................................................12
50 ................................100..................................... 50.................................................................11
60 .................................90...................................... 60.................................................................10
70 .................................80...................................... 70...................................................................9
80 .................................70...................................... 80...................................................................8
90 .................................60...................................... 90...................................................................7
100 .................................50..................................... 100..................................................................6
110 .................................40..................................... 110..................................................................4
120 .................................30..................................... 120..................................................................3
130 .................................20..................................... 130..................................................................2
140 .................................10..................................... 140..................................................................1
150 ..................................0...................................... 150..................................................................0
Adduction from neutral Position (0) to:
0 .................................30....................................... 0....................................................................3
10 .................................20...................................... 10...................................................................2
20 .................................10...................................... 20...................................................................1
30 ..................................0....................................... 30...................................................................0
Ankylosis
Joint ankylosed at:
0................................................................................................................................................60
10................................................................................................................................................56
20................................................................................................................................................51
30................................................................................................................................................47
40................................................................................................................................................42
45................................................................................................................................................40
50................................................................................................................................................43
60................................................................................................................................................49
70................................................................................................................................................54
80................................................................................................................................................60
90................................................................................................................................................66
100................................................................................................................................................71
110................................................................................................................................................77
120................................................................................................................................................83
130................................................................................................................................................89
140................................................................................................................................................94
150 (full abduction) ..................................................................................................................... 100
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................73
20................................................................................................................................................87
30 (full adduction) ..................................................................................................................... 100
Internal/External Rotation
TABLE 17
IMPAIRMENT DUE TO ABNORMAL MOTION AND ANKYLOSIS
OF THE SHOULDER JOINTROTATION
Abnormal Motion
Average range of ROTATION is 130 degrees
Value to total joint motion is 33%
Internal ROTATION from
neutral position ( 0) to:
% Impairment of
Upper Extremity
0 .................................40....................................... 0....................................................................6
10 .................................30...................................... 10...................................................................5
20 .................................20...................................... 20...................................................................3
30 .................................10...................................... 30...................................................................2
40 ..................................0....................................... 40...................................................................0
External rotation from
neutral position (0) to:
0 .................................90....................................... 0..................................................................14
10 .................................80...................................... 10.................................................................12
20 .................................70...................................... 20.................................................................11
30 .................................60...................................... 30...................................................................9
40 .................................50...................................... 40...................................................................8
50 .................................40...................................... 50...................................................................6
60 .................................30...................................... 60...................................................................5
70 .................................20...................................... 70...................................................................3
80 .................................10...................................... 80...................................................................2
90 ..................................0....................................... 90...................................................................0
Ankylosis
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................70
20................................................................................................................................................80
30................................................................................................................................................90
40 (full internal rotation) ............................................................................................................ 100
Joint ankylosed at:
0 (neutral position) ....................................................................................................................60
10................................................................................................................................................50
*20................................................................................................................................................40
30................................................................................................................................................49
40................................................................................................................................................57
50................................................................................................................................................66
60................................................................................................................................................74
70................................................................................................................................................83
80................................................................................................................................................91
90 (full external rotation)............................................................................................................. 100
*position of function
% Impairment of
Upper Extremity
Whole Person
Unit
Hand
60
30
36
18
70
50
20
42
30
12
100
60
40
20
90
36
24
12
54
100
75
10
15
40
30
4
6
36
27
4
5
22
16
2
3
100
100
80
45
20
20
16
9
18
18
14
8
11
11
8
5
100
100
80
45
10
10
8
4
9
9
7
4
5
5
4
2
Joint Swelling due to Synovial HypertrophyThis condition would usually be rated through loss
of motion and is to be considered for impairment only when there is full range of motion of the joint. The
percent of impairment is multiplied by the relative value of the joint (Table 18).
Joint Swelling Due to Synovial Hypertrophy
% Joint Impairment*
Mild..................................................................................................................... 10
Moderate ............................................................................................................ 20
Severe ................................................................................................................ 30
*Use Table 18 to find the relative value of each joint.
Digit Lateral DeviationThe longitudinal alignment of each of the finger joints is measured in
degrees during maximum active extension. Since lateral deviation at any level affects the longitudinal
arch of the digit, deviation affects the entire digit. If lateral deviation is the sole impairment, it is
multiplied by the relative value of the digit to the hand to calculate hand impairment (Table 18). If the
digit has other impairments, the lateral deviation impairment value is combined with them using the
Combined Values Chart, in Section 15.
Ulnar or Radial Deviation
% Digit Impairment*
Mild: Less than 10 ............................................................................................. 10
Moderate: 10 to 30........................................................................................... 20
Severe: Greater than 30.................................................................................... 30
*Use Table 18 to find the relative value of each digit.
Joint InstabilityExcessive passive joint motion is evaluated by comparing it with normal joint
stability and graded according to the degree of severity. Then the percentage of impairment is multiplied
by the relative value of the joint (Table 18). If other impairments of the same joint are present, the values
are combined using the Combined Values Chart.
Joint Instability
% Joint Impairment
Mild: Less than 10 ............................................................................................. 20
Moderate: 10 to 20........................................................................................... 40
Severe: Greater than 20.................................................................................... 60
*Use Table 18 to find the relative value of each joint.
Wrist and Elbow Joint Lateral DeviationThese angles are measured with the wrist or elbow in
maximum active extension. The degree of severity is multiplied by the relative value of the joint to the
upper extremity to obtain upper extremity impairment due to lateral deviation (Table 18). If other
impairments of the same joint are present, they are combined using the Combined Values Chart. After all
impairments for either the wrist or elbow joint have been calculated, they are combined with any other
upper-extremity impairment using the Combined Values Chart.
Lateral Deviation Severity
% Joint Impairment*
Mild: Less than 20 ............................................................................................. 10
Moderate: 20 to 30........................................................................................... 20
Severe: Greater than 30.................................................................................... 30
*Use Table 18 to find the relative value of the wrist and elbow joints.
Carpal InstabilityCarpal instability patterns resulting from lunate or scaphoid pathology can be
classified as mild, moderate, or severe, based on the severity of the radiographic findings (Table 19,
below). The proximal carpal row represents half of the value of the wrist, or 30% of the upper extremity.
Therefore the grades of mild (20%), moderate (40%), and severe (60%) represent upper- extremity
impairments of 6%, 12%, and 18%, respectively. These values may be combined with other upperextremity impairments due to wrist abnormalities using the Combined Values Chart.
In using Table 19, apply only the greatest impairment value determined by the radiographic findings.
Do not combine or add the impairment values shown on Table 19. These radiographic parameters are to
be used only when all other factors including range of motion and grip strength are normal.
TABLE 19
IMPAIRMENT OF UPPER EXTREMITY
DUE TO CARPAL INSTABILITY PATTERNS
Radiographic Findings
Mild
(6%)
Radioscaphoid angle
(scaphoid) ........................................................................... 4059....................... 6070......................... >70
Radiolunate angle
(lunate)....................................................................................... <10....................... 1030......................... >30
Carpal height collapse....................................................................... <5%.....................5% 10%........................>10%
Carpal translation ...............................................................................mild...................... moderate...................... severe
Arthritic changes ................................................................................mild...................... moderate...................... severe
ArthroplastySimple resection arthroplasty is given 40% impairment of the joint value due to loss
of function; implant arthroplasty is given 50% impairment of the joint value due to loss of function. Table
20 provides impairment ratings for the upper extremity for arthroplasty of specific joints, based on these
values.
TABLE 20
IMPAIRMENTS OF UPPER EXTREMITY FOLLOWING
ARTHROPLASTY OF SPECIFIC BONES OR JOINTS
Level of
Arthroplasty*
Shoulder
Total elbow
Radial head (isolated)
Total wrist
Ulnar head (isolated)
Proximal carpal row
Carpal bones
24
28
8
24
8
12
12
30
35
10
30
10
15
15
Thumb**
Carpometacarpal
Metacarpophalangeal
Interphalangeal
11
1
2
13
2
3
7
6
3
9
7
4
3
3
2
4
3
2
* If more than one level is involved, combine from distal to proximal using the Combined Values Chart.
** If more than one thumb joint is involved, add impairments.
*** If more than one joint is involved in the same finger, combine impairments using the Combined Values Chart. If
multiple digits are involved, add the impairment values for the digits.
% Digit
Impairment*
Mild: inconstant triggering during active ROM** ................................................. 20
Moderate: Constant triggering during active ACM .............................................. 40
Severe: Constant triggering during passive ROM............................................... 60
*Use Table 18 to find the relative value of each digit.
**ROM: Range of Motion
01
23
46
79
9 11
12 13
14 16
17 18
19 21
22 23
24 26
27 28
29 31
32 33
34 36
37 38
39 41
42 43
44 46
47 48
49 51
52 53
54 56
57 58
59 61
62 63
64 66
67 68
69 71
72 73
74 76
77 78
79 81
82 83
84 86
87 88
89 91
92 93
94 96
97 98
99 100
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
0
1
2
3
4
5
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
31
32
33
34
35
36
37
38
39
40
% Impairment of
Index or
Middle
Finger
Hand
02 =
0
37 =
1
8 12 =
2
13 17 =
3
18 22 =
4
23 27 =
5
28 32 =
6
33 37 =
7
38 42 =
8
43 47 =
9
48 52 = 10
53 57 = 11
58 62 = 12
63 67 = 13
68 72 = 14
73 77 = 15
78 82 = 16
83 87 = 17
88 92 = 18
93 97 = 19
98 100 = 20
% Impairment of
Ring or
Little
Finger
Hand
0-4 =
0
5 - 14 =
1
15 - 24 =
2
25 - 34 =
3
35 - 44 =
4
45 - 54 =
5
55 - 64 =
6
65 - 74 =
7
75 - 84 =
8
85 - 94 =
9
95 - 100 = 10
% Impairment of
Thumb
Hand
4951
20
5253
21
5456
22
5758
23
5961
24
6263
25
6466
26
6768
27
6971
28
7273
29
7476
30
7778
31
7981
32
8283
33
8486
34
8788
35
8991
36
9293
37
9496
38
9798
39
99100
40
Upper
Extremity
=
0
=
1
=
2
=
3
=
4
=
5
=
5
=
6
=
7
=
8
=
9
=
10
=
11
=
12
=
13
=
14
=
14
=
15
Hand
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Upper
Extremity
=
16
=
17
=
18
=
19
=
20
=
21
=
22
=
23
=
23
=
24
=
25
=
26
=
27
=
28
=
29
=
30
=
31
=
32
Hand
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
Upper
Extremity
=
32
=
33
=
34
=
35
=
36
=
37
=
38
=
39
=
40
=
41
=
41
=
42
=
43
=
44
=
45
=
46
=
47
=
48
Hand
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
Upper
Extremity
=
49
=
50
=
50
=
51
=
52
=
53
=
54
=
55
=
56
=
57
=
58
=
59
=
59
=
60
=
61
=
62
=
63
=
64
Hand
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
Upper
Extremity
=
65
=
66
=
67
=
68
=
68
=
69
=
70
=
71
=
72
=
73
=
74
=
75
=
76
=
77
=
77
=
78
=
79
=
80
Hand
90
91
92
93
94
95
96
97
98
99
100
Upper
Extremity
=
81
=
82
=
83
=
84
=
85
=
86
=
86
=
87
=
88
=
89
=
90
NOTE: Impairment of the upper extremity contributed by the hand may be rounded to the nearest 5 percent only when it is the sole impairment
involved. Consult Table 20 for converting upper extremity impairment to whole person impairment.
TABLE 24Relationship of Impairment of the Upper Extremity to Impairment of the Whole Person
% Impairment of
Upper
Whole
Extremity
Person
% Impairment of
Upper
Whole
Extremity
Person
% Impairment of
Upper
Whole
Extremity
Person
0
1
2
3
4
=
=
=
=
=
0
1
1
2
2
35
36
37
38
39
=
=
=
=
=
21
22
22
23
23
70
71
72
73
74
=
=
=
=
=
42
43
43
44
44
5
6
7
8
9
=
=
=
=
=
3
4
4
5
5
40
41
42
43
44
=
=
=
=
=
24
25
25
26
26
75
76
77
78
79
=
=
=
=
=
45
46
46
47
47
10
11
12
13
14
=
=
=
=
=
6
7
7
8
8
45
46
47
48
49
=
=
=
=
=
27
28
28
29
29
80
81
82
83
84
=
=
=
=
=
48
49
49
50
50
15
16
17
18
19
=
=
=
=
=
9
10
10
11
11
50
51
52
53
54
=
=
=
=
=
30
31
31
32
32
85
86
87
88
89
=
=
=
=
=
51
52
52
53
53
20
21
22
23
24
=
=
=
=
=
12
13
13
14
14
55
56
57
58
59
=
=
=
=
=
33
34
34
35
35
90
91
92
93
94
=
=
=
=
=
54
55
55
56
56
25
26
27
28
29
=
=
=
=
=
15
16
16
17
17
60
61
62
63
64
=
=
=
=
=
36
37
37
38
38
95
96
97
98
99
=
=
=
=
=
57
58
58
59
59
30
31
32
33
34
=
=
=
=
=
18
19
19
20
20
65
66
67
68
69
=
=
=
=
=
39
40
40
41
41
100
60
NOTE: Impairment of the whole person contributed by the upper extremity may be rounded to the nearest 5 percent
only when it is the sole Impairment involved.
Amputation
% Impairment of
Great Toe
Amputation
% Impairment of
Great Toe
At Joint
75
At Joint
100
Abnormal Motion
Abnormal Motion
% Impairment of
Great Toe
45
30
15
0
Ankylosis
Joint Ankylosed at:
0 (neutral position)
*10
20
30 (full flexion)
% Impairment of
Great Toe
45
55
65
75
* Position of function
% Impairment of
Great Toe
At Joint
100
Abnormal Motion
Average range of Dorsi-Plantar-Flexion is 80
Value to total range of joint motion is 100%
Plantar-flexion
Degrees of
from neutral
Joint Motion
position (0) to:
Lost
Retained
0
30
0
10
20
10
20
10
20
30
0
30
% Impairment of
Great Toe
21
14
7
0
Ankylosis
Joint Ankylosed at:
0 (neutral position)
10
20
30 (full plantar flexion)
% Impairment of
Great Toe
55
70
85
100
% Impairment of
Great Toe
34
28
21
14
7
0
Ankylosis
Joint Ankylosed at:
0 (neutral position)
*10
20
30
40
50 (full dorsi-flexion)
% Impairment of
Great Toe
55
49
62
74
87
100
Amputation
% Impairment
of Toe
Amputation
% Impairment
of Toe
At Joint
45
At Joint
80
Abnormal Motion
Abnormal Motion
No functional value
No functional value
Ankylosis
Joint Ankylosed in:
Dorsi-flexion
* Neutral position
Plantar-flexion (hammer toe)
Ankylosis
% Impairment of
Great Toe
45
30
45
% Impairment
of Toe
80
45
80
* Position of function
* Position of function
Amputation
% Impairment of
Second Toe
Amputation
% Impairment of
Third Toe
At Joint
100
At Joint
100
Abnormal Motion
Abnormal Motion
% Impairment of
Second Toe
29
21
14
7
0
21
14
7
0
Ankylosis
Joint Ankylosed at:
(Dorsi-flexion)
* 0 (neutral position)
10
20
30
40 (full dorsi-flexion)
Joint Ankylosed at:
(Plantar-flexion)
* 0 (neutral position)
10
20
30 (full plantar-flexion)
* Position of function
% Impairment of
Second Toe
50
63
75
88
100
% Impairment of
Second Toe
50
67
83
100
% Impairment of
Third Toe
30
20
10
0
20
10
0
Ankylosis
Joint Ankylosed at:
(Dorsi-flexion)
* 0 (neutral position)
10
20
30 (full dorsi-flexion)
Joint Ankylosed at:
(Plantar-flexion)
* 0 (neutral position)
10
20 (full plantar-flexion)
* Position of function
% Impairment of
Third Toe
50
67
83
100
% Impairment of
Third Toe
50
75
100
Amputation
% Impairment of
Fourth Toe
Amputation
% Impairment of
Fifth Toe
At Joint
100
At Joint
100
Abnormal Motion
Abnormal Motion
% Impairment of
Fourth Toe
33
17
0
17
0
Ankylosis
Joint Ankylosed at:
* 0 (neutral position)
10
20 (full dorsi-flexion)
Joint Ankylosed at:
* 0 (neutral position)
10 (full plantar-flexion)
50
75
100
* Position of function
* Position of function
50
0
50
0
Ankylosis
* 0 (neutral position)
10 (full plantar-flexion)
50
100
% Impairment of
Fifth Toe
50
100
50
100
Inversion/Eversion
Amputation
% Impairment of
Lower Extremity
Amputation
% Impairment of
Lower Extremity
At Joint
70
At Joint
70
Abnormal Motion
Abnormal Motion
% Impairment of
Lower Extremity
7
4
0
14
11
7
4
0
25
15
Ankylosis
Joint Ankylosed at:
(Dorsi-flexion)
* 0 (neutral position)
10
20 (full dorsi-flexion)
Joint Ankylosed at:
(Plantar-flexion)
* 0 (neutral position)
10
20
30
40 (full plantar-flexion)
% Impairment of
Lower Extremity
30
50
70
30
40
50
60
70
% Impairment of
Lower Extremity
5
4
2
0
4
2
0
Ankylosis
Joint Ankylosed at:
(Inversion)
* 0 (neutral position)
10
20
30 (full inversion)
Joint Ankylosed at:
(Eversion)
* 0 (neutral position)
10
20 (full eversion)
% Impairment of
Lower Extremity
10
43
57
70
10
50
60
* Position of function
Rating
Arthritis not to be rated less than 1 year after onset .................................................... 5%20% L.E.
Ligamentous instability................................................................................................ 5% 15% L.E.
Arthroplasty.................................................................................................................. 5%20% L.E.
Foot
Disorders:
Rating
Arthritis, not to be rated less than 1 year after onset ................................................... 5%20% L.E.
Ligamentous instability................................................................................................. 5%15% L.E.
Arthroplasty.................................................................................................................. 5%20% L.E.
KNEE JOINT
Flexion/Extension
Amputation
% Impairment of
Lower Extremity
At Joint
90
Abnormal Motion*
Average range of Flexion-Extension is 150
Value to total range of joint motion is 100%
Retained active flexion of:
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Extension back to (extension lag):
0 (neutral position)
10
20
30
40
50 to 150 (full flexion)
53
49
46
42
39
35
32
28
25
21
18
14
11
7
4
0
% Impairment of
Lower Extremity
0
1
7
17
27
90
0 (neutral position)
**10.
20
30
40
50 to 150 (full flexion)
% Impairment of
Lower Extremity
53
50
60
70
80
90
Impairment of
Lower Extremity
10-30% if in optimum
position
% Impairment of
Lower Extremity
Ankylosis
Joint Ankylosed at:
Disorder
Flexion of Knee
HIP JOINT
Flexion
Extension
Amputation
% Impairment of
Lower Extremity
At Joint
100
Amputation
% Impairment of
Lower Extremity
Abnormal Motion
At Joint
100
Abnormal Motion
Ankylosis
Joint Ankylosed at:
0 (neutral position)
10
20
* 25
30
40
50
60
70
80
90
100 (full flexion)
% Impairment of
Lower Extremity
70
62
54
50
53
60
67
73
80
87
93
100
Ankylosis
Joint Ankylosed at:
0 (neutral position)
10
20
30 (full backward extension)
Extension of hip
% Impairment of
Lower Extremity
10-30
30
10-30
40
5-20
* Position of function
% Impairment of
Lower Extremity
70
80
90
100
Abduction/Adduction
Rotation
Amputation
% Impairment of
Lower Extremity
At Joint
100
Abnormal Motion
Average range of Abduction-Adduction is 60
Value to total range of joint motion is 33%
Abduction
Degrees of
from neutral
Joint Motion
position (0) to:
Lost
Retained
0
40
0
10
30
10
20
20
20
30
10
30
40
0
40
Adduction from
Neutral position (0) to:
0
40
0
10
10
10
20
0
20
% Impairment of
Lower Extremity
16
12
8
4
0
8
4
0
Ankylosis
Joint Ankylosed at:
* 0 (neutral position)
10
20
30
40 (full abduction)
Joint Ankylosed at:
* 0 (neutral position)
10
20 (full adduction)
* Position of function
% Impairment of
Lower Extremity
70
78
85
93
100
70
85
100
Amputation
% Impairment of
Lower Extremity
At Joint
100
Abnormal Motion
Average range of Rotation is 90
Value to total range of joint motion is 33%
Internal Rotation
Degrees of
from neutral
Joint Motion
position (0) to:
Lost
Retained
0
40
0
10
30
10
20
20
20
30
10
30
40
0
40
External Rotation from
Neutral position (0) to:
0
50
0
10
40
10
20
30
20
30
20
30
40
10
40
50
0
50
% Impairment of
Lower Extremity
10
8
5
3
0
13
10
8
5
3
0
Ankylosis
Joint Ankylosed at:
* 0 (neutral position)
10
20
30
40 (full internal rotation)
Joint Ankylosed at:
0
10
20
30
40
50 (full external rotation)
% Impairment of
Lower Extremity
70
78
85
93
100
70
76
82
88
94
100
* Position of function
=
=
=
=
% Impairment of
Great Toe
Foot
0
1
2
3
=
=
=
=
4
5
6
7
53 57
58 62
=
=
10
11
63 68
69 73
74 79
80 84
=
=
=
=
12
13
14
15
85 90
91 95
96100
=
=
=
16
17
18
42 46
=
8
47 52
=
9
Note: Impairment of the foot contributed by the great toe may be
rounded to the nearest 5% only when it is the sole impairment involved.
Consult Table 19 for converting foot impairment to lower extremity
impairment.
% Impairment of
Lower
Foot
Extremity
34 =
24
35 =
25
36 =
25
37 =
26
38 =
27
% Impairment of
Lower
Foot
Extremity
68 =
48
69 =
48
70 =
49
71 =
50
72 =
50
5
6
7
8
9
=
=
=
=
=
4
4
5
6
6
39
40
41
42
43
=
=
=
=
=
27
28
29
29
30
73
74
75
76
77
=
=
=
=
=
51
52
53
53
54
10
11
12
13
14
=
=
=
=
=
7
8
8
9
10
44
45
46
47
48
=
=
=
=
=
31
32
32
33
34
78
79
80
81
82
=
=
=
=
=
55
55
56
57
57
15
16
17
18
19
=
=
=
=
=
11
11
12
13
13
49
50
51
52
53
=
=
=
=
=
34
35
36
36
37
83
84
85
86
87
=
=
=
=
=
58
59
60
60
61
20
21
22
23
24
=
=
=
=
=
14
15
15
16
17
54
55
56
57
58
=
=
=
=
=
38
39
39
40
41
88
89
90
91
92
=
=
=
=
=
62
62
63
64
64
25
26
27
28
29
=
=
=
=
=
18
18
19
20
20
59
60
61
62
63
=
=
=
=
=
41
42
43
43
44
93
94
95
96
97
=
=
=
=
=
65
66
67
67
68
30
31
32
33
=
=
=
=
21
22
22
23
64
65
66
67
=
=
=
=
45
46
46
47
98
99
100
=
=
=
69
69
70
17 - 49
50 - 83
84 - 100
=
=
=
=
=
2
2
3
3
4
39
40
41
42
43
=
=
=
=
=
16
16
16
17
17
73
74
75
76
77
=
=
=
=
=
29
30
30
30
31
10
11
12
13
14
=
=
=
=
=
4
4
5
5
6
44
45
46
47
48
=
=
=
=
=
18
18
18
19
19
78
79
80
81
82
=
=
=
=
=
31
32
32
32
33
15
16
17
18
19
=
=
=
=
=
6
6
7
7
8
49
50
51
52
53
=
=
=
=
=
20
20
20
21
21
83
84
85
86
87
=
=
=
=
=
33
34
34
34
35
20
21
22
23
24
=
=
=
=
=
8
8
9
9
10
54
55
56
57
58
=
=
=
=
=
22
22
22
23
23
88
89
90
91
92
=
=
=
=
=
35
36
36
36
37
25
26
27
28
29
=
=
=
=
=
10
10
11
11
12
59
60
61
62
63
=
=
=
=
=
24
24
24
25
25
93
94
95
96
97
=
=
=
=
=
37
38
38
38
39
30
31
32
33
=
=
=
=
12
12
13
13
64
65
66
67
=
=
=
=
26
26
26
27
98
99
100
=
=
=
39
40
40
% Impairment of
Amputated Ankylosed in
Full
Position
Exten- of
Full
sion
Function Flexion
Lower
Whole
Digit Foot Extremity Person
Hemipelvectomy
50
Great
18
14
13
18
100
40
Great, Second
21
17
15
21
100
40
90
36
90
36
24
20
17
24
24
20
17
24
24
20
17
24
27
23
19
27
27
23
19
27
27
23
19
27
Gritti-Stokes amputation
90
36
90
36
70
28
30
26
21
30
Great, Third
21
17
15
21
24
20
17
24
24
20
17
24
27
23
19
27
Great, Fourth
21
17
15
24
20
17
Great, Fifth
21
17
15
21
100
70
28
21
75
53
21
24
Mid-metatarsal amputation
50
35
14
30
21
30
21
Second
Second, Third
12
12
12
Second, Fourth
Second, Fifth
Third
100
18
13
At interphalangeal joint
75
14
10
Third, Fourth
100
At proximal
interphalangeal joint
80
Third, Fifth
At distal interphalangeal
joint
45
Fourth
Fourth, Fifth
Fifth
52
1. Language Disturbances
a.
b.
c.
d.
Inability to comprehend or express language symbols sufficient for daily living, with no
functional communication ..............................................................................................................................95
b.
c.
d.
e.
f.
53
% Impairment of
the Whole Person
b.
Mild to moderate emotional disturbance under ordinary stresses of daily living ............................................30
c.
d.
Slight severity and under such control that most of the activities of daily living can be
performed ......................................................................................................................................................10
b.
c.
d.
b.
c.
d.
Able to rise to standing position and walk, with or without assistive devices,
independent at community level, except for difficulty with elevations, grades, stairs,
and distances.................................................................................................................................................10
b.
Able to rise to standing position and walk with or without assistive devices, and is
independent at household but not community level .......................................................................................20
c.
d.
e.
f.
g.
h.
Preferred
Extremity
Nonpreferred
Extremity
54
Both
Extremities
b.
c.
d.
8. Respiration
a.
b.
c.
d.
b.
c.
d.
b.
c.
Sexual function is possible, but with some degree of difficulty for erection or
ejaculation in males, or awareness due to sensory loss in either sex. ...........................................................10
b.
Reflex sexual function is possible, but without awareness due to sensory loss.............................................20
c.
SKULL DEFECTS
Unfilled Skull Defects
% Impairment of
the Whole Person
a.
Up to 5 sq cm...................................................................................................................................................1
b.
6 10 sq cm ....................................................................................................................................................3
c.
11 16 sq cm ..................................................................................................................................................5
d.
17 26 sq cm ................................................................................................................................................10
e.
27 42 sq cm ................................................................................................................................................15
f.
43 or more sq cm ...........................................................................................................................................20
55
% Impairment of
the Whole Person
SKULL FRACTURES
Skull fractures .........................................................................................................................................................0
HEADACHES
Vascular, tension, or combination (if associated with neurologic or musculoskeletal
condition of the head or neck, the primary condition may be ratable.) ....................................................................0
CRANIAL NERVES
1. Olfactory
a.
b.
2. Optic
a.
b.
6. Trigeminal
a.
b.
c.
d.
e.
f.
7. Facial
a.
b.
c.
56
(See Determination Procedures at the end of this section for grading schemes to determine whole-person
impairment due to motor or sensory loss.)
THORACIC NERVES
Nerve
Unilateral
Involvement
Bilateral
Involvement
Maximum %
Loss of Function
Due to Sensory
Deficit, or Pain
Maximum %
Loss of Function
Due to Loss of
Strength
(See Determination Procedures at the end of this section for grading schemes to determine whole-person
impairment due to motor or sensory loss.)
Maximum %
Loss of Function
Due to Sensory
Deficit, or Pain
Maximum % Loss
of Function Due to
Motor Deficit or
Loss of Power
(See Determination Procedures at the end of this section for grading schemes to determine the percentage
of upper extremity. Convert upper-extremity impairment to whole-person only when all upper-extremity
impairments have been combined.)
57
Maximum % Loss
of Function Due to
Motor Deficit or
Loss of Power
(See Determination Procedures at the end of this section for grading schemes to determine the percentage
of upper extremity. Convert upper-extremity impairment to whole-person only when all upper-extremity
impairments have been combined.)
Maximum %
Loss of Function
Due to Sensory
Deficit, or Pain
Maximum % Loss
of Function Due to
Motor Deficit or
Loss of Power
(See Determination Procedures at the end of this section for grading schemes to determine the percentage
of upper extremity. Convert upper-extremity impairment to whole-person only when all upper-extremity
impairments have been combined.)
58
Neuropathy
Site
Moderate
Severe
(Convert upper-extremity impairment to whole-person only when all upper-extremity impairments have
been combined.)
(For an alternate rating method, use Grading Schemes at the end of this section for upper-extremity
peripheral nerve involvement; use only one method.)
Maximum %
Loss of Function
Due to Sensory
Deficit, or Pain
Maximum %
Loss of Function
Due to Loss of
Strength
L-3.............................................................................................. 5 ............................................... 20
L-4.............................................................................................. 5 ............................................... 34
L-5.............................................................................................. 5 ............................................... 37
S-1 ............................................................................................. 5 ............................................... 20
(See Determination Procedures at the end of this section for grading schemes to determine the percentage
of lower extremity. Convert lower-extremity impairment to whole-person only when all lower-extremity
impairments have been combined.)
Maximum %
Loss of Function
Due to Loss of
Strength
(See Determination Procedures at the end of this section for grading schemes to determine the percentage
of lower extremity. Convert lower-extremity impairment to whole-person only when all lower-extremity
impairments have been combined.)
Maximum %
Loss of Function
Due to Sensory
Deficit, or Pain
Maximum % Loss
of Function Due to
Motor Deficit or
Loss of Power
59
60
Grade
Grade
1. Range of motion against gravity and full resistance (normal strength) ........................................0%
2. Range of motion against gravity and some resistance, or reduced fine
movements and motor control, may include abnormalities documented
by electrophysiological studies (good strength)....................................................................1 40%
3. Range of motion against gravity, but without resistance (fair strength) .............................41 60%
4. Range of motion with gravity eliminated (poor strength)...................................................61 75%
5. Slight palpable muscle contraction (trace strength)............................................................76 99%
6. No contractibility and no muscle function (zero strength)........................................................100%
Procedure for determining Impairment Due to Motor Involvement
1. Identify the motion involved
2. Identify the muscle(s) performing the function
3. Determine the nerve(s) that innervate the involved muscle(s) and find the value for maximum
percentage loss due to loss of strength or power, according to the appropriate table.
4. Grade the degree of loss of strength or power according to the Grading Scheme.
5. Multiply the value of the nerve by the degree of loss of strength or power.
61
62
The results of well-standardized psychological tests and other projective techniques may be useful in
establishing the existence of a mental disorder. For example, intelligence tests are useful in establishing
mental retardation, and projective techniques may provide useful data in supporting diagnoses of other
mental disorders. Broad-based neuropsychological assessments may be useful in determining brainfunction deficiencies, particularly in cases involving subtle findings, such as may be seen in traumatic
brain injury. In addition, the process of taking a standardized test requires concentration, persistence, and
pace. Test results should, therefore, include both the objective data and a narrative description of clinical
findings. Narrative reports of intellectual assessment should include a discussion of whether obtained IQ
scores are considered valid and consistent with the individuals developmental history and degree of
functional restriction.
SPECIAL CONSIDERATIONS
Particular problems often are involved in evaluating mental impairments in individuals who have long
histories of repeated hospitalizations or prolonged outpatient care with supportive therapy and
medication. Individuals with chronic psychotic disorders commonly have their lives structured in such a
way as to minimize stress and reduce their signs and symptoms. The results of a single examination may
not adequately describe these individuals sustained ability to function. It is, therefore, vital to review
pertinent information relative to the individuals condition, especially at times of increased stress.
Effects of structured settings: An evaluation of individuals whose symptoms are controlled or
attenuated by psychosocial factors must consider the ability of the individual to function outside such
highly structured settings.
Effects of medication: Attention must be given to the effect of medication on the individuals signs,
symptoms, and ability to function. While psychotropic medications may control certain primary
manifestations of a mental disorder, such as hallucinations, such treatment may or may not affect the
functional limitations imposed by the mental disorder. Neuroleptics, the medicines necessary to control
signs of an amotivational like syndrome, used in the treatment of some mental illnesses, may cause
drowsiness, blunted affect, or other side effects involving other body systems. Such side effects must be
considered in evaluating overall severity of impairment as well as the patients functional capacity.
Pain: The assessment of impairment due to the perception of pain, especially in circumstances in
which the complaint exceeds what is expected based on physical findings, is complex and controversial.
The perception of pain may be distorted by mental disorders. Pain may be an element in a somatic
delusion in a patient with a Major Depression or Psychotic Disorder. It may become the object of an
obsessive preoccupation or a chief complaint in a Conversion Disorder. The latter has been called
Psychogenic Pain Disorder or Idiopathic Pain Disorder, but these terms often are used more loosely
to describe any complaint of pain that is greater than the physician expects for the normal patient with
the same physical findings. The more specific disorders with impairments are somewhat easier to evaluate
than cases in which the perception of pain is said to have a psychogenic component. Such cases require
specialized assessment, perhaps using a multidisciplinary, multispeciality approach.
63
TABLE 1
Evaluation of Psychiatric Impairment
Class of
Impairment
Percentage of
Impairment
0%
1-5%
6-14%
15-24%
25+%
Intelligence
(including
intelligence lost)
normal or
better
slight deficit or
reduction
moderate
deficit or
reduction
moderately
severe deficit
reduction
severe deficit
reduction
Thinking
no deficit
slight deficit
moderate
severe deficit
moderately
severe deficit
severe deficit
Perception
no deficit
slight deficit
moderate
deficit
moderately
severe deficit
severe deficit
Judgment
no deficit
slight deficit
moderate
deficit
moderately
severe deficit
severe deficit
Affect
normal
slight problem
moderate
problem
moderately
problem
severe
problem
Behavior
normal
slight problem
moderate
problem
moderately
severe
severe
problem
Mental Status
Impairment Description
Mental Status
Intelligence
Normal
Thinking
Moderately severe deficit; cannot draw rational conclusions from single statements
Perception
Judgment
Affect
Between moderate and severe deficit; mood swings from hostile to friendly
Behavior
64
Impairment Description
Impairment Class
Mental Status
Intelligence
Normal
Thinking
Perception
Judgment
Affect
Behavior
Collective
Impairment*
* Whole-person impairment rating: Patient is vocationally unemployable and will remain so. Socially, the
patient is moderately impaired, but the degree of impairment varies from time to time, depending upon
the amount of stress to which the patient is subjected and whether the patient takes prescription
medication regularly.
Reference
1. Social Security Administration: Federal Old-Age, Survivors and Disability Insurance; Listing of
Impairments, Medical Disorders; Final Rule. Fed. Reg. 20 CFR par 404 (Reg No A) 50 (167), 3503835070, 1985
65
Predicted normal FVC values for men and women are found in Tables 2 and 3, respectively.
3. Predicted normal FEV1 Values for men and women are found in Tables 4 and 5, respectively.
4. Predicted normal Single Breath Dco values for men and women are found in Tables 6 and 7,
respectively.
TABLE 1
CLASSES OF RESPIRATORY IMPAIRMENT
NOTE: Those factors contained in the history and physical exam should also be considered in determining the
severity of the impairment.
FVC
FEV1
FEV1/FVC
(as percent
Dco
Class 1 1-14%
Impairment of
Whole Person
Class 2 15-29%
Impairment of
Whole Person
Class 3 30-54%
Impairment of
Whole Person
Class 4 55-95%
Impairment of
Whole Person
or
Between 20 and 25 ml
(kg.min)
or
Between 15 and 20 ml
(kg.min)
25 ml/(kg.min)
(kg.min)
or
15 ml/(kg.min)
FVC is Forced Vital Capacity; FEV1 is Forced Expiratory Volume in the first second; Dco is primarily of value for persons with
restrictive lung disease in Classes 2 and 3; if the FVC, FEV1 and FEV1/FVC ratio are normal and the Dco is between 41% and 79%,
then an exercise test is required.
VO2 Max, or measured exercise capacity is useful in assessing whether a persons complaint of dyspnea (see Table 1) is a result
of respiratory or other complications. A persons cardiac and conditioning status must be considered in performing the test and in
interpreting the results.
66
TABLE 2
PREDICTED NORMAL FVC VALUES (LITERS) FOR MEN (BTPS)
Age
18
20
22
24
26
146
3.72
3.68
3.64
3.60
3.55
148
3.84
3.80
3.76
3.72
3.67
150
3.96
3.92
3.88
3.84
3.79
152
4.08
4.04
4.00
3.95
3.91
154
4.20
4.16
4.12
4.08
4.03
156
4.32
4.28
4.24
4.20
4.15
158
4.44
4.40
4.36
4.32
4.27
160
4.56
4.52
4.48
4.44
4.39
162
4.68
4.64
4.60
4.56
4.51
164
4.80
4.76
4.72
4.68
4.63
166
4.92
4.88
4.84
4.80
4.75
Height(cm)
168 170 172
5.04 5.16 5.28
5.00 5.12 5.24
4.96 5.08 5.20
4.92 5.04 5.16
4.87 4.99 5.11
174
5.40
5.36
5.32
5.28
5.23
176
5.52
5.48
5.44
5.40
5.35
178
5.64
5.60
5.56
5.52
5.47
180
5.76
5.72
5.68
5.64
5.59
182
5.88
5.84
5.80
5.76
5.71
184
6.00
5.96
5.92
5.88
5.83
186
6.12
6.08
6.04
6.00
5.95
188
6.24
6.20
6.16
6.12
6.07
190
6.36
6.32
6.28
6.24
6.19
192
6.48
6.44
6.40
6.36
6.31
194
6.60
6.56
6.52
6.48
6.43
28
30
32
34
36
3.51
3.47
3.43
3.38
3.34
3.63
3.59
3.55
3.50
3.46
3.75
3.71
3.67
3.62
3.58
3.87
3.83
3.79
3.74
3.70
3.99
3.95
3.91
3.86
3.82
4.11
4.07
4.03
3.98
3.94
4.23
4.19
4.15
4.10
4.06
4.35
4.31
4.27
4.22
4.18
4.47
4.43
4.39
4.34
4.30
4.59
4.55
4.51
4.46
4.42
4.71
4.67
4.63
4.58
4.54
4.83
4.79
4.75
4.70
4.66
4.95
4.91
4.87
4.82
4.78
5.07
5.03
4.99
4.94
4.90
5.19
5.15
5.11
5.06
5.02
5.31
5.27
5.23
5.18
5.14
5.43
5.39
5.35
5.30
5.26
5.55
5.51
5.47
5.42
5.38
5.67
5.63
5.59
5.54
5.50
5.79
5.75
5.71
5.66
5.62
5.91
5.87
5.83
5.78
5.74
6.03
5.99
5.95
5.90
5.86
6.15
6.11
6.07
6.02
5.98
6.27
6.23
6.19
6.14
6.10
6.39
6.35
6.31
6.26
6.22
38
40
42
44
46
3.30
3.25
3.21
3.17
3.13
3.42
3.37
3.33
3.29
3.25
3.54
3.49
3.45
3.41
3.37
3.66
3.61
3.57
3.53
3.49
3.78
3.73
3.69
3.65
3.61
3.90
3.85
3.81
3.77
3.73
4.02
3.97
3.93
3.89
3.85
4.14
4.09
4.05
4.01
3.97
4.26
4.21
4.17
4.13
4.09
4.38
4.33
4.29
4.25
4.21
4.50
4.45
4.41
4.37
4.33
4.62
4.57
4.53
4.49
4.45
4.74
4.69
4.65
4.61
4.57
4.86
4.81
4.77
4.73
4.69
4.98
4.93
4.89
4.85
4.81
5.10
5.05
5.01
4.97
4.93
5.22
5.17
5.13
5.09
5.05
5.34
5.29
5.25
5.21
5.17
5.46
5.41
5.37
5.33
5.29
5.58
5.53
5.49
5.45
5.41
5.70
5.65
5.61
5.57
5.53
5.82
5.77
5.73
5.69
5.65
5.94
5.89
5.85
5.81
5.77
6.06
6.01
5.97
5.93
5.89
6.18
6.13
6.09
6.05
6.01
48
50
52
54
56
3.08
3.04
3.00
2.95
2.91
3.20
3.16
3.12
3.07
3.03
3.32
3.28
3.24
3.19
3.15
3.44
3.40
3.36
3.31
3.27
3.56
3.52
3.48
3.43
3.39
3.68
3.64
3.60
3.55
3.51
3.80
3.76
3.72
3.67
3.63
3.92
3.88
3.84
3.79
3.75
4.04
4.00
3.96
3.91
3.87
4.16
4.12
4.08
4.03
3.99
4.28
4.24
4.20
4.15
4.11
4.40
4.36
4.32
4.27
4.23
4.52
4.48
4.44
4.39
4.35
4.64
4.60
4.56
4.51
4.47
4.76
4.72
4.68
4.63
4.59
4.88
4.84
4.80
4.75
4.71
5.00
4.96
4.92
4.87
4.83
5.12
5.08
5.04
4.99
4.95
5.24
5.20
5.16
5.11
5.07
5.36
5.32
5.28
5.23
5.19
5.48
5.44
5.40
5.35
5.31
5.60
5.56
5.52
5.47
5.43
5.72
5.68
5.64
5.59
5.55
5.84
5.80
5.76
5.71
5.67
5.96
5.92
5.88
5.83
5.79
58
60
62
64
66
2.87
2.83
2.78
2.74
2.70
2.99
2.95
2.90
2.86
2.82
3.11
3.07
3.02
2.98
2.94
3.23
3.19
3.14
3.10
3.06
3.35
3.31
3.26
3.22
3.18
3.47
3.43
3.38
3.34
3.30
3.59
3.55
3.50
3.46
3.42
3.71
3.67
3.62
3.58
3.54
3.83
3.79
3.74
3.70
3.66
3.95
3.91
3.86
3.82
3.78
4.07
4.03
3.98
3.94
3.90
4.19
4.15
4.10
4.06
4.02
4.31
4.27
4.22
4.18
4.14
4.43
4.39
4.34
4.30
4.26
4.55
4.51
4.46
4.42
4.38
4.67
4.63
4.58
4.54
4.50
4.79
4.75
4.70
4.66
4.62
4.91
4.87
4.82
4.78
4.74
5.03
4.99
4.94
4.90
4.86
5.15
5.11
5.06
5.02
4.98
5.27
5.23
5.18
5.14
5.10
5.39
5.35
5.30
5.26
5.22
5.51
5.47
5.42
5.38
5.34
5.63
5.59
5.54
5.50
5.46
5.75
5.71
5.66
5.62
5.58
68
70
72
74
2.65
2.61
2.57
2.53
2.77
2.73
2.69
2.65
2.89
2.85
2.81
2.77
3.01
2.97
2.93
2.89
3.13
3.09
3.05
3.01
3.25
3.21
3.17
3.13
3.37
3.33
3.29
3.25
3.49
3.45
3.41
3.37
3.61
3.57
3.53
3.49
3.73
3.69
3.65
3.61
3.85
3.81
3.77
3.73
3.97
3.93
3.89
3.85
4.09
4.05
4.01
3.97
4.21
4.17
4.13
4.09
4.33
4.29
4.25
4.21
4.45
4.41
4.37
4.33
4.57
4.53
4.49
4.45
4.69
4.65
4.61
4.57
4.81
4.77
4.73
4.69
4.93
4.89
4.85
4.81
5.05
5.01
4.97
4.93
5.17
5.13
5.09
5.05
5.29
5.25
5.21
5.17
5.41
5.37
5.33
5.29
5.53
5.49
5.45
5.41
FVC in liters = 0.0600 H 0.0214 A 4.650. R = 0.54, SEE = 0.644, 95% Confidence Interval = 1.115.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. BTPS = body temperature, ambient pressure and saturated with water vapor at these conditions.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
67
TABLE 3
PREDICTED NORMAL FVC VALUES (LITERS) FOR WOMEN (BTPS)
Age
18
20
22
24
26
146
3.19
3.15
3.10
3.06
3.02
148
3.29
3.24
3.20
3.16
3.12
150
3.39
3.34
3.30
3.26
3.21
152
3.48
3.44
3.40
3.35
3.31
154
3.58
3.54
3.50
3.45
3.41
156
3.68
3.64
3.59
3.55
3.51
158
3.78
3.74
3.69
3.65
3.61
160
3.88
3.83
3.79
3.75
3.70
162
3.98
3.93
3.89
3.85
3.80
164
4.07
4.03
3.99
3.94
3.90
166
4.17
4.13
4.09
4.04
4.00
Height(cm)
168 170 172
4.27 4.37 4.47
4.23 4.32 4.42
4.18 4.28 4.38
4.14 4.24 4.34
4.10 4.20 4.29
174
4.56
4.52
4.48
4.43
4.39
176
4.66
4.2
4.58
4.53
4.49
178
4.76
4.72
4.67
4.63
4.59
180
4.86
4.82
4.77
4.73
4.69
182
4.96
4.91
4.87
4.83
4.78
184
5.06
5.01
4.97
4.93
4.88
186
5.15
5.11
5.07
5.02
4.98
188
5.25
5.21
5.17
5.12
5.08
190
5.35
5.31
5.26
5.22
5.18
192
5.45
5.41
5.36
5.32
5.28
194
5.55
5.50
5.46
5.42
5.37
28
30
32
34
36
2.97
2.93
2.89
2.84
2.80
3.07
3.03
2.99
2.94
2.90
3.17
3.13
3.08
3.04
3.00
3.27
3.23
3.18
3.14
3.10
3.37
3.32
3.28
3.24
3.19
3.46
3.42
3.38
3.34
3.29
3.56
3.52
3.48
3.43
3.39
3.66
3.62
3.57
3.53
3.49
3.76
3.72
3.67
3.63
5.39
3.86
3.81
3.77
3.73
3.68
3.96
3.91
3.87
3.83
3.78
4.05
4.01
3.97
3.92
3.88
4.15
4.11
4.07
4.02
3.98
4.25
4.21
4.16
4.12
4.08
4.35
4.31
4.26
4.22
4.18
4.45
4.40
4.36
4.32
4.27
4.54
4.50
4.46
4.42
4.37
4.64
4.60
4.56
4.51
4.47
4.74
4.70
4.65
4.61
4.57
4.84
4.80
4.75
4.71
4.67
4.94
4.89
4.85
4.81
4.76
5.04
4.99
4.95
4.91
4.86
5.13
5.09
5.05
5.00
4.96
5.23
5.19
5.15
5.10
5.06
5.33
5.29
5.24
5.20
5.16
38
40
42
44
46
2.76
2.71
2.67
2.63
2.58
2.86
2.81
2.77
2.73
2.68
2.95
2.91
2.87
2.82
2.78
3.05
3.01
2.97
2.92
2.88
3.15
3.11
3.06
3.02
2.98
3.25
3.21
3.16
3.12
3.08
3.35
3.30
3.26
3.22
3.17
3.45
3.40
3.36
3.32
3.27
3.54
3.50
3.46
3.41
3.37
3.64
3.60
3.56
3.51
3.47
3.74
3.70
3.65
3.61
3.57
3.84
3.79
3.75
3.71
3.67
3.94
3.89
3.85
3.81
3.76
4.03
3.99
3.95
3.90
3.86
4.13
4.09
4.05
4.00
3.96
4.23
4.19
4.14
4.10
4.06
4.33
4.29
4.24
4.20
4.16
4.43
4.38
4.34
4.30
4.25
4.53
4.48
4.44
4.40
4.35
4.62
4.58
4.54
4.49
4.45
4.72
4.68
4.64
4.59
4.55
4.82
4.78
4.73
4.69
4.65
4.92
4.87
4.83
4.79
4.75
5.02
4.97
4.93
4.89
4.84
5.11
5.07
5.03
4.98
4.94
48
50
52
54
56
2.54
2.50
2.46
2.41
2.37
2.64
2.60
2.55
2.51
2.47
2.74
2.69
2.65
2.61
2.57
2.84
2.79
2.75
2.71
2.66
2.93
2.89
2.85
2.80
2.76
3.03
2.99
2.95
2.90
2.86
3.13
3.09
3.04
3.00
2.96
3.23
3.19
3.14
3.10
3.06
3.33
3.28
3.24
3.20
3.15
3.43
3.38
3.34
3.30
3.25
3.52
3.48
3.44
3.39
3.35
3.62
3.58
3.54
3.49
3.45
3.72
3.68
3.63
3.59
3.55
3.82
3.78
3.73
3.69
3.65
3.92
3.87
3.83
3.79
3.74
4.01
3.97
3.93
3.89
3.84
4.11
4.07
4.03
3.98
3.94
4.21
4.17
4.12
4.08
4.04
4.31
4.27
4.22
4.18
4.14
4.41
4.36
4.32
4.28
4.23
4.51
4.46
4.42
4.38
4.33
4.60
4.56
4.52
4.47
4.43
4.70
4.66
4.62
4.57
4.53
4.80
4.76
4.71
4.67
4.63
4.90
4.86
4.81
4.77
4.73
58
60
62
64
66
2.33
2.28
2.24
2.20
2.15
2.42
2.38
2.34
2.29
2.25
2.52
2.48
2.44
2.39
2.35
2.62
2.58
2.53
2.49
2.45
2.72
2.68
2.63
2.59
2.55
2.82
2.77
2.73
2.69
2.64
2.91
2.87
2.83
2.79
2.74
3.01
2.97
2.93
2.88
2.84
3.11
3.07
3.02
2.98
2.94
3.21
3.17
3.12
3.08
3.04
3.31
3.26
3.22
3.18
3.14
3.41
3.36
3.32
3.28
3.23
3.50
3.46
3.42
3.37
3.33
3.60
3.56
3.52
3.47
3.43
3.70
3.66
3.61
3.57
3.53
3.80
2.76
3.71
3.67
3.63
3.90
3.85
3.81
3.77
3.72
4.00
3.95
3.91
3.87
3.82
4.09
4.05
4.01
3.96
2.92
4.19
4.15
4.11
4.06
4.02
4.29
4.25
4.20
4.16
4.12
4.39
4.34
4.30
4.26
4.22
4.49
4.44
4.40
4.36
4.31
4.58
4.54
4.50
4.45
4.41
4.68
4.64
4.60
4.55
4.51
68
70
72
74
2.11
2.07
2.02
1.98
2.21
2.16
2.12
2.08
2.31
2.26
2.22
2.18
2.40
2.36
2.32
2.27
2.50
2.46
2.42
2.37
2.60
2.56
2.51
2.47
2.70
2.66
2.61
2.57
2.80
2.75
2.71
2.67
2.90
2.85
2.81
2.77
2.99
2.95
2.91
2.86
3.09
3.05
3.01
2.96
3.19
3.15
3.10
3.06
3.29
3.24
3.20
3.16
3.39
3.34
3.30
3.26
3.48
3.44
3.40
3.36
3.58
3.54
3.50
3.45
3.68
3.64
3.59
3.55
3.78
3.74
3.69
3.65
3.88
3.83
3.79
3.75
3.98
3.93
3.89
3.85
4.07
4.03
3.99
3.94
4.17
4.13
4.09
4.04
4.27
4.23
4.18
4.14
4.37
4.33
4.28
4.24
4.47
4.42
4.38
4.34
FVC in liters = 0.0491 H 0.0216 A 3.590. R = 0.74, SEE = 0.393, 95% Confidence Interval = 0.676.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. BTPS = body temperature, ambient pressure and saturated with water vapor at these conditions.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
68
TABLE 4
PREDICTED NORMAL FEV1 FOR MEN
Age
18
20
22
24
26
146
3.42
3.37
3.32
3.27
3.22
148
3.50
3.45
3.40
3.35
3.30
150
3.58
3.53
3.48
3.43
3.39
152
3.66
3.61
3.57
3.52
3.47
154
3.75
3.70
3.65
3.60
3.55
156
3.83
3.78
3.73
3.68
3.63
158
3.91
3.86
3.81
3.77
3.72
160
3.99
3.95
3.90
3.85
3.80
162
4.08
4.03
3.98
3.93
3.88
164
4.16
4.11
4.06
4.01
3.97
166
4.24
4.19
4.15
4.10
4.05
Height(cm)
168 170 172
4.33 4.41 4.49
4.28 4.36 4.44
4.23 4.31 4.39
4.18 4.26 4.35
4.13 4.21 4.30
174
4.57
4.53
4.48
4.43
4.38
176
4.66
4.61
4.56
4.51
4.46
178
4.74
4.69
4.64
4.59
4.54
180
4.82
4.77
4.73
4.68
4.63
182
4.91
4.86
4.81
4.76
4.71
184
4.99
4.94
4.89
4.84
4.79
186
5.07
5.02
4.97
4.92
4.88
188
5.15
5.11
5.05
5.01
4.90
190
5.24
5.19
5.14
5.09
5.04
192
5.32
5.27
5.22
5.17
5.12
194
5.40
5.35
5.30
5.26
5.21
28
30
32
34
36
3.17
3.12
3.07
3.02
2.98
3.25
3.21
3.16
3.11
3.06
3.34
3.29
3.24
3.19
3.14
3.42
3.37
3.32
3.27
3.22
3.50
3.45
3.40
3.36
3.31
3.59
3.54
3.49
3.44
3.39
3.67
3.62
3.57
3.52
3.47
3.75
3.70
3.65
3.60
3.56
3.83
3.78
3.74
3.69
3.64
3.92
3.87
3.82
3.77
3.72
4.00
3.95
3.90
3.85
3.80
4.08
4.03
3.98
3.94
3.89
4.16
4.12
4.07
4.02
3.97
4.25
4.20
4.15
4.10
4.05
4.33
4.28
4.23
4.18
4.14
4.41
4.36
4.32
4.27
4.22
4.50
4.45
4.40
4.35
4.30
4.58
4.53
4.48
4.43
4.38
4.66
4.61
4.56
4.52
4.47
4.74
4.70
4.65
4.60
4.55
4.83
4.78
4.73
4.68
4.63
4.91
4.86
4.81
4.76
4.71
4.99
4.94
4.90
4.85
4.80
5.08
5.03
4.98
4.93
4.88
5.16
5.11
5.06
5.01
4.96
38
40
42
44
46
2.93
2.88
2.83
2.78
2.73
3.01
2.96
2.91
2.86
2.81
3.09
3.04
3.00
2.95
2.90
3.18
3.13
3.08
3.03
2.98
3.26
3.21
3.16
3.11
3.06
3.34
3.29
3.24
3.19
3.15
3.42
3.38
3.33
3.28
3.23
3.51
3.46
3.41
3.36
3.31
3.59
3.54
3.49
3.44
3.39
3.67
3.62
3.57
3.53
3.48
3.76
3.71
3.66
3.61
3.56
3.84
3.79
3.74
3.69
3.64
3.94
3.87
3.82
3.77
3.73
4.00
3.95
3.91
3.86
3.81
4.09
4.04
3.99
3.94
3.89
4.17
4.12
4.07
4.02
3.97
4.25
4.20
4.15
4.11
4.06
4.33
4.29
4.24
4.19
4.14
4.42
4.37
4.32
4.27
4.22
4.50
4.45
4.40
4.35
4.31
4.58
4.53
4.49
4.44
4.39
4.67
4.62
4.57
4.52
4.47
4.75
4.70
4.65
4.60
4.55
4.83
4.78
4.73
4.69
4.64
4.91
4.87
4.82
4.77
4.72
48
50
52
54
56
2.68
2.63
2.59
2.54
2.49
2.77
2.72
2.67
2.62
2.57
2.85
2.80
2.75
2.70
2.65
2.93
2.88
2.83
2.79
2.74
3.01
2.97
2.92
2.87
2.82
3.10
3.05
3.00
2.95
3.90
3.18
3.13
3.08
3.03
2.98
3.26
3.21
3.17
3.12
3.07
3.35
3.30
3.25
3.20
3.15
3.43
3.38
3.33
3.28
3.23
3.51
3.46
3.41
3.36
3.32
3.59
3.55
3.50
3.45
3.40
3.68
3.63
3.58
3.53
3.48
3.76
3.71
3.66
3.61
3.56
3.84
3.79
3.74
3.70
3.65
3.93
3.88
3.83
3.78
3.73
4.01
3.96
3.91
3.86
3.81
4.09
4.04
3.99
3.94
3.90
4.17
4.12
4.08
4.03
3.98
4.25
4.21
4.16
4.11
4.06
4.34
4.29
4.24
4.19
4.14
4.42
4.37
4.32
4.28
4.23
4.50
4.46
4.41
4.36
4.31
4.59
4.54
4.49
4.44
4.39
4.67
4.62
4.57
4.52
4.48
58
60
62
64
66
2.44
2.39
2.34
2.29
2.24
2.52
2.47
2.42
2.38
2.33
2.60
2.55
2.51
2.46
2.41
2.69
2.64
2.59
2.54
2.49
2.77
2.72
2.67
2.62
2.58
2.85
2.80
2.76
2.71
2.66
2.94
2.89
2.84
2.79
2.74
3.02
2.97
2.92
2.87
2.82
3.10
3.05
3.00
2.96
2.91
3.18
3.14
3.09
3.04
2.99
3.27
3.22
3.17
3.12
3.07
3.35
3.30
3.25
3.20
3.15
3.43
3.38
3.34
3.29
3.24
3.52
3.47
3.42
3.37
3.32
3.60
3.55
3.50
3.45
3.40
3.68
3.63
3.58
3.53
3.49
3.76
3.72
3.67
3.62
3.57
3.85
3.80
3.75
3.70
3.65
3.93
3.88
3.83
3.78
3.73
4.01
3.96
3.91
3.87
3.82
4.10
4.05
4.00
3.95
3.90
4.18
4.13
4.08
4.03
3.98
4.26
4.21
4.16
4.11
4.07
4.34
4.29
4.25
4.20
4.15
4.43
4.38
4.33
4.28
4.23
68
70
72
74
2.20
2.15
2.10
2.05
2.28
2.23
2.18
2.13
2.36
2.31
2.26
2.21
2.44
2.39
2.35
2.30
2.53
2.48
2.43
2.38
2.61
2.56
2.51
2.46
2.69
2.64
2.59
2.55
2.77
2.73
2.68
2.63
2.86
2.81
2.76
2.71
2.94
2.89
2.84
2.79
3.02
2.97
3.93
2.88
3.11
3.06
3.01
2.96
3.19
3.14
3.09
3.04
3.27
3.22
3.17
3.13
3.35
3.31
3.26
3.21
3.44
3.39
3.34
3.29
3.52
3.47
3.42
3.37
3.60
3.55
3.51
3.46
3.69
3.64
3.59
3.54
3.77
3.72
3.67
3.62
3.85
3.80
3.75
3.70
3.93
3.98
3.84
3.79
4.02
3.97
3.92
3.87
4.10
4.05
4.00
3.95
4.18
4.13
4.08
4.04
FEV1 in liters = 0.0414 H 0.0244 A 2.190. R = 0.64, SEE = 0.486, 95% Confidence Interval = 0.842.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. BTPS = body temperature, ambient pressure and saturated with water vapor at these conditions.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
69
TABLE 5
PREDICTED NORMAL FEV1 FOR WOMEN
Age
18
20
22
24
26
146
2.96
2.91
2.85
2.80
2.75
148
3.02
2.97
2.92
2.87
2.82
150
3.09
3.04
2.99
2.94
2.89
152
3.16
3.11
3.06
3.01
2.96
154
3.23
3.18
3.13
3.08
3.03
156
3.30
3.25
3.20
3.15
3.09
158
3.37
3.32
3.26
3.21
3.16
160
3.43
3.38
3.33
3.28
3.23
162
3.50
3.45
3.40
3.35
3.30
164
3.57
3.52
3.47
3.42
3.37
166
3.64
3.59
3.54
3.49
3.44
Height(cm)
168 170 172
3.71 3.78 3.85
3.66 3.73 3.79
3.61 3.67 3.74
3.56 3.62 3.69
3.50 3.57 3.64
174
3.91
3.86
3.81
3.76
3.71
176
3.98
3.93
3.88
3.83
3.78
178
4.05
4.00
3.95
3.90
3.85
180
4.12
4.07
4.02
3.97
3.91
182
4.19
4.14
4.09
4.03
3.98
184
4.26
4.20
4.15
4.10
4.05
186
4.32
4.27
4.22
4.17
4.12
188
4.39
4.34
4.29
4.24
4.19
190
4.46
4.41
4.36
4.31
4.26
192
4.53
4.48
4.43
4.38
4.33
194
4.60
4.55
4.50
4.44
4.39
28
30
32
34
36
2.70
2.65
2.60
2.55
2.50
2.77
2.72
2.67
2.62
2.57
2.84
2.79
2.74
2.68
2.63
2.91
2.86
2.80
2.75
2.70
2.97
2.92
2.87
2.82
2.77
3.04
2.99
2.94
2.89
2.84
3.11
3.06
3.01
2.96
2.91
3.18
3.13
3.08
3.03
2.98
3.25
3.20
3.15
3.10
3.04
3.32
3.27
3.21
3.16
3.11
3.39
3.33
3.28
3.23
3.18
3.45
3.40
3.35
3.30
3.25
3.52
3.47
3.42
3.37
3.32
3.59
3.54
3.49
3.44
3.39
3.66
3.61
3.56
3.51
3.45
3.73
3.68
3.63
3.57
3.52
3.80
3.74
3.69
3.64
3.59
3.86
3.81
3.76
3.71
3.66
3.93
3.88
3.83
3.78
3.73
4.00
3.95
3.90
3.85
3.80
4.07
4.02
3.97
3.92
3.87
4.14
4.09
4.04
3.98
3.93
4.21
4.15
4.10
4.05
4.00
4.27
4.22
4.17
4.12
4.07
4.34
4.29
4.24
4.19
4.14
38
40
42
44
46
2.45
2.40
2.34
2.29
2.24
2.51
2.46
2.41
2.36
2.31
2.58
2.53
2.48
2.43
2.38
2.65
2.60
2.55
2.50
2.45
2.72
2.67
2.62
2.57
2.52
2.79
2.74
2.69
2.64
2.58
2.86
2.81
2.75
2.70
2.65
2.92
2.87
2.82
2.77
2.72
2.99
2.94
2.89
2.84
2.79
3.06
3.01
2.96
2.91
2.86
3.13
3.08
3.03
2.98
2.93
3.20
3.15
3.10
3.05
2.99
3.27
3.22
3.17
3.11
3.06
3.34
3.28
3.23
3.18
3.13
3.40
3.35
3.30
3.25
3.20
3.47
3.42
3.37
3.32
3.27
3.54
3.49
3.44
3.39
3.34
3.61
3.56
3.51
3.46
3.41
3.68
3.63
3.58
3.52
3.47
3.75
3.69
3.64
3.59
3.54
3.81
3.76
3.71
3.66
3.61
3.88
3.83
3.78
3.73
3.68
3.95
3.90
3.85
3.80
3.75
4.02
3.97
3.92
3.87
3.82
4.09
4.04
3.99
3.93
3.88
48
50
52
54
56
2.19
2.14
2.09
2.04
1.99
2.26
2.21
2.16
2.11
2.06
2.33
2.28
2.23
2.18
2.12
2.40
2.35
2.29
2.24
2.19
2.46
2.41
2.36
2.31
2.26
2.53
2.48
2.43
2.38
2.33
2.60
2.55
2.50
2.45
2.40
2.67
2.62
2.57
2.52
2.47
2.74
2.69
2.64
2.59
2.53
2.81
2.76
2.70
2.65
2.60
2.88
2.82
2.77
2.72
2.67
2.94
2.89
2.84
2.79
2.74
3.01
2.96
2.91
2.86
2.81
3.08
3.03
2.98
2.93
2.88
3.15
3.10
3.05
3.00
2.94
3.22
3.17
3.12
3.06
3.01
3.29
3.23
3.18
3.13
3.08
3.35
3.30
3.25
3.20
3.15
3.42
3.37
3.32
3.27
3.22
3.49
3.44
3.39
3.34
3.29
3.56
3.51
3.46
3.41
3.36
3.63
3.58
3.53
3.47
3.42
3.70
3.65
3.59
3.54
3.49
3.76
3.71
3.66
3.61
3.56
3.83
3.78
3.73
3.68
3.63
58
60
62
64
66
1.94
1.89
1.83
1.78
1.73
2.00
1.95
1.90
1.85
1.80
2.07
2.02
1.97
1.92
1.87
2.14
2.09
2.04
1.99
1.94
2.21
2.16
2.11
2.06
2.01
2.28
2.23
2.18
2.13
2.07
2.35
2.30
2.24
2.19
2.14
2.42
2.36
2.31
2.26
2.21
2.48
2.43
2.38
2.33
2.28
2.55
2.50
2.45
2.40
2.35
2.62
2.57
2.52
2.47
2.42
2.69
2.64
2.59
2.54
2.48
2.76
2.71
2.66
2.60
2.55
2.83
2.77
2.72
2.67
2.62
2.89
2.84
2.79
2.74
2.69
2.96
2.91
2.86
2.81
2.76
3.03
2.98
2.93
2.88
2.83
3.10
3.05
3.00
2.95
2.90
3.17
3.12
3.07
3.01
2.96
3.24
3.18
3.13
3.08
3.03
3.30
3.25
3.20
3.15
3.10
3.37
3.32
3.27
3.22
3.17
3.44
3.39
3.34
3.29
3.24
3.51
3.46
3.41
3.36
3.31
3.58
3.53
3.48
3.42
3.37
68
70
72
74
1.68
1.63
1.58
1.53
1.75
1.70
1.65
1.60
1.82
1.77
1.72
1.67
1.89
1.84
1.78
1.73
1.95
1.90
1.85
1.80
2.02
1.97
1.92
1.87
2.09
2.04
1.99
1.94
2.16
2.11
2.06
2.01
2.23
2.18
2.13
2.08
2.30
2.25
2.19
2.14
2.37
2.31
2.26
2.21
2.43
2.38
2.33
2.28
2.50
2.45
2.40
2.35
2.57
2.52
2.47
2.42
2.64
2.59
2.54
2.49
2.71
2.66
2.61
2.55
2.78
2.72
2.67
2.62
2.84
2.79
2.74
2.69
2.91
2.86
2.81
2.76
2.98
2.93
2.88
2.83
3.05
3.00
2.95
2.90
3.12
3.07
3.02
2.96
3.19
3.14
3.08
3.03
3.25
3.20
3.15
3.10
3.32
3.27
3.22
3.17
FEV1 in liters = 0.0342 H 0.0255 A 1.578. R = 0.80, SEE = 0.326, 95% Confidence Interval = 0.561.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. BTPS = body temperature, ambient pressure and saturated with water vapor at these conditions.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
70
TABLE 6
PREDICTED NORMAL SINGLE BREATH DCO VALUES FOR MEN (STPD)
Age
18
20
22
24
26
146
29.8
29.3
28.9
28.5
28.1
148
30.6
30.2
29.7
29.3
28.9
150
31.4
31.0
30.6
30.1
29.7
152
32.2
31.8
31.4
31.0
30.5
154
33.1
32.6
32.2
31.8
31.4
156
33.9
33.4
33.0
32.6
32.2
158
34.7
34.3
33.8
33.4
33.0
160
35.5
35.1
34.7
34.2
33.8
162
36.3
35.9
35.5
35.1
34.6
164
37.1
36.7
36.3
35.9
35.5
166
38.0
37.5
37.1
36.7
36.3
Height(cm)
168 170 172
38.8 39.6 40.4
38.4 39.2 40.0
37.9 38.8 39.6
37.5 38.3 39.2
37.1 37.9 38.7
174
41.2
40.8
40.4
40.0
39.6
176
42.1
41.6
41.2
40.8
40.4
178
42.9
42.5
42.0
41.6
41.2
180
43.7
43.3
42.9
42.4
42.0
182
44.5
44.1
43.7
43.3
42.8
184
45.4
44.9
44.5
44.1
43.7
186
46.2
45.7
45.3
44.9
44.5
188
47.0
46.6
46.1
45.7
45.3
190
47.8
47.4
47.0
46.5
46.1
192
48.6
48.2
47.8
47.4
46.9
194
49.4
49.0
48.6
48.2
47.8
28
30
32
34
36
27.7
27.2
26.8
26.4
26.0
28.5
28.1
27.6
27.2
26.8
29.3
28.9
28.5
28.1
27.6
30.1
29.7
29.3
28.9
28.4
30.9
30.5
30.1
29.7
29.3
31.8
31.3
30.9
30.5
30.1
32.6
32.2
31.7
31.3
30.9
33.4
33.0
32.6
32.1
31.7
34.2
33.8
33.4
33.0
32.5
35.0
34.6
34.2
33.8
33.4
35.9
35.4
35.0
34.6
34.2
36.7
36.3
35.8
35.4
35.0
37.5
37.1
36.7
36.2
35.8
38.3
37.9
37.5
37.1
36.6
39.1
38.7
38.3
37.9
37.5
40.0
39.6
39.1
38.7
38.3
40.8
40.4
39.9
39.5
39.1
41.6
412
40.8
40.4
39.9
42.4
42.0
41.6
41.2
40.7
43.2
42.8
42.4
42.0
41.6
44.1
43.6
43.2
42.8
42.4
44.9
44.5
44.1
43.6
43.2
45.7
45.3
44.9
44.4
44.0
46.5
46.1
45.7
45.3
44.8
47.3
46.9
46.5
46.1
45.7
38
40
42
44
46
25.6
25.1
24.7
24.3
23.9
26.4
26.0
25.5
25.1
24.7
27.2
26.8
26.4
25.9
25.5
28.0
27.6
27.2
26.8
26.3
28.8
28.4
28.0
27.6
27.2
29.7
29.2
28.8
28.4
28.0
30.5
30.1
29.6
29.2
28.8
31.3
30.9
30.5
30.0
29.6
32.1
31.7
31.3
30.9
30.4
32.9
32.5
32.1
31.7
31.3
33.8
33.3
32.9
32.5
32.1
34.6
34.2
33.7
33.3
32.9
35.4
35.0
34.6
34.1
33.7
36.2
35.8
35.4
35.0
34.6
37.0
36.6
36.2
35.8
35.4
37.9
37.4
37.0
36.6
36.2
38.7
38.3
37.8
37.4
37.0
39.5
39.1
38.7
38.2
37.8
40.3
39.9
39.5
39.1
38.6
41.1
40.7
40.3
39.9
39.5
42.0
41.5
41.1
40.7
40.3
42.8
42.4
41.9
41.5
41.1
43.6
43.2
42.8
42.3
41.9
44.4
44.0
43.6
43.2
42.7
45.2
44.8
44.4
44.0
43.6
48
50
52
54
56
23.5
23.1
22.6
22.2
21.8
24.3
23.9
23.4
23.0
22.6
25.1
24.7
24.3
23.8
23.4
25.9
25.5
25.1
24.7
24.2
26.7
26.3
25.9
25.5
25.1
27.6
27.1
26.7
26.3
25.9
28.4
28.0
27.6
27.1
26.7
29.2
28.8
28.4
27.9
27.5
30.0
29.6
29.2
28.8
28.3
30.8
30.4
30.0
29.6
29.2
31.7
31.2
30.8
30.4
30.0
32.5
32.1
31.6
31.2
30.8
33.3
32.9
32.5
32.0
31.6
34.1
33.7
33.3
32.9
32.4
34.9
34.5
34.1
33.7
33.3
35.8
35.4
34.9
34.5
34.1
36.6
36.2
35.7
35.3
34.9
37.4
37.0
36.6
36.1
35.7
38.2
37.8
37.4
37.0
36.5
39.1
38.6
38.2
37.8
37.4
39.9
39.4
39.0
38.6
38.2
40.7
40.3
39.9
39.4
39.0
41.5
41.1
40.7
40.2
39.8
42.3
41.9
41.6
41.1
40.6
43.1
42.7
42.3
41.9
41.5
58
60
62
64
66
21.4
20.9
20.5
20.1
19.7
22.2
21.8
21.3
20.9
20.5
23.0
22.6
22.2
21.7
21.3
23.8
23.4
23.0
22.6
22.1
24.6
24.2
23.8
23.4
23.0
25.5
25.0
24.6
24.2
23.8
26.3
25.9
25.4
25.0
24.6
27.1
26.7
26.3
25.8
25.4
27.9
27.5
27.1
26.7
26.2
28.7
28.3
27.9
27.5
27.1
29.6
29.1
28.7
28.3
27.9
30.4
30.0
29.5
29.1
28.7
31.2
30.8
30.4
29.9
29.5
32.0
31.6
31.2
30.8
30.4
32.8
32.4
32.0
31.6
31.2
33.7
33.2
32.8
32.4
32.0
34.5
34.1
33.6
33.2
32.8
35.3
34.9
34.5
34.1
33.6
36.1
35.7
35.3
34.9
34.4
36.9
36.5
36.1
35.7
35.3
37.8
37.3
36.9
36.5
36.1
38.6
38.2
37.7
37.3
36.9
39.4
39.0
38.6
38.1
37.7
40.2
39.8
39.4
39.0
38.6
41.0
40.6
40.2
39.8
39.4
68
70
72
74
19.3
18.8
18.4
18.0
20.1
19.7
19.2
18.8
20.9
20.5
20.1
19.6
21.7
21.3
20.9
20.5
22.6
22.1
21.7
21.3
23.4
22.9
22.5
22.1
24.2
23.8
23.3
22.9
25.0
24.6
24.2
23.7
25.8
25.4
25.0
24.6
26.6
26.2
25.8
25.4
27.5
27.0
26.6
26.2
28.3
27.9
27.4
27.0
29.1
28.7
28.3
27.8
29.9
29.5
29.1
28.7
30.7
30.3
29.9
29.5
31.6
31.1
30.7
30.3
32.4
32.0
31.5
31.1
38.2
32.8
32.4
31.9
34.0
33.6
33.2
32.8
34.9
34.4
34.0
33.6
35.7
35.2
34.8
34.4
36.5
36.1
35.6
35.2
37.3
36.9
36.5
36.0
38.1
37.7
37.3
36.9
38.9
38.5
38.1
37.7
Dco in ml/min/mm Hg = 0.0410 H 0.210 A 26.31. R = 0.60, SEE = 0.482, 95% Confidence Interval = 8.2.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. STPD = temperature 0C, pressure 760 mm Hg and dry (0 water vapor).
The regression analysis has been normalized to a standard hemoglobin of 14.6 g/dl using Cotes modification and the relationship
described by Roughton and Forster.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
71
TABLE 7
PREDICTED NORMAL SINGLE BREATH DCO VALUES FOR WOMEN (STPD)
Age
18
20
22
24
26
146
26.0
25.7
25.4
25.1
24.8
148
26.5
26.2
25.9
25.6
25.3
150
27.0
26.7
26.5
26.2
25.9
152
27.6
27.3
27.0
26.7
26.4
154
28.1
27.8
27.5
27.2
26.9
156
28.6
28.4
28.1
27.8
27.5
158
29.2
28.9
28.6
28.3
28.0
160
29.7
29.4
29.1
28.8
28.5
162
30.2
30.0
29.7
29.4
29.1
164
30.8
30.5
30.2
29.9
29.6
166
31.3
31.0
30.7
30.4
30.1
Height(cm)
168 170 172
31.9 32.4 3.9
31.6 32.1 32.6
31.3 31.8 32.3
31.0 31.5 32.0
30.7 31.2 31.7
174
33.5
33.2
32.9
32.6
32.3
176
34.0
33.7
33.4
33.1
32.8
178
34.5
34.2
33.9
33.6
33.3
180
35.1
34.8
34.5
34.2
33.9
182
35.6
35.3
35.0
34.7
34.4
184
36.1
35.8
35.5
35.2
34.9
186
36.7
36.4
36.1
35.8
35.5
188
37.2
36.9
36.6
36.3
36.0
190
37.7
37.4
37.1
36.8
36.5
192
38.3
38.0
37.7
37.4
37.1
194
38.8
38.5
38.2
37.9
37.6
28
30
32
34
36
24.5
24.2
23.9
23.6
23.3
25.0
24.7
24.4
24.1
23.8
25.6
25.3
25.0
24.7
24.4
26.1
25.8
25.5
25.2
24.9
26.6
26.3
26.0
25.7
25.4
27.2
26.9
26.6
26.3
26.0
27.7
27.4
27.1
26.8
26.5
28.2
27.9
27.6
27.3
27.1
28.8
28.5
28.2
27.9
27.6
29.3
29.0
28.7
28.4
28.1
29.8
29.5
29.2
28.9
28.7
30.4
30.1
29.8
29.5
29.2
30.9
30.6
30.3
30.0
29.7
31.4
31.1
30.8
30.6
30.3
32.0
31.7
31.4
31.1
30.8
32.5
32.2
31.9
31.6
31.3
33.0
32.7
32.4
32.2
31.9
33.6
33.3
33.0
32.7
32.4
34.1
33.8
33.5
33.2
32.9
34.6
34.3
34.1
33.8
33.5
35.2
34.9
34.6
34.3
34.0
35.7
35.4
35.1
34.8
34.5
36.2
35.9
35.7
35.4
35.1
36.8
36.5
36.2
35.9
35.6
37.3
37.0
36.7
36.4
36.1
38
40
42
44
46
23.0
22.7
22.4
22.1
21.8
23.6
23.3
23.0
22.7
22.4
24.1
23.8
23.5
23.2
22.9
24.6
24.3
24.0
23.7
23.4
25.2
24.9
24.6
24.3
24.0
25.7
25.4
25.1
24.3
24.5
26.2
25.9
25.6
25.3
25.0
26.8
26.5
26.2
25.9
25.6
27.3
27.0
26.7
26.4
26.1
27.8
27.5
27.2
26.9
26.6
28.4
28.1
27.8
27.5
27.2
28.9
28.6
28.3
28.0
27.7
29.4
29.1
28.8
28.5
28.2
30.0
29.7
29.4
29.1
28.8
30.5
30.2
29.9
29.6
29.3
31.0
30.7
30.4
30.1
29.8
31.6
31.3
31.0
30.7
30.4
32.1
31.8
31.5
31.2
30.9
32.6
32.3
32.0
31.7
31.4
33.2
32.9
32.6
32.3
32.0
33.7
33.4
33.1
32.8
32.5
34.2
33.9
33.6
33.3
33.0
34.8
34.5
34.2
33.9
33.6
35.3
35.0
34.7
34.4
34.1
35.8
35.5
35.2
34.9
34.6
48
50
52
54
56
21.5
21.2
20.9
20.6
20.4
22.1
21.8
21.5
21.2
20.9
22.6
22.3
22.0
21.7
21.4
23.1
22.8
22.5
22.3
22.0
23.7
23.4
23.1
22.8
22.5
24.2
23.9
23.5
23.3
23.0
24.7
24.4
24.1
23.9
23.6
25.3
25.0
24.7
24.4
24.1
25.8
25.5
25.2
24.9
24.6
26.3
26.0
25.8
25.5
25.2
26.9
26.6
26.3
26.0
25.7
27.4
27.1
26.8
26.5
26.2
27.9
27.6
27.4
27.1
26.8
28.5
28.2
27.9
27.6
27.3
29.0
28.7
28.4
28.1
27.8
29.5
29.3
29.0
28.7
28.4
30.1
29.8
29.5
29.2
28.9
30.6
30.3
30.0
29.7
29.4
31.1
30.9
30.6
30.3
30.0
31.7
31.4
31.1
30.8
30.5
32.2
31.9
31.6
31.3
31.0
32.8
32.5
32.2
31.9
31.6
33.3
33.0
32.7
32.4
32.1
33.8
33.5
33.2
32.9
32.6
34.4
34.1
33.8
33.5
33.2
58
60
62
64
66
20.1
19.8
19.5
19.2
18.9
20.6
20.3
20.0
19.7
19.4
21.1
20.8
20.5
20.2
19.9
21.7
21.4
21.1
20.8
20.5
22.2
21.9
21.6
21.3
21.0
22.7
22.4
22.1
21.8
21.5
23.3
23.0
22.7
22.4
22.1
23.8
23.5
23.2
22.9
22.6
24.3
24.0
23.7
23.4
23.1
24.9
24.6
24.3
24.0
23.7
25.4
25.1
24.8
24.5
24.2
25.9
25.6
25.3
25.0
24.1
26.5
26.2
25.9
25.6
25.3
27.0
26.7
26.4
26.1
25.8
27.5
27.2
26.9
26.6
26.3
28.1
27.8
27.5
27.2
26.9
28.6
28.3
28.0
27.7
27.4
29.1
28.8
28.5
28.2
28.0
29.7
29.4
29.1
28.8
28.5
30.2
29.9
29.6
29.3
29.0
30.7
30.4
30.1
29.8
29.6
31.3
31.0
30.7
30.4
30.1
31.8
31.5
31.2
30.9
30.6
32.3
32.0
31.7
31.5
31.2
32.9
32.6
32.3
32.0
31.7
68
70
72
74
18.6
18.3
18.0
17.7
19.1
18.8
18.5
18.2
19.6
19.3
19.1
18.8
20.2
19.9
19.6
19.3
20.7
20.4
20.1
19.8
21.2
21.0
20.7
20.4
21.8
21.5
21.2
20.9
22.3
22.0
21.1
21.4
22.8
22.6
22.3
22.0
23.4
23.1
22.8
22.5
23.9
23.5
23.3
23.0
24.5
24.2
23.9
23.6
25.0
24.7
24.4
24.1
25.5
25.2
24.9
24.6
26.1
25.8
25.5
25.2
26.6
26.3
26.0
25.7
27.1
26.8
26.5
26.2
27.7
27.4
27.1
26.8
28.2
27.9
27.6
27.3
28.7
28.4
28.1
27.8
29.3
29.0
28.7
28.4
29.8
29.5
29.2
28.9
30.3
30.0
29.7
29.4
30.9
30.6
30.3
30.0
31.4
31.1
30.8
30.5
Dco in ml/min/mm Hg = 0.0267 H 0.148 A 10.34. R = 0.60, SEE = 3.40, 95% Confidence Interval = 5.74.
2
Definitions of abbreviations: R = coefficient of determination, SEE = standard error of estimate, H = height in cm, and A = age in
years. STPD = temperature 0C, pressure 760 mm Hg and dry (0 water vapor).
The regression analysis has been normalized to a standard hemoglobin of 14.6 g/dl using Cotes modification and the relationship
described by Roughton and Forster.
The axes of the table are age (in years) at the side, and height (in cm) at the top. The predicted normal FVC in liters for the male
patient is found at the intersection of the row for his age, and the column for his height.
Adapted from Crapo RO, Morris AH, Gardner RM: Reference spirometric values using techniques and equipment that meets ATS
recommendations. Am Rev Respir Dis 1981; 123:659-664.
72
Comment
Asthma
Hypersensitivity pneumonitis
A person with this condition may need to be removed from exposure to the
causative agent or other agents with similar sensitizing properties in order to
avoid future attacks and chronic sequelae.
Pneumoconiosis
Sleep Disorders
Lung Cancers
All persons with lung cancers are to be considered severely impaired at the
time of diagnosis. At a re-evaluation at one year after the diagnosis is
established, if the person is found to be free of all evidence of tumor
recurrence, then he or she should be rated according to the physiologic
parameters in Table 8. If there is evidence of tumor, the person remains
severely impaired. If the tumor recurs at a later date, the person immediately
is considered to be severely impaired.
73
The patient has cardiac disease, but no resulting limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
Class 2:
The patient has cardiac disease resulting in slight limitation of physical activity. The patient is
comfortable at rest and in the performance of ordinary, light, daily activities. Greater-than-ordinary
physical activity, such as heavy physical exertion, results in fatigue, palpitation, dyspnea, or anginal
pain.
Class 3:
The patient has cardiac disease resulting in marked limitation of physical activity. The patient is
comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
Class 4:
The patient has cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of inadequate cardiac output, pulmonary congestion, systemic congestion, or the anginal
syndrome, may be present, even at rest. If any physical activity is undertaken, discomfort is increased.
EXERCISE TESTING
In most circumstances the physician should attempt to quantitate limitations due to symptoms by
observing the patient during exercise. The most widely used and standardized exercise protocols involve
the use of a motor-driven treadmill with varying grades and speeds. The protocols vary slightly, but they
all attempt to relate the exercise to excess energy expended and to functional class. The excess energy
expended usually is expressed with the MET, a term that represents the multiples of resting metabolic
energy utilized for any given activity. One MET is considered to be 3.5 ml(kg.min). The 70kg person who
burns 1.2 kilocalories per minute sitting at rest uses approximately 3 METs when walking 4 kilometers
per hour.
Table 2 displays the relationship of excess energy expenditures in METs to functional class according
to the protocols of several investigators. With all the protocols, the exercise periods last for three minutes;
the periods are represented in the table by boxes with numbers giving the estimated METs involved.
If a treadmill is not available, steps may be used to attempt to quantitate the exercise capacity of a
patient. Table 3 shows the relationships of exercise with steps of various heights, excess energy
expenditure, and functional class. Estimations of excess energy expenditure also can be made with a
bicycle ergometer (Table 4).
Some laboratories are equipped to measure oxygen consumption and carbon dioxide production
during exercise. Data on a patient acquired by these techniques may become the most accurate method of
estimating a patients exercise capacity.
A major problem with using any exercise-testing technique to attempt to quantitate an individuals
functional capacity is the marked variability in the patients abilities and willingness to cooperate.
Therefore, the physician also must estimate the individuals cooperation and effort during the test; some
patients will continue far beyond where they should, while others will stop after minimal effort because
they feel fatigued.
TABLE 2
RELATIONSHIP OF METS AND FUNCTIOPNAL CLASS
ACCORDING TO FIVE TREADMILL PROTOCOLS
METS
Treadmill Tests
Ellestad
1.6
1.7
3.0
10
11
12
13
14
15
4.0
16
5.0
10 percent grade
Bruce
1.7
2.5
3.4
4.2
10
12
14
16
Balke
2.5
7.5
Balke
METS
Clinical Status
Functional
Class
10
12
14
16
18
Naughton
10
1.0
20
22
24
26
13
14
15
16
12.5
15
17.5
20
22.5
10
11
12
3.5
10.5
14
17.5
1.6
Symptomatic Patients
Diseased, Recovered
Sedentary Healthy
Physically Active Subjects
IV
III
II
I and Normal
In the Ellestad protocol, the numbers in the boxes are miles per hour (mph); in the Bruce protocol the top numbers are mph and the bottom
numbers are the percent grade. In the Balke and Naughton protocols the numbers are the percent grade.
Adapted from Fox SM III, Naughton JP, Haskell WL: Physical activity and the prevention of coronary heart disease. Annals of Clinical
Research 1971; 3:404-432 Copyright 1971 The Finnish Medical Society Duodecim.
TABLE 3
RELATIONSHIP OF METS AND FUNCTIONAL CLASS
ACCORDING TO TWO-STEP PROTOCOL
Height of Step
(cm)
.
4
12
16
20
24
12
18
25
32
35
METS
Clinical Status
Functional
Class
1.6
.
28
32
36
40
10
11
12
13
14
15
16
Symptomatic Patients
Diseased, Recovered
Sedentary Healthy
Physically Active Subjects
IV
III
II
I and Normal
Source: Fox SM III, Naughton JP, Haskell WL: Physical activity and the prevention of coronary heart disease. Annals of Clinical Research
1971; 3:404-432 Copyright 1971 The Finnish Medical Society Duodecim.
74
75
TABLE 4
ENERGY EXPENDITURE IN METS DURING BICYCLE ERGOMETRY
Body Weight
(kg)
(lb)
150
25
300
50
450
75
600
100
750
125
900
150
1050
175
1200
200
17.9
20.7
23.3
1350
225
1500
250
1650
275
1800
300
20
44
4.0
6.0
10.0
14.0
18.0
22.0
30
66
3.4
4.7
7.3
10.0
12.7
15.3
40
88
3.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
22.0
50
110
2.8
3.6
5.2
6.8
8.4
10.0
11.5
13.2
14.8
16.3
18.0
19.6
21.1
60
132
2.7
3.3
4.7
6.0
7.3
8.7
10.0
11.3
12.7
14.0
15.3
16.7
18.0
70
154
2.6
3.1
4.3
5.4
6.6
7.7
8.8
10.0
11.1
12.2
13.4
14.0
15.7
80
176
2.5
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
90
198
2.4
2.9
3.8
4.7
5.6
6.4
7.3
8.2
9.1
10.0
10.9
11.8
12.6
100
220
2.4
2.8
3.6
4.4
5.2
6.0
6.8
7.6
8.4
9.2
10.0
10.8
11.6
110
242
2.4
2.7
3.4
4.2
4.9
5.6
6.3
7.1
7.8
8.5
9.3
10.0
10.7
120
264
2.3
2.7
33
4.0
4.7
5.3
6.0
6.7
7.3
8.0
8.7
9.3
10.0
Source: American College of Sports medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. Philadelphia, Lea
and Febiger, 1975, p.17. Copyright 1975, American College of Sports Medicine.
TABLE 5
MAXIMAL AND 90% OF MAXIMAL
ACHIEVABLE HEART RATE, BY AGE AND SEX
Heart Rate
Age
Men
Maximal
90% Maximal
30
193
173
35
191
172
40
189
170
45
187
168
50
184
166
55
182
164
60
180
162
65
178
160
Women
Maximal
90% Maximal
190
171
185
167
181
163
177
159
172
155
168
151
163
147
159
143
76
77
or
The patient has recovered from valvular heart surgery but continues to have symptoms or signs of congestive
heart failure.
78
The patient has either fixed or dynamic focal obstruction of at least 50% of one or more coronary arteries,
demonstrated by angiography;
and
Moderate dietary adjustments or drugs are required to prevent angina or to remain free of symptoms and signs
of congestive heart failure, but the patient continues to develop symptoms of angina pectoris or congestive heart
failure during ordinary daily activities (functional class 3 or 4), or there are signs or laboratory evidence of cardiac
enlargement and abnormal ventricular function;
or
The patient has recovered from coronary artery bypass surgery or angioplasty and continues to require treatment
and have symptoms as described above.
79
The patient has recovered from surgery for the treatment of congenital heart disease but continues to have
functional class 3 symptoms, or continues to have signs of congestive failure or cyanosis, and there is evidence
of cardiomegaly and significant residual valvular stenosis or regurgitation, left-to-right shunt, right-to-left shunt, or
elevated pulmonary vascular resistance.
Class 4Impairment of the Whole Person, 5595%
The patient has signs of congenital heart disease and experiences symptoms of congestive heart failure at less
than ordinary daily activities (functional class 4);
and
Dietary therapy and drugs do not prevent symptoms or signs of congestive heart failure;
and
There is evidence from physical examination or laboratory studies of cardiac chamber hypertrophy or dilation, or
the pulmonary vascular resistance remains elevated at greater than one-half of the systemic vascular resistance;
or the severity of the valvular stenosis or regurgitation is estimated to be moderate to severe; or there is a left-toright shunt with the pulmonary flow being greater than two times the systemic flow; or there is a left-to-right shunt
with the pulmonary vascular resistance being elevated to greater than one-half the systemic vascular resistance;
or there is a right-to-left shunt;
or
The patient has recovered from heart surgery for the treatment of congenital heart disease and continues to have
symptoms or signs of congestive heart failure causing impairment as outlined above.
80
CARDIOMYOPATHIES
Cardiomyopathies result in impairment of the whole person by causing abnormal ventricular function.
Abnormal ventricular function may not result in abnormal hemodynamics, or it may result in pulmonary
and/or systemic organ congestion and decreased cardiac output. Abnormal ventricular functions related to
coronary heart disease, valvular heart disease, and hypertensive heart disease are covered in their
respective sections. Cardiomyopathies may also cause arrhythmias; these are considered in a different
section of this chapter. Some cardiomyopathies are reversible. Every effort should be made to identify the
reversible forms and to treat them appropriately over an adequate period of time before estimating any
suspected permanent impairment.
Impairment Classification for Cardiomyopathies
Class 1Impairment of the Whole Person, 014%
The patient is asymptomatic and there is evidence of impaired left ventricular function from clinical examination
or laboratory studies;
and
There is no evidence of congestive heart failure or cardiomegaly from physical examination or laboratory studies.
Class 2Impairment of the Whole Person, 1529%
The patient is asymptomatic and there is evidence of impaired left ventricular function from physical examination
or laboratory studies;
and
Moderate dietary adjustment or drug therapy is necessary for the patient to be free of symptoms and signs of
congestive heart failure;
or
The patient has recovered from surgery for the treatment of hypertrophic cardiomyopathy and meets the criteria
above.
81
82
or
The patient has recovered from surgery to remove the pericardium but continues to have the symptoms, signs,
and laboratory evidence described above.
Class 4Impairment of the Whole Person, 5595%
The patient has symptoms on performance of ordinary daily activities (functional class 3 or 4) in spite of using
appropriate dietary restrictions or drugs, and evidence from physical examination or laboratory studies of
pericardial heart disease;
and
The patient has signs or laboratory evidence of congestion of the lungs or other organs;
or
The patient has recovered from surgery to remove the pericardium and continues to have symptoms, signs, and
laboratory evidence described above.
ARRHYTHMIAS
Arrhythmias tend to fluctuate remarkably in the frequency with which they occur. Thus, adequate
documentation of the arrhythmia and estimation of the frequency with which it occurs must be made. The
associated symptoms may be considerably different from the symptoms of other forms of heart disease.
Arrhythmias may cause syncope, palpitation, dizziness, light headedness, chest heaviness, or shortness of
breath or combinations of these symptoms.
The degree of impairment from cardiac arrhythmias often will have to be combined with the degree
of impairment due to an underlying heart disease; this combining should be done according to the
Combined Values Chart. After instituting therapy for the arrhythmias, one should allow an appropriate
amount of time to pass before estimating the extent of the permanent impairment.
Impairment Classification for Cardiac Arrhythmias
Class 1Impairment of the Whole Person, 014%
The patient is asymptomatic during ordinary activities and a cardiac arrhythmia is documented by ECG;
and
There is no documentation of three or more consecutive ectopic beats or periods of asystole greater than 1.5
seconds, and both the atrial and ventricular rates are maintained between 50 and 100 beats per minute;
and
There is no evidence of organic heart disease.
Class 2Impairment of the Whole Person, 1529%
The patient is asymptomatic during ordinary daily activities and a cardiac arrhythmia is documented by ECG;
and
Moderate dietary adjustment, or the use of drugs, or an artificial pacemaker, is required to prevent symptoms
related to the cardiac arrhythmia;
or
The arrhythmia persists and there is organic heart disease.
Class 3Impairment of the Whole Person, 3054%
The patient has symptoms despite the use of dietary therapy or drugs or of an artificial pacemaker and a cardiac
arrhythmia is documented with ECG;
but
The patient is able to lead an active life and the symptoms due to the arrhythmia are limited to infrequent
palpitations and episodes of lightheadedness or other symptoms of temporarily inadequate cardiac output.
Class 4Impairment, 5595%
The patient has symptoms due to documented cardiac arrhythmia that are constant and interfere with ordinary
daily activities (functional class 3 or 4);
or
83
The patient has frequent symptoms of inadequate cardiac output documented by ECG due to frequent episodes
of cardiac arrhythmia;
or
The patient continues to have episodes of syncope that are either due to or have a high probability of being
related to the arrhythmia. To fit into this category of impairment, the symptoms must be present despite the use
of dietary therapy, drugs, or artificial pacemakers.
If an arrhythmia is a result of organic heart disease, the arrhythmia should be evaluated separately and
its impairment rating should be combined with the impairment rating for the organic heart disease using
the Combined Values Chart.
84
or
There is vascular damage evidenced by signs such as an amputation at or above a wrist; or amputation of two or
more digits of both extremities with evidence of persistent vascular disease; or persistent widespread or deep
ulceration involving one extremity;
or
Raynauds phenomenon occurs on exposure to temperatures lower than 15C (59F), and it is only partially
controlled by medication.
Class 5Impairment of Upper Extremity, 8095%
The patient experiences severe and constant pain at rest;
or
There is vascular damage evidenced by signs such as amputation at or above the wrists of both extremities; or
amputation of all digits of both extremities with evidence of persistent vascular disease; or persistent,
widespread, or deep ulceration involving both extremities;
or
Raynauds phenomenon occurs on exposure to temperatures lower than 20C (68F) and is poorly controlled by
medication.
85
or
There is vascular damage as evidenced by signs such as an amputation at or above an ankle, or amputation of
two or more digits of two extremities with evidence of persistent vascular disease, or persistent widespread or
deep ulceration involving one extremity.
Class 5Impairment of Lower Extremity, 8095
The patient experiences severe and constant pain at rest;
or
There is vascular damage as evidenced by signs such as amputations at or above the ankles of two extremities,
or amputation of all digits of two or more extremities, with evidence of persistent vascular disease or of
persistent, widespread, or deep ulceration involving two or more extremities.
86
ANEMIA
Persistent refractory anemia may cause impairment, regardless of etiology; the degree of impairment
is related to the severity of the anemia and the need for transfusions.
Under the best of circumstances, with normal survival of the transfused red cells, the beneficial
effects of transfusions last 68 weeks. In patients with hemolytic anemias due to serum factors, and in
some patients who have been transfused many times, the survival of transfused cells becomes shortened
and transfusions must be repeated at shorter intervals of 15 weeks. As hemolysis becomes more severe,
impairment increases.
(Mild anemia with a hemoglobin level of about l0gm/100ml is associated with little impairment in a
patient who has a normal cardiovascular system)
TABLE 1
CRITERIA FOR EVALUATING PERMANENT IMPAIRMENT
RELATED TO ANEMIA
Symptoms
Hemoglobin Level
(gm/100m)
Transfusion
Requirement
Impairment
(%)
87
TABLE 2
CRITERIA FOR EVALUATING PERMANENT IMPAIRMENT
RELATED TO POLYCYTHEMIA
ERYTHROCYTOSIS:
Symptoms
% Impairment
88
LOSS OF VISION
Clearly distinguish between complete and partial loss of vision and rate complete loss of vision in
both eyes as 85%, while complete loss of vision in one eye when the vision in the opposite eye is normal
is rated at 24%.
For partial loss of vision, rules to be followed in determining impairment include:
1. All medically acceptable attempts to correct must have been exhausted.
2. Determination must await 6 months freedom from all external signs of inflammation.
3. Determination to be deferred 12 months in case of
a. Extrinsic muscle disturbance
b. Retinal injury
c. Sympathetic ophthalmia
d. Traumatic cataract
4. Testing is to be performed with corrective lenses unless otherwise stipulated.
89
Maximum Limits for each Coordinate FactorMPPI states the standards for testing and the
normal limits for each factor. The standards prescribed are identical to those established in the AMA
document.
Central visual acuity refers to the ability to recognize letters that subtend an angle of five minutes,
each part of which subtends an angle of one minute at the distance viewed. The normal, or 100%, VA is
considered to be 20/20 Snellen or AMA chart or 14/14/AMA card for near vision. These standards refer
to a chart imprinted with block letters or numbers in gradually decreasing sites, identified by distances at
which they are normally visible. It is used in testing visual acuity. The numerator is the test distance in
feet. The denominator is the distance at which the smallest letter discriminated by the patient would
subtend five minutes of arc.
Visual Field EfficiencyThe maximum, or normal, visual field is defined as 500 degrees, which is
the sum of degrees in the eight principal meridians from the central point of fixation to the outermost
limits of visual perception, using a 3 mm white target at 33 centimeters. 100%, or normal, VFE is visual
extension from central point of fixation in the following eight principal meridians.
1.
2.
3.
4.
5.
6.
7.
8.
Outward................................................... 85
Down and outward .................................. 85
Down ....................................................... 65
Down and in ............................................ 50
Inward...................................................... 60
In and up.................................................. 55
Upward .................................................... 60
Up and out ............................................... 55
Total...................... 500
The minimum of the visual field is defined as 5% concentric central contraction.
Ocular MotilityMaximum ocular motility is present if there is normal ocular motor coordination
with no diplopia in all parts of the field of binocular fixation. The minimum limit of ocular motility is
defined as diplopia in all parts of the field of binocular fixation, or absence of binocular motor
coordination.
Visual Field
a. Perimetric standards for determination are as previously described, except that in cases of aphakia
the white disc shall be 6mm rather than 3mm.
b. The amount of radial contraction shall be determined in the eight principal meridians, as defined.
The visual field loss of each eye, expressed as a percentage, is the sum of the degrees of field
vision loss in the principal meridians divided by 500.
c. If the central contraction is 5 degrees, the loss is 100%
d. If the field impairment is irregular and not fairly disclosed by the principal meridians, the loss in a
number of additional radii shall be used and the divisor in the equation shall be adjusted
accordingly.
90
e. When the loss is limited to less than the full visual field, the degrees of loss in each included
meridian shall be added to one-half of the sum of the two boundary meridians, boundary
perimeters being the principal meridians on either side of the impaired field.
Ocular motility will be measured in all parts of the motor field either with or without correction as
determined by the examiner to provide the most accurate determination.
a. All directions of gaze shall be tested from the extent of diplopia, with a test light on the perimeter
at 300mm or on a tangent screen at a distance of one meter from the eye.
b. Reference is made to the AMA Guides for description of plotting requirements for the test results;
(see Figure 1)
c. The percentage loss of ocular motility is the sum of the percentages of loss on motility due to
diplopia in the meridian of maximum impairment. This percentage is assigned to the injured eye,
or in the case of bilateral injury to the eye with the greatest impairment of CVA and VF. This is
considered to be the eye with the greatest loss of CVA and the greatest loss of visual field and the
percentage loss of ocular motility in the contralateral eye is considered to be 0, and for purposes
of calculation, a value of 0 is deemed to be 1%.
TABLE 1
IMPAIRMENT OF THE VISUAL SYSTEM AS IT RELATES
TO IMPAIRMENT OF THE WHOLE PERSON
% Impairment of
Visual System
% Impairment of
Whole Person
0 .................................0
1 .................................1
2 .................................2
3 .................................3
4 .................................4
5 .................................5
6 .................................6
7 .................................7
8 .................................8
9 .................................8
10 .................................9
11 ...............................10
12 ...............................11
13 ...............................12
14 ...............................13
15 ...............................14
16 ...............................15
17 ...............................16
18 ...............................17
19 ...............................18
20 ...............................19
21 ...............................20
22 ...............................21
23 ...............................22
24 ...............................23
25 ...............................24
26 ...............................25
27 ...............................25
28 ...............................26
29 ...............................27
30 ...............................28
31 ...............................29
32 ...............................30
33 ...............................31
34 ...............................32
35 ...............................33
36 ...............................34
37 ...............................35
38 ...............................36
39 ...............................37
40 ...............................38
41 ...............................39
42 ...............................40
43 ...............................41
44 ...............................42
% Impairment of
Visual System
% Impairment of
Whole Person
45..................................42
46..................................43
47..................................44
48..................................45
49..................................46
50..................................47
51..................................48
52..................................49
53..................................50
54..................................51
55..................................52
56..................................53
57..................................54
58..................................55
59..................................56
60..................................57
61..................................58
62..................................59
63..................................59
64..................................60
65..................................61
66..................................62
67..................................63
68..................................64
69..................................65
70..................................66
71..................................67
72..................................68
73..................................69
74..................................70
75..................................71
76..................................72
77..................................73
78..................................74
79..................................75
80..................................76
81..................................76
82..................................77
83..................................78
84..................................79
85..................................80
86..................................81
87..................................82
88..................................83
89..................................84
90 100.........................85
91
FIGURE 1
PERCENT/LOSS OF OCULAR MOTILITY
OF ONE EYE IN DIPLOPIA FIELDS
30
10
20
10
10
10
Left 10
20
20
10
20
20
10
20
50
30
30
40
10
10 Right
92
93
HEARING LOSS
For objective techniques to determine hearing impairment, take the following steps.
a. Test each ear separately with a pure-tone audiometer and record the hearing levels at 500Hz,
1,000 Hz, 2,000 Hz, and 3,000 Hz. It is necessary that the hearing level for each frequency be
determined in every patient.
The following rules apply for extreme values.
1. If the hearing level at a given frequency is greater than 100dB or is beyond the range of the
audiometer, the level shall be taken as 100dB.
2. If the hearing level for a given frequency is better than normal, the level shall be taken as 0
dB.
b. Total these four decibel values for each ear separately. Hearing levels are determined in dB
according to ANSI-1969 standards.
c. Consult Table 1 for percentage of monaural hearing impairments(s). "DSHL" is the decibel sum
of the hearing threshold levels at 500, 1,000, 2,000 and 3,000 Hz, and is equated to percent of
monaural hearing impairment.
d. Consult Table 3 to determine percent of binaural hearing impairment.
e. Consult Table 2 to determine impairment of the whole person.
TABLE 1
MONAURAL HEARING IMPAIRMENT
DSHL
100
0.0
105
110
115
120
1.9
3.8
5.6
7.5
125
130
135
140
9.4
11.2
13.1
15.0
145
150
155
160
16.9
18.8
20.6
22.5
165
170
175
180
24.4
26.2
28.1
30.0
185
31.9
DSHL
190
195
200
33.8
35.6
37.5
205
210
215
220
39.4
41.2
43.1
45.0
225
230
235
240
46.9
48.9
50.6
52.5
245
250
255
260
54.4
56.2
58.1
60.0
265
270
275
280
61.9
63.8
65.6
67.5
DSHL
285
290
295
300
69.3
71.2
73.1
75.0
305
310
315
320
76.9
78.8
80.6
82.5
325
330
335
340
84.4
86.2
88.1
90.0
345
350
355
360
90.9
93.8
95.6
97.5
365
99.4
368
100.0
or greater
TABLE 2
THE RELATIONSHIP OF BINAURAL
HEARING IMPAIRMENT TO
IMPAIRMENT OF THE WHOLE PERSON
% Binaural
Hearing
Impairment
0 1.7
1.8 4.2
4.3 7.4
7.5 9.9
10.0 13.1
13.2 15.9
16.0 18.8
18.9 21.4
21.5 24.5
24.6 27.1
27.2 30.0
30.1 32.8
32.9 35.9
36.0 38.5
38.6 41.7
41.8 44.2
44.3 47.4
47.5 49.9
% Impairment
of the Whole
Person
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
% Binaural
Hearing
Impairment
50.0 53.1
54.2 55.7
55.8 58.8
58.9 61.4
61.5 64.5
64.6 67.1
67.2 70.0
70.1 72.8
72.9 75.9
76.0 78.5
78.6 81.7
81.8 84.2
84.3 87.4
87.5 89.9
90.0 93.1
93.2 95.7
95.8 98.8
98.9 100.0
% Impairment
of the Whole
Person
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
The axes are the sum of hearing levels at 500, 1,000, 2,000 and 3,000 Hz. The sum for the worse ear is
read at the side; the sum for the better ear is read at the bottom. At the intersection of the row for the worse
ear and the column for the better ear is the hearing handicap.
.6
TABLE 3
COMPUTATION OF BINAURAL HEARING IMPAIRMENT
94
95
EQUILIBRIUM
Equilibrium or orientation in space is maintained by the visual, kinesthetic, and vestibular
mechanisms.
Vertigo, or vestibular dysequilibrium, is a sense movement that is perceived by the patient as
subjective, in the case of movement of self, or as objective, in the case of movement of the
environment.
The movements may be described as a sense of spinning, pulsion, or tilting of the visual environment
with change of head position.
This section is primarily concerned with permanent impairment resulting from defects of the
vestibular (labyrinthine) mechanisms and its central connections. The defects are evidenced by loss of
equilibrium produced by: (1) loss of vestibular function; or (2) disturbances of vestibular function. (Lightheadedness and abnormalities of gait not associated with vertigo are not considered.)
Class 1Impairment of the Whole Person, 0%
A patient belongs in Class 1 when (a) signs of vestibular dysequilibrium are present without supporting objective
findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living can be performed without assistance.
Class 2Impairment of the Whole Person, 5 - 10%
A patient belongs in Class 2 when (a) signs of vestibular dysequilibrium are present with supporting objective
findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living are performed without assistance,
except for complex activities such as bike riding, or certain activities related to the patients work, such as
walking on girders or scaffolds.
Class 3Impairment of the Whole Person, 11 - 30%
A patient belongs in Class 3 when (a) signs of vestibular dysequilibrium are present with supportive objective
findings (e.g., nystagmus, ataxia); and (b) the patients usual activities of daily living cannot be performed without
assistance, except such simple activities as self care, some household duties, walking on the street, and riding in
a motor vehicle operated by another person.
Class 4Impairment of the Whole Person, 31 - 60%
A patient belongs in Class 4 when (a) signs of vestibular dysequilibrium are present with supportive objective
findings (e.g., nystagmus, ataxia); and (b) usual activities of daily living cannot be performed without assistance,
except for self care.
Class 5Impairment of the Whole person, 61 - 95%
A patient belongs in Class 5 when (a) signs of vestibular dysequilibrium are present with supportive objective
findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living cannot be performed without
assistance, except self-care not requiring ambulation; and (c) confinement to the home or premises is necessary.
96
RESPIRATION
Air passage defects may result in permanent impairment. The following provides a rating
classification system for air passage defects (excluding larynx air ways and lung parenchyma). Permanent
impairment from obstructive sleep apnea should be evaluated using the neurologic section.
Classes of Air Passage Defects
Class 1Impairment of the Whole Person, 0 - 10%
A recognized air passage defect exists.
Dyspnea does not occur at rest.
Dyspnea is not produced by walking or climbing stairs freely, performance of other usual activities of daily living,
stress, prolonged exertion, hurrying, hill climbing, or recreation* requiring intensive effort or similar activity.
Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx,
upper trachea (to 4th ring), lower trachea, bronchi, or complete obstruction of the nose (bilateral), or
nasopharynx.
*prophylactic restriction of activity such as strenuous competitive sports does not exclude patient from Class 1.
NOTE: Patients with successful permanent tracheostomy or stoma should be rated at 25% impairment of the
whole person.
Class 2Impairment of the Whole Person,11 - 30%
A recognized air passage defect exists.
Dyspnea does not occur at rest.
Dyspnea is not produced by walking freely on the level, climbing at least one flight of ordinary stairs, or the
performance of other usual activities of daily living.
Dyspnea is produced by stress, prolonged exertion, hurrying, hill climbing, recreation except sedentary forms, or
similar activity.
Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx,
upper trachea (to 4th ring), lower trachea, bronchi, or complete obstruction of the nose (bilateral) or
nasopharynx.
Class 3Impairment of the Whole Person, 31 - 50%
A recognized air passage defect exists.
Dyspnea does not occur at rest.
Dyspnea is produced by walking more than one or two blocks on the level, climbing one flight of ordinary stairs
even with periods of rest, performance of other usual activities of daily living, stress, hurrying, hill climbing,
recreation, or similar activity.
Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx,
upper trachea (to 4th ring), lower trachea, or bronchi.
Class 4Impairment of the Whole Person, 51 -75%
A recognized air passage defect exists.
Dyspnea occurs at rest, although patient is not necessarily bedridden.
Dyspnea is aggravated by the performance of any of the usual activities of daily living beyond personal
cleansing, dressing, grooming or its equivalent.
Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx,
upper trachea (to 4th ring), lower trachea, or bronchi.
97
DYSARTHRIA
Impairment rating in this section is concerned with voice production and articulate speech. Language
content and receptive speech disorders are considered in the section on impairment rating of neurologic
disorders.
A classification chart, oral reading paragraph, and examining procedures for use in estimating speech
impairment are described below.
Classification Chart Judgments as to the amount of impairment should be made with reference to the
classes, percentages, and examples provided in the Speech Classification Chart (on page 98-99). The
fifteen categories of the chart suggest activities or situations with different levels of impairment. Data
gathered from direct observation of the patient or from interviews should be compared with these
categories, and values should be assigned considering the specific impairments that are present.
Oral Reading Paragraph The paragraph of 100 words, entitled, The Smith House, composed of
10 sentences, provides a uniform means of comparing a speech example of the patient with the
performance of normal speakers. The phonetic elements of the paragraph are selected particularly for
their relevance to intelligibility of speech.
The Smith House
Larry and Ruth Smith have been married nearly 14 years. They have a small place near Long
Lake. Both of them think theres nothing like the country for health. Their two boys would rather live
there than any other place. Larry likes to keep some saddle horses close to the house. These make
it easy to keep his sons amused. If they wish, the boys can go fishing along the shore. When it
rains, they usually want to watch television. Ruth has a cherry tree on each side of the kitchen
door. In June they enjoy the juice and jelly.
Examining Procedures
General Orientation The examining physician should have normal hearing as defined in the earlier
section on Hearing.
The setting of the examination should be a reasonably quiet office that approximates the noise level
conditions of everyday living. The examiner should base judgments of impairment on two kinds of
evidence: (1) Direct observation of the patients speech in the office; for example, during conversation,
during the interview, and while reading and counting aloud; and (2) reports pertaining to the patients
performances in situations of everyday living. The reports or the evidence should be supplied by
observers who know the patient well.
The standard of evaluation is the concept of a normal speakers performance in average situation of
everyday living. It is assumed in this context that an average speaker usually can perform as follows: (1)
Talk in a loud voice when the occasion demands it. (2) Sustain phonation for at least 10 seconds in one
breath. (3) Complete at least a 10 word sentence in one breath. (4) Form all of the phonetic units of
American speech, and join them together intelligibly. (5) Maintain a rate of at least 75 to 100 words per
minute, and sustain a flow of speech for a reasonable length of time.
98
Specific Procedures
a. Place the patient approximately 8 feet from the examiner.
b. Interview the patient. This will permit observation of the patients speech in ordinary
conversation while obtaining information pertinent to his or her history.
c. Listen to the patients speech as the patient reads aloud the short paragraph, The Smith House.
For this exercise, seat the patient with the back towards the physician; maintaining a separation of
8 feet. Instruct the patient as follows: You are to read this passage so that I can hear you plainly.
Be sure to speak so that I can understand you.
d. If additional reading procedures are required, simple prose paragraphs from a magazine may be
used. A nonreader may be requested to give name, address, the days of the week, the months of
the year, etc. Additional evidence regarding the patients rate of speech and ability to sustain it
may be obtained by noting the time required to count to 100 by ones. Completion of the latter
task in 60 to 75 seconds is accepted as normal.
e. Record judgment of the patients speech capacity with regard to each of the three sections of the
Speech Classification Chart.
f. The degree of impairment of the speech function is equivalent to the greatest percentage of
impairment recorded in any one of the three sections of the classification chart.
Can produce speech of intensity sufficient for most of the needs of everyday speech
communication, although this sometimes may require effort and occasionally may be
beyond the patients capacity.
Class 2
1135%
Speech Impairment
Can produce speech of intensity sufficient for many of the needs of everyday speech
communication, and is usually heard under average conditions; however, may have
difficulty in automobiles, buses, trains, stations, restaurants, etc.
Class 3
3560%
Speech Impairment
Can produce speech of intensity sufficient for some of the needs of everyday speech
communication, such as close conversation; however, has considerable difficulty in
such noisy places as listed above; the voice tires rapidly and tends to become inaudible
after a few seconds.
Class 4
6185%
Speech Impairment
Can produce speech of intensity sufficient for a few of the needs of everyday speech
communication; can barely be heard by a close listener or over the telephone, perhaps
may be able to whisper; audibly, but has no voice.
Class 5
86100%
Speech Impairment
Can produce speech of intensity sufficient for none of the needs of everyday speech
communication.
99
Intelligibility
Class 1
010%
Speech Impairment
Can perform most of the articulatory acts necessary for everyday speech
communication, although listeners occasionally ask the patient to repeat and the
patient may find it difficult or even impossible to produce a few phonetic units.
Class 2
1135%
Speech Impairment
Can perform many of the necessary articulatory acts for everyday speech
communication. Can speak name, address, etc., and be understood by a stranger, but
may have numerous inaccuracies; sometimes appears to have difficulty articulating.
Class 3
3660%
Speech Impairment
Can perform some of the necessary articulatory acts for everyday speech
communication; can usually converse with family and friends, however, strangers may
find it difficult to understand the patient; may often be asked to repeat.
Class 4
6185%
Speech Impairment
Can perform a few of the necessary articulatory acts for everyday speech
communication; can produce some phonetic units; may have approximations for a few
words such as names of own family; however, unintelligible out of context.
Class 5
86100%
Speech Impairment
Can perform none of the articulatory acts necessary for everyday speech
communication.
Functional Efficiency
Class 1
010%
Speech Impairment
Can meet most of the demands of articulation and phonation for everyday speech
communication with adequate speed and ease, although occasionally the patient may
hesitate or speak slowly.
Class 2
1135%
Speech Impairment
Can meet many of the demands of articulation and phonation for everyday speech
communication with adequate speed and ease, but sometimes gives impression of
difficulty, and speech may sometimes be discontinuous, interrupted, hesitant, or slow.
Class 3
3660%
Speech Impairment
Can meet some of the demands of articulation and phonation for everyday speech
communication with adequate speed and ease, but often can only sustain consecutive
speech for brief periods, may give the impression of being rapidly fatigued.
Class 4
6185%
Speech Impairment
Can meet a few of the demands of articulation and phonation for everyday speech
communication with adequate speed and ease, such as single words or short phrases,
but cannot maintain uninterrupted speech flow; speech is labored, rate is impractically
slow.
Class 5
86100%
Speech Impairment
Can meet none of the demands of articulation and phonation for everyday speech
communication with adequate speed and ease.
% Impairment of
the Whole Person
0 .................................0
5 .................................2
10 .................................4
15 .................................5
20 .................................7
25 .................................9
30 ...............................10
35 ...............................12
40 ...............................14
45 ...............................16
%Speech
Impairment
% Impairment of
the Whole Person
50..................................18
55..................................19
60..................................21
65..................................23
70..................................24
75..................................26
80..................................28
85..................................30
90..................................32
95..................................33
100 ................................35
NOTE: Impairment of the whole person contributed by speech impairment rounded to the nearest 5% only when it is
the sole impairment involved.
TABLE 1
DESIRABLE WEIGHTS IN ENGLISH AND METRIC
BY SEX, HEIGHT AND BODY BUILD
[Indoor Clothing Weighing 5 lb (2.3 kg) for men and 3 lb. (1.4 kg) for Women; and shoes with 1 in (2.5 cm) Heels)]*
Men
Women
Height
Weight lb (kg)
Height
Weight lb (kg)
in (cm)
Small Frame
in (cm)
Small Frame
62(157)
58(147)
63(160)
59(150)
64(163)
60(152)
65(165)
61(155)
66(168)
62(157)
67(170)
63(160)
68(173)
64(163)
69(175)
65(165)
70(178)
66(168)
71(180)
67(170)
72(183)
68(173)
73(185)
69(175)
74(188)
70(178)
75(190)
71(180)
76(193)
72(183)
Medium Frame
Large Frame
Medium Frame
*Source: 1979 Body Build Study, Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980.
Copyright 1983, The Metropolitan Life Insurance Company. Courtesy Statistical Bulletin, Metropolitan Life Insurance Company.
Large Frame
ANUS
Classes of Anal Impairment
Class 1Impairment of the Whole Person, 15%
Signs of organic anal disease are present or there is anatomic loss or alteration;
or
There is mild incontinence involving gas and/or liquid stool;
or
Anal symptoms are mild, intermittent, and controlled by treatment.
Class 2Impairment of the Whole Person, 615%
Signs of organic anal disease are present or there is anatomic loss or alteration;
and
Moderate but partial fecal incontinence is present requiring continual treatment;
or
Continual anal symptoms are present and incompletely controlled by treatment.
Class 3Impairment of the Whole Person, 1625%
Signs of organic anal disease are present and there is anatomic loss or alteration;
and
Complete fecal incontinence is present;
or
Signs of organic anal disease are present and severe anal symptoms unresponsive or not amenable to therapy
are present.
HEPATOBILIARY SYSTEM
Objective procedures useful in establishing hepatobiliary impairment include, but are not limited to:
(1) radiography employing contrast materials, including percutaneous and endoscopic cholangiography,
and nuclide scintigraphy; (2) ultrasonography; (3) computerized tomography (CT scan); (4) angiography
(5) liver biopsy; and (6) selected laboratory tests to assess various functions of the liver and biliary ducts.
Classes of Liver and Biliary Impairment (Liver Impairment)
Class 1Impairment of the Whole Person, 15%
There is objective evidence of persistent liver disease even though no symptoms of liver disease are present,
and no history of ascites, jaundice, or bleeding esophageal varices within 3 years;
and
Nutrition and strength are good;
and
Biochemical studies indicate minimal disturbance in liver function;
or
Primary disorders of bilirubin metabolism are present.
Use the Combined Values Chart for determining the total whole person impairment if more than one
category of impairment is used.
URINARY DIVERSION
Permanent, surgically created forms of urinary diversion usually are provided to compensate for
anatomic loss and to allow for egress of urine. They are evaluated as a part of, and in conjunction with,
the assessment of the involved portion of the urinary tract.
Irrespective of how well these diversions function in the preservation of renal integrity and the
disposition of urine, the following values for the diversions should be combined with those determined
under the criteria previously given for the portion of the urinary tract involved.
Type of Diversion
% Impairment of the Whole Person
Uretero-intestinal............................................................................................................................................10
Cutaneous Ureterostomy ...............................................................................................................................10
Nephrostomy or Intubated Ureterostomy .......................................................................................................15
Cystectomy with Urinary Diversion.................................................................................................................24
URINARY BLADDER
When evaluating permanent impairment of the bladder, the status of the upper urinary tract must also
be considered. The appropriate impairment values for both should be combined using the Combined
Values Charts in order to determine the extent of impairment of the whole person.
Class 1Impairment of the Whole Person, 110%
A person belongs in Class 1 when the patient has symptoms and signs of bladder disorder requiring intermittent
treatment with normal function between episodes of malfunction.
Class 2Impairment of the Whole Person, 1120%
A person belongs in Class 2 when (a) there are symptoms and/or signs of bladder disorder requiring continuous
treatment, or (b) there is good bladder reflex activity, but no voluntary control.
Class 3Impairment of the Whole Person, 21 30%
A patient belongs in Class 3 when the bladder has poor reflex activity, that is, there is intermittent dribbling, and
no voluntary control.
Class 4Impairment of the Whole Person, 3140%
A patient belongs in Class 4 when there is no reflex or voluntary control of the bladder, that is, there is
continuous dribbling.
URETHRA
When evaluating permanent impairment of the urethra, one must also consider the status of the upper
urinary tract and bladder. The values for all parts of the urinary system should be combined using the
Combined Values Charts to determine the extent of impairment of the whole person.
Class 1Impairment of the Whole Person, 19%
A patient belongs in Class 1 when symptoms and signs of urethral disorder are present that require intermittent
therapy for control.
Class 2Impairment of the Whole Person, 1020%
A person belongs in Class 2 when there are symptoms and signs of a urethral disorder that cannot be effectively
controlled by treatment.
Scrotum
Class 1Impairment of the Whole Person, 19%
A patient belongs in Class 1 when there are symptoms and signs of scrotal loss or disease and there is no
evidence of testicular malfunction, although there may be testicular malposition.
Class 2Impairment of the Whole Person, 1015%
A patient belongs in Class 2 when (a) there are symptoms and signs of architectural alteration or disease such
that the testes must be implanted in other than a scrotal position to preserve testicular function, and pain or
discomfort is present with activity; OR (b) there is total loss of the scrotum.
Cervix-Uterus
Class 1Impairment of the Whole Person, 1 14%
A patient belongs in Class 1 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are
present that do not require continuous treatment; or (b) cervical stenosis, if present, requires no treatment; or (c)
there is anatomic loss of the cervix and/or uterus in the postmenopausal years.
Class 2Impairment of the Whole Person, 15 29%
A patient belongs in Class 2 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are
present that require continuous treatment; or (b) cervical stenosis, if present, requires periodic treatment.
Class 3Impairment of the Whole Person, 30 35%
A patient belongs in Class 3 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are
present that are not controlled by treatment; or (b) cervical stenosis is complete; or (c) anatomic or complete
functional loss of the cervix and/or uterus occurs in premenopausal years.
Fallopian Tubes-Ovaries
Class 1Impairment of the Whole Person, 1 14%
A patient belongs in Class 1 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or
ovaries are present that do not require continuous treatment; or (b) only one fallopian tube and/or ovary is
functioning in the premenopausal years; or (c) there is bilateral loss of function of the fallopian tubes and/or
ovaries in the postmenopausal years.
Class 2Impairment of the Whole Person, 15 29%
A patient belongs in Class 2 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or
ovaries are present that require continuous treatment, but tubal patency persists and ovulation is possible.
Class 3Impairment of the Whole Person, 30 35%
A patient belongs in Class 3 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or
ovaries are present and there is total loss of tubal patency or total failure to produce ova in the premenopausal
years; or (b) bilateral loss of the fallopian tubes and/or ovaries occurs in premenopausal years.
When appropriate, other impairments, i.e., neurologic or visual impairments, may be combined with
the above impairments.
May combine with other disorders where appropriate, i.e., cardiovascular disease.
Hypoparathyroidism is a chronic condition of variable severity that requires long term medical
therapy in most cases. The degree of severity determines the degree of permanent impairment according
to the following:
Severity of Hypoparathyroidism
% Impairment of the Whole Person
Symptoms and signs easily controlled by medical therapy ........................................................................ 15
Intermittent hypercalcemia and/or hypocalcemia and more frequent
symptoms in spite of careful medical attention......................................................................................... 620
When other disorders exist, i.e., renal calculi, renal failure, these disorders may be combined with the
above impairments.
HYPOGLYCEMIA
Class 1Impairment of the Whole Person, 0%
A patient has Class 1 impairment when surgical removal of an islet-cell adenoma results in complete remission
of the symptoms and signs of hypoglycemia, and there are no postoperative sequelae.
Class 2Impairment of the Whole Person, 150%
A patient with symptoms and signs of hypoglycemia has Class 2 impairment of the whole person ranging from
1% to 50%, depending on the degree of control obtained with diet and medications and on how the condition
affects activities of daily living.
GONADS
A patient with anatomic loss or alteration of the gonads that results in an absence or abnormally high
level of gonadal hormones would have 0% to 5% impairment of the whole person. Impairment due to
inability to reproduce and other impairments associated with gonadal dysfunction should be evaluated in
accordance with the criteria set forth in the genitourinary section.
MAMMARY GLANDS
The mammary glands make, store, and deliver milk. Absence of the mammary glands does not cause
impairment of the whole person in males, but in females it will prevent nursing. Absence of mammary
gland function in females due to an endocrine disorder can be rated 020% of the whole person.
Cosmetic deformities should be rated under the section covering skin. In some endocrine disorders there
may be galactorrhea in the female and gynecomastia in the male. Gynecomastia in the male may be
accompanied by galactorrhea.
A female patient in the childbearing age with absence of the breasts, a patient with galactorrhea
sufficient to require the use of absorbent pads, and a male patient with painful gynecomastia that
interferes in the performance of daily activities would each have 0% to 5% impairment of the whole
person.
Signs or symptoms of skin disorders classified in Classes 1 and 2 may be intermittent and may not be
present at the time of examination.
NOTE: For specific examples of patients within each class, refer to the AMA Guides to the Evaluation
of Permanent Impairment (current edition), chapter on Skin Disease. Disfigurement and behavioral
changes that may be present should be evaluated in accordance with the section on Mental and Behavioral
Disorders.
The values are derived from the formula A+B(1-A) = combined value of A and B, where A and B are the decimal
equivalents of the impairment ratings. In the chart, all values are expressed as percents. To combine any two
impairment values, locate the larger of the values on the left side of the chart and read along that row until you come
to the column indicated by the smaller value at the bottom of the chart. At the intersection of the row and the column
is the combined value.
For example, to combine 35% and 20%, read down the side of the chart until you come to 35%. Then read
across the 35% row until come to the column indicated by 20% at the bottom of the chart. The intersection of the row
and column is the number 48. Therefore, 35% combined with 20% is 48%. Due to the construction of this chart, the
larger impairment value must be identified at the left side of the chart.
If three or more impairment values are to be combined, select any two and find their combined value as above.
Then use that value and the third value to locate the combined value of all. This process can be repeated indefinitely,
the final value in each instance being the combination of all the previous values. In each step of this process, the
larger impairment value must be identified at the left side of the chart.