Guides to the Evaluation of Permanent Impairment

Corrections and Clarifications

SIXTH EDITION

Guides to the Evaluation of
Permanent Impairment

August 2008

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ii

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 1

Note: Changes to the original text are in red.

Chapter 1 Chapter 2

Page 15, Right column, Paragraph 1 Page 19, Paragraph 1
This chapter outlines the key concepts, principles,
condition. As tests are the most objective source and rationale underlying the application of the AMA
of data available, the results that would lead to Guides to impairment rating for all human organ
a patient being placed in one class, as opposed systems. Anything in subsequent chapters interpreted
to another, must be described as specifically as conflicting with or modifying the content outlined
as possible in the chapter and in the grid itself. herein is preempted by the rules contained in this
Each chapter will delineate the key factor of the chapter. By analogy, this chapter is the “constitution”
impairment class within a given grid. Tests that of the Guides.
identify organ-specific functional deficits that
are not necessarily associated with impairment in Page 19, Paragraph 2
ADLs, or are predominantly obtained to develop
treatment protocols or assess prognosis, should be The Guides is written by medical doctors for
listed in this section, as well as dynamic tests that medical doctors and others permitted to do
describe organ function. For example, for cardiac impairment evaluations. It is a tool to translate
disease, an ECG is a relatively static test, whereas human pathology resulting from a trauma or disease
an ejection fraction could be used for the functional process into a percentage of the whole person.
assessment. Likewise, for renal disease the serum
creatinine would be the objective test, whereas the Page 23, Right Column, Paragraph 3
creatinine clearance is more indicative of organ
function. Typically, a combination of the key factor It must be emphasized, however, that even though
and non-key factors will be used to determine a the Guides is mainly written by and for medical
place within a class and grade, and the key factor doctors for medical doctors and others permitted to
may vary within chapters or between chapters. do impairment evaluations, nonphysician evaluators
Although the default rating for each class is, by may analyze an impairment evaluation to determine
definition, the median grade, the examiner can if it was performed in accordance with the Guides.
adjust this if a suitable rationale is provided.

Page 17, Reference 46

46. Anagnostis C, Gatchel RJ, Mayer TG. The pain
disability questionnaire: a new psychometrically sound
measure for chronic musculoskeletal disorders. Spine.
2004;29:2290–2303; discussion 2303.

2 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 20, Table 2-1, Fundamental Principles of the Guides, Numbers 1, 6, 13, and 14

1. Concepts and philosophy in this chapter are the fundamental principles of the Guides.; they shall preempt anything in
subsequent chapters that conflicts with or compromises these principles.

6. Impairment evaluation requires medical knowledge. Physicians duly recognized by an appropriate jurisdiction should
perform such assessments within their applicable scope of practice and field of expertise.

13. Subjective complaints that are not clinically verifiable are generally not ratable under the Guides. (see chapter 3, pain
for potential exceptions)

14. Round all fractional impairment ratings, whether intermediate or final, to the nearest whole number, unless
otherwise specified.

Page 25, Left Column, Paragraph 1

2.4d Pain and Suffering
The impairment ratings in the body organ system
chapters make allowance for most of the functional
losses accompanying pain. It should be recognized
that a zero percent impairment rating in Chapters
4-17 is a numerical impairment rating. The broader
impairment rating issues associated with pain are
discussed in further detail in Chapter 3.

Page 29, Reference 6

6. Guidotti TL, Rose SG. Science on the witness stand:
evaluating scientific evidence. In: Guidotti TL, Rose
SG, eds: Law, Adjudication, and Policy. Beverly Farms,
Mass: OEM Health Information; 2001. 509 US 579, 113
SCt 2786 (1993).

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 3

Page 30, Figure 2-3: Sample Report for Permanent Medical Impairment

Patient Name:______________________________ Birthdate:__________________Sex: M___ F___
Address: ______________________________________________________ Phone: ______________
ID Number: _________________Exam Date: ______________Injury Date:_____________________
Diagnosis:_________________________________________________________________________
__________________________________________________________________________________

Introduction: Purpose (impairment or IME evaluation, personal injury, workers compensation) and proce-
dures (who performed the exam, patient consent, location of examination) _________________________
__________________________________________________________________________________
__________________________________________________________________________________

History of Clinical Presentation:________________________________________________________
__________________________________________________________________________________

Functional History:___________________________________________________________________
__________________________________________________________________________________

Physical Examination or Physical Findings: ______________________________________________
__________________________________________________________________________________

Clinical Studies or Objective Test Results:________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________

Burden of Treatment Compliance: (when applicable) ________________________________________
__________________________________________________________________________________

Impairment Rating and Rationale: Organ System and Whole Person Impairment (WPI)

Body Part or System Chapter Number, Key Factor Grade Modifiers for: Final Class Whole
Page Number, and Functional History, and Grade Person
Table Number Class Physical Exam, Used in Impairment (%)
Clinical Studies & Rating
BOTC (if applicable)

1.
2.
3.

Calculated Total Whole Person Impairment: _____________ %

Discussion of Rationale of Impairment and any Possible Inconsistencies in the Examination: _____
__________________________________________________________________________________
__________________________________________________________________________________

Recommendation: (Further diagnostic or therapeutic follow-up care) ____________________________
__________________________________________________________________________________
__________________________________________________________________________________

Work Ability, Work Restrictions: (if requested, review abilities and limitations in reference to essential
job activities) ________________________________________________________________________
__________________________________________________________________________________

Examining Physician: Printed Name: _______________________ Signature: ___________________
Date:____________ Examination Location: ______________________________________________

4 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 43, Appendix 3-1 Pain Disability Questionnaire
Page 600, Figure 17-A Pain Disability Questionnaire (PDQ)

Patient Name: ________________________________________________ Date: ___________________________

Instructions: These questions ask for your views about how your pain now affects how you function in everyday activities.
Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?

Work normally Unable to work at all

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

2. Does your pain interfere with personal care (such as washing, dressing, etc.)?

Take care of myself completely Need help with all my personal care

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

3. Does your pain interfere with your traveling?

Travel anywhere I like Only travel to see doctors

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

4. Does your pain affect your ability to sit or stand?

No problems Cannot sit / stand at all

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?

No problems Cannot do at all

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?

No problems Cannot do at all

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

7. Does your pain affect your ability to walk or run?

No problems Cannot walk / run at all

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

8. Has your income declined since your pain began?

No decline Lost all income

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

9. Do you have to take pain medication every day to control your pain?

No medication needed On pain medication throughout the day

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

10. Does your pain force you to see doctors much more often than before your pain began?

Never see doctors See doctors weekly

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?

No problem Never see them

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

12. Does your pain interfere with recreational activities and hobbies that are important to you?

No interference Total interference

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home

and housework) because of your pain?

Never need help Need help all the time

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

14. Do you now feel more depressed, tense, or anxious than before your pain began?

No depression / tension Severe depression / tension

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

15. Are there emotional problems caused by your pain that interfere with your family, social, and / or work activities?

No problems Severe problems

0 -------- 1 -------- 2 -------- 3 -------- 4 -------- 5 -------- 6 -------- 7 -------- 8 -------- 9 -------- 10

___________________________________________________
Examiner

Anagnostis C, Gatchel RJ, Mayer TG. The Pain Disability Questionnaire: A New Psychometrically Sound Measure for Chronic Musculoskeletal Disorders.
Spine 2004; 29 (20): 2290-2302.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 5

Chapter 3 and Chapter 17

Pages 43-44 and Pages 599-600
Note: The Pain Disability Questionnaire is used in Chapter 3, Pain-Related Impairment, on pages 43-44, and in
Chapter 17, The Spine and Pelvis, on pages 599-600. The format in the Guides, 6e utilizes a centimeter scale to
score; however, the format is not to scale. An alternative approach provides numerical scales.

Page 44, Appendix 3-2, Pain Disability Questionnaire (PDQ)

Administering the Pain Disability Questionnaire

Follow these instructions for administering and scoring the PDQ:

1. Reproduce the PDQ (Appendix 3-1) and ask the patient to complete all items on the questionnaire.
2. If necessary, the patient may complete the form with the assistance of a translator or reader. Be certain all 15

questions are answered. If the patient is unable to complete the PDQ, no functional assessment score will be given.
3. The evaluating doctor will score the PDQ by adding together the marked integer in each question.
4. If the patient fails to mark a question, the default score for that question is 0.
5. Apply the final score to Table 3-1 and consider this in the Steps of Assessment as described in Section 3.3d.
The PDQ scores can be divided into 5 distinct categories: no disability (score of 0); mild (scores of 1 to 70); moderate (scores
of 71 to 100); severe (scores of 101 to 130); and extreme (scores of 131 to 150).

6 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Chapter 4

Page 49, Table 4-2

Relationship of METs and Functional Class According to 5 Treadmill Protocolsa

METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

TREADMILL TESTS 5.0
10
Ellestad 1.7 3.0 4.0
Miles per hour 10 10 10 3.4 3.4
% grade 24 26

Bruce 1.7 2.5 3.4 4.2
Miles per hour 10 12 14 16
% grade

Balke 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4
Miles per hour 2 4 6 8 10 12 14 16 18 20 22
% grade

Balke 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0
Miles per hour 0 2.5 5 7.5 10 12.5 15 17.5 20 22.5
% grade

Naughton 1.0 2.0 2.0 2.0 2.0 2.0 2.0
Miles per hour 0 0 3.5 7 10.5 14 17.5
% grade

METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

CLINICAL STATUS

Symptomatic
patients

Diseased,
recovered

Sedentary healthy

Physically active

Functional class IV III II I and Normal

a Adapted from: Fox SM III, Naughton JP, Haskell WL. Physical activity and the prevention of coronary heart disease. Ann Clin Res.
1971;3:40 4 – 432.

Page 53, Table 4-5 Criteria for Rating Permanent Impairment due to Valvular Heart Diseasea:
Row 6, Columns 4 and 5

OBJECTIVE TEST No ventricular No ventricular Mild ventricular Moderate ven- Severe ventricular
RESULTSd dysfunction or dysfunction or dysfunction or tricular dysfunc- dysfunction or
dilation dilation chamber dilation tion or chamber chamber dilation
dilation
Trace regurgi- Mild stenosis or Moderate steno- Moderate or
tation or mild regurgitation on sis or regurgita- Moderate or severe stenosis or
mitral valve pro- echo tion on echo severe stenosis or regurgitation
lapse with trace regurgitation on
regurgitation on METs ≥7; Bruce METs <7 but ≥5; echo Surgical correc-
echocardiogram protocol ≥6 min; Bruce protocol tion not feasible
(echo) VO2max >20 >3 min; VO2max Surgical correc-
16-20 post- tion not feasible METs <2; Bruce
Normal function- valvular surgery protocol <1 min;
ing prosthetic and meets above METs <5 but ≥2; VO2max <10
valve criteria Bruce protocol ≥1 BNP >500e; AVA
min but <3 min <1.0; AVG >50;
BNP <100e; AVA post-valvular sur- MVA <1.0;
>1.5; AVG <25; gery and meets MVG >10
MVA >1.5; above criteria;
MVG <5 VO2max 10-15

BNP >100 but
<500e; AVA 1.0-
1.5; AVG 25-50;
MVA 1.0-1.5;
MVG 5-10

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 7

Page 55, Table 4-6 Criteria for Rating Impairment due to Coronary Artery Diseasea:
Row 6, Columns 4 and 5

OBJECTIVE TEST Normal coronary Luminal irregu- Obtained HR Stress testing Stress testing
RESULTSd angiography larities on coro- >90% maximum shows 1-2mm shows >2 mm
nary angiogram predicted with ST-segment ST-segment
Normal (<50% stenosis) no ST-segment changes changes
echocardiography changes, VT, or
Normal hypotension Coronary angio- Coronary angio-
Equivocal or low- echocardiography grams show grams show
riske myocardial METs ≥7 (may be ≥70% fixed ≥70% fixed
perfusion scan or Normal or low- omitted if unable obstruction obstruction
stress echo risk myocardial to walk)
perfusion scan or and and
EBCT 0-100 stress echo Coronary angio-
grams shows METs <7 but ≥5; METs <5;
EBCT >100 ≥50%-70% fixed
obstruction VO2max 10-15 VO2max <10
VO2max>20 or or
VO2max 16-20
moderate severe (>50%)
No or mildly (25%-50%) reversible defect
reversible defect reversible defect on myocardial
(<25%) on myo- on myocardial perfusion scan or
cardial perfusion perfusion scan or stress echo
scan or stress stress echo
echo Recovered from
Recovered from CABG or PCI,
Recovered from CABG or PCI, continues
CABG or PCI; con- continues treatment
tinues treatment treatment

Page 59, Table 4-7 Criteria for Rating Impairment due to Cardiomyopathiesa:
Row 6, Columns 3, 4, and 5

OBJECTIVE TEST Normal Minimally Mildly impaired Moderately Severely impaired
RESULTSd echocardiography impaired LV func- LV function (EF impaired LV func- LV function (EF
tion, minimal 41-50%), or slight tion (EF 30-40%), < 30%), or severe
BNP level normal septal (< 1.1 cm) septal hyper- or moderate sep- gradient across
hypertrophy trophy (1.1-1.2 tal hypertrophy septal hyper-
or evidence of cm), evidence of (1.3-1.4 cm) with trophy (> 1.4
minimal restric- restriction, or moderate gradi- cm), evidence
tive disease on mild diastolic dys- ent, or evidence of restriction or
echocardiogra- function (E > A)e of restriction or severe diastolic
phy (echo) on echo moderate dia- dysfunction
stolic dysfunction (E < A) on echo
Present on Present on (E=A) on echo
therapy therapy Present on
Present on therapy
and and therapy
and
at least 1 of: at least 1 of: and
at least 1 of:
BNP level normal VO2max 16-20 at least 1 of:
VO2max > 20 METs ≥7 VO2max < 10
METs ≥7 BNP < 100 VO2max 10-15 METs < 5
METs < 7 but ≥ 5 BNP > 500
BNP 100-500
Malignant ven-
Malignant ven- tricular dysrhyth-
tricular dysrhyth- mias (post-AICD
mias (post-AICD or biventricular
or biventricular pacemaker)
pacemaker)

8 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 61, Table 4-8, Criteria for Rating Impairment due to Pericardial Heart Diseasea:
Row 6, Columns 3, 4, and 5

OBJECTIVE TEST Normal echocar- One or more of One or more of One or more of One or more of
RESULTSd diography and the following: the following: the following: the following:
ECG small pericar- mild effusion moderate effu- Severe effu-
dial effusion, or evidence sion or evidence sion, evidence
Normal ESR evidence of peri- of constrictive of constrictive of tamponade
carditis on ECG, pericarditis on pericarditis on or constrictive
minimally ele- echocardiog- echocardiog- pericarditis
vated ESR (< 30), raphy, ECG raphy, ECG with severe LV
evidence of peri- evidence of dysfunction
and carditis, mildly pericarditis, mod- on echocar-
elevated ESR erately elevated diography, ECG
at least 1 of: (30-50) ESR (51-70), evidence of peri-
carditis, signifi-
BNP level normal and and cantly elevated
ESR (> 71),
VO2max > 20 at least 1 of: at least 1 of:
METs ≥7 and
BNP < 100 BNP 100-500
or at least 1 of:
VO2max 16-20 VO2max 10-15
status post- METs ≥7 METs < 7 but ≥ 5 BNP > 500
pericardiectomy
or surgical peri- or and VO2max < 10
cardial window METs < 5
status post- failed surgi-
pericardiectomy cal attempt or and
or surgical peri- no response to
cardial window surgery failed surgi-
cal attempt or
no response to
surgery

Page 66, Table 4-10

TABLE 4 -10

Classification of Blood Pressure for Adults

Classification Systolic Diastolic

Normal < 120 < 80%

Pre-hypertension 120-139 80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension ≥ 160 ≥ 100

Page 69, Table 4-12 Criteria for Rating Impairment due to Peripheral Vascular Disease –
Lower Extremity: Row 2, Column 1

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

UNILATERAL LE 0 2%-10% 11%-23% 24%-40% 45%-65%

IMPAIRMENT
RATING (%)a

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 9

Page 70, Table 4-13 Criteria for Rating Impairment due to Peripheral Vascular Disease –
Upper Extremity: Rows 2 and 4

Row 2 CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4
0 2%-10% 11%-23% 24%-40% 45%-65%
CLASS

UNILATERAL UE
IMPAIRMENT
RATING (%)

Row 4 No intermittent Intermittent Intermittent Intermittent Severe and con-
claudication or claudication with claudication with claudication sistent pain at
HISTORY pain at rest or heavy upper moderate upper with mild upper rest or severe
transient edema extremity usage, extremity usage extremity usage edema
persistent edema or mild edema or moderate
No curtailment of or pain with cold edema
activity exposure

Page 71, Left Column, Example 4-27: Lower
Extremity Peripheral Vascular Disease

CLASS 4
45%- 65% Impairment of the Lower Extremity

Page 71, Left Column, Example 4-27: Lower
Extremity Peripheral Vascular Disease, Impair-
ment Rating

Impairment Rating: 65% (Class 4E). According to
Table 4-12, the objective test results, physical find-
ings, and history all place the examinee in class 4E,
impairment rating 65%, for each extremity, or 26%
WPI for each lower extremity. As per the Combined
Values Chart, page 604, whole person impairment
of 45%.

10 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Chapter 5

Page 88, Table 5-4, Criteria for Rating Permanent Impairment due to Pulmonary Dysfunction:
Row 6, Columns 2, 3, 5 and 6

OBJECTIVE FVC Ն80% of FVC between FVC between FVC between FVC below
TESTS predicted 70% and 79% of 60% and 69% of 50% and 59% of 50% predicted
FVC predicted predicted predicted
and or
FEV1 FEV1 Ն80% of or or or FEV1 below 45%
predicted FEV1 between FEV1 between FEV1 between of predicted
FEV1/FVC (%) 65% and 79% of 64% and 55% of 45% and 54% of
and predicted predicted predicted or
DLco FEV1/FVC (%)Ͼ DLco below 45%
lower limits of or or or of predicted
V˙ o2 max normal and/ DLco between DLco between DLco between
or (Ͼ75% of 65% and 74% of 55% and 64% of 45% and 54% of or
predicted) predicted predicted predicted Ͻ15mL/(kgиmin)

and or or or or
DLco Ն75% of between 22 and between 21 and between 17 and Ͻ4.3 METs
predicted 25 mL/(kgиmin) 18 mL/(kgиmin) 15 mL/(kgиmin)

or or or or
Ͼ25mL/(kgиmin) 6.1–7.1 METs 5.1–6.0 METs 4.3–5.0 METs
or Ͼ7.1 METs

Page 90 Table 5-5, Criteria for Rating Permanent Impairment due to Asthmaa: Row 4, Column 4

CLINICAL No medication Occasional Daily low-dose Daily medium or Asthma not
PARAMETERS required bronchodilator inhaled steroid high-dose (500 controlled by
(MINIMUM use (not daily to 1000 mcg per treatment
MEDICATION use) (<500 mcg per day) inhaled
NEED, day of beclom- steroid and/or
FREQUENCY OF ethasone or short periods of
ATTACKS, ETC) equivalent) systemic steroids
and a long acting
bronchodilator
Daily use of
steroids, systemic
and inhaled,
and daily use
of maximum
bronchodilators

Chapter 6 Chapter 7

Page 104, Right Column, Last sentence Page 135, Example 7-6: Upper Urinary Tract
Disease: Impairment Rating
choose to rate these up to a 3% whole person impair-
ment. Pain from such disorders is to be rated by the rating of 19%. See BOTC in the Appendix. Combine
pain chapter (Chapter 3). any permanent impairment percent related to a
complication such as osteoporosis if it develops with

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 11

Page 144, Table 7-6, Criteria for Rating Permanent Impairment due to Penile Disease:
Row 1, Column 5, and Row 6, Footnote

T A B L E 7 - 6 Criteria for Rating Permanent Impairment due to Penile Diseaseb

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3

a Key factor.
bCombine with rating for prostate disease (Table 7-9) or urinary incontinence (Bladder Disease, Table 7-4) when present.

Page 149, Table 7-9, Criteria for Rating Impairment due to Prostate Disease: Rows 1 and 4, Column 5

T A B L E 7 - 9 Criteria for Rating Impairment due to Prostate Diseasea

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3

HISTORY No symptoms of Mild to moderate Frequent moderate Frequent and
prostatic and seminal signs and symptoms of symptoms of pro- severe symptoms of
vessel dysfunction prostatic dysfunction static dysfunction prostatic dysfunction
and no treatment that do not require despite continuous only partially respon-
required continuous treatment treatment sive to treatment

Chapter 11

Page 250, Table 11-1, Monaural Hearing Loss and Impairment

Monaural Hearing Loss and Impairmenta

DSHLb % DSHLb % DSHLb %
100 0
190 33.8 285 69.3
105 1.9 195 35.6 290 71.2
110 3.8 200 37.5 295 73.1
115 5.6 300 75.0
120 7.5
205 39.4 305 76.9
125 9.4 210 41.2 310 78.8
130 11.2 215 43.1 315 80.6
135 13.1 220 45.0 320 82.5
140 15.0
225 46.9 325 84.4
145 16.9 230 48.8 330 86.2
150 18.8 235 50.6 335 88.1
155 20.6 240 52.5 340 90.0
160 22.5
245 54.4 345 91.9
165 24.4 250 56.2 350 93.8
170 26.2 255 58.1 355 95.6
175 28.1 260 60.0 360 97.5
180 30.0 365 99.4
265 61.9 Ն370 100.0
270 63.8
185 31.9 275 65.6
280 67.5

a Audiometers are calibrated to ANSI Standard S3.6-1996
reference levels.4

b Decibel sum of the hearing threshold levels at 500, 1000, 2000,
and 3000 Hz.

12 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Chapter 12

Page 304, Table 12-9, Correction for Central Scotomata

If the Visual Acuity Score is 100-90 89-80 79-70 69-60 59-50 Յ49 or less
that is, if the VAS loss is 0-10 11-20 21-30 31-40 41-50 Ͼ50
and visual acuity is Ն20/30 Ն20/50 Ն20/80 Ն20/125 Ն20/200 <20/200
Ignore central field loss up to 2º 4º 6º 8º 10º

Chapter 13

Page 321, Right Column, Bullet 4:
• To offer single values rather than ranges for

impairment categories. Ranges implied a level of
impairment rating validity that does not exist.

Page 322, Left Column, Paragraph 10

• Focal neuropathies are most often rated when
assessing the upper and lower extremities. They
have been assigned to those chapters and are not
rated here. CRPS is rated in the upper and lower
extremity chapters.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 13

Page 329, Table 13-6, Criteria for Rating Impairment due to Sleep and Arousal Disorders:
Row 3, Column 6

DESCRIPTION Normal daytime Reduced daytime Reduced daytime Reduced daytime Severe reduction
alertness; no alertness; sleep alertness; inter- alertness; moder- of daytime alert-
impairment of pattern such that feres with ability ate impairment ness; individual
ADLs individual can to perform ADLs in ADLs unable to care for
perform ADLs (eg, cannot drive) self in any situa-
tion or manner

Page 341, Right Column, Paragraph 1 Page 343, Left Column, last line

using Tables 15-26 and 16-15 in the chapters on facial sensation is uncommon. Combine the impair-
impairment rating of the upper and lower extremi-
ties, respectively. Right Column, Paragraph 1

ment percentage for sensation loss that involves the
trigeminal nerve with the estimated impairment
percentage for pain or motor loss. Pin, cold, and
light touch are the best parameters for localization

Page 343, Table 13-19, Criteria for Rating Trigeminal or Glossopharyngeal Neuralgia:
Row 4, Columns 3, 4, and 5

DESCRIPTION No neuralgia Mild uncontrolled Moderately severe, Severe, uncontrolled,
facial neuralgic pain uncontrolled facial unilateral or bilateral
that may interfere neuralgic pain that facial neuralgic pain
with ADLs or mild interferes with ADLs that prevents per-
motor loss or moderate motor formance of ADLs or
loss severe motor loss

14 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Chapter 14

Page 348, Right Column, Paragraph 2
contrast, the validity and interrater reliability of the
major mental illnesses/disorders; mood disorders
(eg, depression or mania) and schizophrenia are
well established.

Page 349, Left Column, Paragraph 5

• Psychosexual disorders (sexual and gender
identity).

Page 350, Partial Table 14-3, Selected Psychological Assessment Tools in Adults

Personality and Symptoms Assessment
Minnesota Multiphasic Personality Inventory (MMPI) is one of the most widely used objective tests. Developed in the
1940s, the test has been revised in the late 1980s (MMPI-2) and more recently for adolescents (MMPI-A). After the
patient responds to more than 550 questions, at least 54 clinical and 10 validity scales are generated as well as a score of
unanswered responses.

Millon Clinical Multiaxial Inventory (MCMI-III) uses DSM-IV terminology and is helpful in differentiating types of
personality disorders. An adolescent inventory has also been formulated.

Personality Assessment Inventory (PAI) provides information to assist in screening, diagnosis, and treatment for
psychopathology, which parallels DSM-IV categories. Validity scales are included.

Intellectual Assessment
Wechsler Intelligence Test: administered by trained examiner, yields verbal, performance, and full-scale IQ. There are
versions for adults (Wechsler Adult Intelligence Scale–IV edition, or WAIS-IV), for children (Wechsler Intelligence Scale for
Children–IV edition, or WISC-IV), and preschoolers (Wechsler Preschool and Primary Scales of Intelligence III, or WPPSI-
III). In addition to the IQ score, the WAIS-IV yields 4 indices—verbal comprehension, perceptual organization, working
memory, and speed of information processing—and the WISC-IV indices include verbal comprehension, perceptual
organization, freedom from distractibility, and processing speed. Organic disease or preexisting learning disability
may be suspected if there is: (1) a discrepancy in the full-scale IQ and premorbid function; (2) discrepancy of >15 points
between the verbal IQ and performance IQ; (3) high intersubtest scatter, and (4) impaired performance on certain
sections (similarities, digit symbol, block design).

Standardized tests of social adaptive behavior may also be useful in quantifying the effects of intellectual deficits.

Academic Assessment
These scales focus on academic skills: reading, spelling, writing, language, and math:

• Wide Range Achievement Test-IV (WRAT-IV): quick.

• Woodcock-Johnson III NU Tests of Achievement: most comprehensive; useful for learning disabilities.

• Wechsler Individual Achievement Test (WIAT): comprehensive; linked with Wechsler Intelligence Scales.

• Peabody Individual Achievement Test-Revised, Second Edition.

Page 355, Left Column, Paragraph 1 Page 355, Left Column, Paragraph 5

with many general medical diagnoses, early return The GAF constitutes Axis V of the DSM-IV. The
to the workplace in some capacity facilitates a suc- GAF is a 100-point single-item rating scale for
cessful return to work. evaluating overall symptoms, occupational function-
ing, and social functioning. Scores from 91 to 100
measure individuals who have superior functioning
without active psychopathology. Interval 81 to 90
includes individuals with minimal or no active psy-
chopathology but function at a lesser level. Clinical
psychiatrists and psychologists may indicate a GAF
score in multiaxial assessment of their patients, and
the scale has undergone considerable psychometric
assessment in the scientific community.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 15

Page 357, Table 14-9, Impairment Score of Chapter 15
Brief Psychiatric Rating Scale (BPRS)
Page 384, Figure 15-1
BPRS Summed Score BPRS Impairment Score
24–30 0% Shoulder
31–35 5%
36–40
41– 45 10%
46–50 15%
51–60 20%
61–70 30%
71–168 40%
50%

Page 360, Right Column, Paragraph 3 Elbow
ary gain. He would not consider electroconvulsive
therapy, but did participate in cognitive behavioral Wrist
therapy. After more than 1 year of various medi- Digits / hands
cine trials, his symptoms seemed to stabilize and
he was thought to have reached Maximum Medical Page 387, Left Column, Paragraph 2
Improvement (MMI). ment values when a grid permits its use as an
option; this is a significant change from prior edi-
Page 361, Left Column, Sentence before tions. Range of motion ratings cannot be combined
Step 2 with other approaches, with the exception of ampu-
Find the BPRS impairment score in Table 14-9: 0%. tation. Complex regional pain syndrome ratings
cannot be combined with other approaches.
Page 361, Right Column, Sentence after
Step 4 Page 387, Right Column, Paragraph 4
BPRS impairment score: 0%. and biceps tendonitis, the examiner should use the
diagnosis with the highest causally-related impair-
Page 362, Right Column, Sentence before ment rating for the impairment calculation. Thus,
Step 2 when rating rotator cuff injury/impingement or
Find the BPRS impairment score in Table 14-9: glenohumeral pathology/surgery, incidental
10%. resection arthroplasty of the AC joint is not rated.

16 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 389, Right Column, Paragraph 2 Page 390, Left Column, Paragraph 3

Selection of the optimal diagnosis requires judg- multiple digits involved, the digit impairments at
ment and experience. If more than 1 diagnosis can the hand level are added. Impairment cannot exceed
be used, the highest causally-related impairment 100% of digit. If a whole person permanent impair-
rating should be used; this will generally be the ment is necessary, the hand impairment is converted
more specific diagnosis. Typically, 1 diagnosis will to upper extremity impairment and ultimately to
adequately characterize the impairment and its whole person impairment.
impact on ADLs. Certain diagnoses may span more
than 1 class; therefore, these diagnoses are associ- Page 390, Right Column, Paragraph 2
ated with specific objective findings on physical
examination or clinical studies to ensure place- ligamentous, and soft-tissue structures encompass-
ment in the appropriate class. Painful disorders in a ing the wrist joint. Instructions are provided in
regional grid are rated only once; it is duplicative to Sections 15.1 and 15.3 and involve the use of Table
rate in both “soft tissue” and “muscle tendon.” 15-3, Wrist Regional Grid, and the Table 15-6
adjustment grid (and associated Tables 15-7 to 15-9).

Page 397, Partial Table 15-3, Wrist Regional Grid: Upper Extremity Impairments: Row 5, Column 3

Posttraumatic Posttraumatic, 1 3 57 9 If motion loss,
degenerative No residual find- may assess per
joint disease* ings: ϩ/Ϫ surgical Posttraumatic Section 15.7,
(DJD) treatment DJD with docu- Range of Motion
mented specific Impairment
injury, mild asym- (not combined
metric arthritic with diagnosis
changes noted on impairment)
imaging

Page 400, Table 15-4 (continued), Elbow Regional Grid: Upper Extremity Impairments: Rows 4 and 7

Posttraumatic Posttraumatic, 1 3 57 9
degenerative No residual find-
joint disease ings: ϩ/Ϫ surgical Posttraumatic
(DJD)* treatment DJD with docu-
mented specific
Radial head injury, mild
(isolated) asymmetric
arthroplasty* arthritic changes
noted on imaging

6 7 8 9 10

Normal motion

9 10 11 12 13

Complicated,
unstable, or
infected

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 17

Page 402, Partial Table 15-5 (continued), Shoulder Regional Grid: Upper Extremity Impairments: Row 5

Note: These were removed because of unnecessary duplications in the Table.

Rotator cuff 0 3 4 56 7
tear or tendon
rupture* No residual find- Residual loss,
ings: ϩ/Ϫ surgical functional with
treatment normal motion

Page 403, Partial Table 15-5, Shoulder Regional Grid: Upper Extremity Impairments: Row 7
Note: These were removed because of unnecessary duplications in the Table.

Shoulder joint 0 8 9 10 11 12 16 18 20 22 24 34 37 40 43 46
dislocation*
No residual find- Mild: can be com- Moderate: cannot Severe: cannot be
ings: ϩ/Ϫ surgical pletely reduced be completely reduced
treatment manually reduced manually

Page 404, Partial Table 15-5 (continued), Shoulder Regional Grid: Upper Extremity Impairments:
Rows 4 and 5, Columns 3 and 4

Unidirectional 0 4 5 67 8 20 22 24 25 25
shoulder
instability* No residual find- Occult (consis- Dislocating
ings: ϩ/Ϫ surgical tent relationship humeral head
treatment of symptoms (confirmed his-
with activities tory of acute
and grade 1 trauma, consis-
instability) tent relationship
of symptoms with
9 10 11 12 13 activities, grade 3
or 4 instability)
Subluxing
humeral head
(confirmed his-
tory of acute
trauma, consis-
tent relationship
of symptoms with
activities, grade 2
instability)

Multidirectional 0 9 10 11 12 13 22 23 24 25 25
shoulder insta-
bility (excluding No significant History of trau- Dislocating
patients with objective abnor- matic episode humeral head
bilateral multidi- mal findings of and shoulder (confirmed his-
rectional shoul- soft-tissue injury instability dem- tory of acute
der instability)* at MMI onstrated in 2 or trauma, consis-
more directions tent relationship
of symptoms with
Post op patients activities, grade 3
with persistent or 4 instability)
symptoms with
no instability may
be rated with
ROM. If ROM is
normal rate by
nonspecific shoul-
der pain*

18 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 405, Partial Table 15-5, Shoulder Regional Grid: Upper Extremity Impairments: Row 6, Column 3

Posttraumatic Posttraumatic, 1 3 57 9
degenerative No residual find-
joint disease ings: ϩ/Ϫ surgical Posttraumatic
(DJD)* treatment DJD with docu-
mented specific
injury, mild asym-
metric arthritic
changes noted on
imaging

Page 405, Partial Table 15-5, Shoulder Regional Grid: Upper Extremity Impairments: Row 8, Column 1

Total sShoulder 20 22 24 25 25 26 28 30 32 34
arthroplasty*
Implant with Resection with
normal motion normal motion

34 37 40 43 46

Complicated,
unstable, or
infected

Page 405, Left Column, Paragraph 1

The adjustment grid, as described in the introduc-
tion, is used to assign a grade within the class
defined by the regional grid. The grade for a given
class is determined by considering functional his-
tory, physical examination findings, and the results
of relevant clinical studies. If a non-key factor or
grade modifier was used for primary placement in
the regional grid as, for example, X-ray findings
in the case of carpal instability, that same specific
finding may not be used again to determine the
grade modifier.

Page 406, Table 15-7, Functional History Adjustment: Upper Extremities: Row 4

AND able to perform AND able to per- AND requires assis- AND unable to
self-care activities form self-care tance to perform perform self-care
independently activities with self-care activities activities
modification but
unassisted

Page 407, Left Column, Section 15.3b,
Paragraph 2

with each specific ratable condition. If a physical
finding has been used to determine class place-
ment, that specific finding should not be considered
again, for example, range of motion in the upper
extremity. If physical examination

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 19

Page 408, Table 15-8, Physical Examination Adjustment: Upper Extremities: Rows 8 and 10

Shoulder Grade 1 (slight) Grade 2 (moderate) Grade 3 (serious)
instability; instability; easily instability; dislocat-
subluxable subluxable able with anesthesia
or sedation

Range of None Mild decrease from Moderate decrease Severe decrease Very severe decrease
Motion normal or uninjured from normal or from normal or from normal or unin-
(reference opposite side uninjured opposite uninjured opposite jured opposite side
Section 15.7) side side
For digit impair- For digit impair-
ments only, this For digit impairments For digit impairments ments only, this
reflects a total digit only, this reflects a only, this reflects a reflects a total digit
impairment Ͻ20% total digit impair- total digit impair- impairment Ͼ70%
digit impairment. ment of 20% to 39% ment of 40% to 70% digit impairment.
For wrist, elbow, digit impairment. digit impairment. For wrist, elbow,
and shoulder this For wrist, elbow, and For wrist, elbow, and and shoulder this
reflects a total joint shoulder this reflects shoulder this reflects reflects a total joint
impairment of Ͻ12% a total joint impair- a total joint impair- impairment Ͼ42%
upper extremity ment of 12% to 23% ment of 24% to 42% upper extremity
impairment. upper extremity upper extremity impairment.
impairment. impairment.

Page 409, Left Column, Paragraph 3 Page 414, Example 15-3: Stenosing Tenosyno-
vitis, Symptomatic, Impairment Rating
Electrodiagnostic studies should be performed only
by a licensed physician who is qualified by educa- History: Grade modifier 2; Physical examination:
tion, training, and experience in these procedures. Grade modifier 2; Clinical tests: Grade modifier
Typically, these studies are performed by board not applicable (n/a). Net adjustment compared with
certified neurologists and physical medicine spe- diagnostic class is ϩ2, assigned to grade E (high-
cialists. Others duly recognized by an appropriate est assignment). Therefore, 8% digit impairment.
jurisdiction may perform such studies within their Converts by Table 15-12 to 2% HI, 1% UEI, and 1%
applicable scope of practice and field of expertise. WPI.
The studies must be performed in accordance with
established standards. Class 1 Example Calculation: Default for
Diagnosis ϭ 6% Digita

CDX GMFH GMPE GMCS

1 2 2 n/a

Net adjustment
(GMFH Ϫ CDX) (2 Ϫ 1) ϭ 1

ϩ (GMPE Ϫ CDX) ϩ (2 Ϫ 1) ϭ 1
ϩ (GMCS Ϫ CDX) n/a

Net adjustment ϭ 2
Result is class 1 adjustment ϩ2, which equals class 1
grade E ϭ 8% digit

Page 415, Example 15-5: Contusion
History: The man’s hand and wrist were struck by a

20 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications
Page 420, Table 15-11

TABLE 15-11

Impairment Values Calculated From Upper
Extremity Impairment

% Impairment % Impairment

Whole Upper Hand Thumb Index Ring Whole Upper Hand Thumb Index Ring
and and and and
Person Extremity Middle Small Person Extremity Middle Small
Finger Finger Finger Finger

0 0 00 0 0 Very Severe 57
Mild 31 51 58
1 13 6 11 31 52 59
1 2 26 11 22 32 53 60
1 3 38 17 33 32 54 61
2 4 4 11 22 44 33 55 62
2 5 6 14 28 56 34 56 63
3 6 7 17 33 67 34 57 64
4 7 8 19 39 78 35 58 65
4 8 9 22 44 89 35 59 66
5 9 10 25 50 100 35 59 67
5 10 11 28 56 36 60 68
6 11 12 31 60 37 61 69
7 12 13 33 65 37 62 70
7 13 14 36 70 38 63 71
8 38 64 72
Moderate 14 16 39 80 39 65 73
8 15 17 42 85 40 66 74
9 16 18 44 90 40 67 75
10 17 19 47 95 41 68 76
10 18 20 50 100 41 68 77
11 19 21 53 41 69 78
11 20 22 56 42 70 79
12 21 23 58 43 71 80
13 22 24 61 43 72 81
13 23 26 64 44 73 82
14 24 27 67 44 74 83
14 25 28 69 45 75 84
15 46 76 85
Severe 26 29 72 46 77 86
16 27 30 75 46 77 87
16 28 31 78 47 78 88
17 29 32 81 47 79 89
17 30 33 83 48 80 90
18 31 34 86 49 81 91
19 32 36 89 49 82 92
19 33 37 92 50 83 93
20 34 38 94 50 84 94
20 35 39 97 51 85 95
21 36 40 100 52 86 96
22 37 41 52 86 97
22 38 42 52 87 98
23 39 43 53 88 99
23 40 44 53 89 100
24 41 46 54 90
25 42 47 55 91
25 43 48 55 92
26 44 49 56 93
26 45 50 56 94
27 46 51 57 95
28 47 52 58 96
28 48 53 58 97
29 49 54 59 98
29 50 56 59 99
30 60 100

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 21

Page 424, Table 15-13 Page 429, Left Column, Example 15-14:
Digital Nerve Contusion (continued)
TABLE 15-13
Physical Exam: Normal, except for decreased
Monofilament Test Criteria sensation distal to ring finger DIP joint, ulnar
aspect, with 2-point discrimination 18 mm.
Grams of Force Interpretation
Clinical Studies: None.
1.65 to 2.83 Normal
Diagnosis: Digital neuroma, ulnar digital nerve,
3.22 to 3.61 Diminished light touch ring finger.

3.84 to 4.31 Diminished protective Page 433, Right Column, Paragraph 3
sensation
Constant symptoms means that pain or numbness is
4.56 to 6.65 Loss of protective sensation constantly present and at least conduction block if
not axon loss must be present on electrodiagnostic
Ն6.65 No response, no sensation testing to substantiate the symptom severity.

Page 426, Right Column, Figure 15-5 – Legend Pages 436 – 444, Table 15-21, Peripheral Nerve
Impairment: Upper Extremity Impairments.
Digit Impairment due to Finger Amputation at Correction in Column 2 (CLASS 0)
Various Lengths (top scale) or Total Transverse
Sensory Loss (bottom scale) Note: Change all numerals in column two to 0
(zero), remove the hyphen and additional number.
Page 428, Right Column, Example 15-14: Digi- (Incorrect: 0-1. Correct: 0).
tal Nerve Contusion

Current Symptoms: Sensation of numbness over
the ulnar aspect of her right ring finger distal

Page 441, Partial Table 15-21 (continued) Peripheral Nerve Impairment: Upper Extremity
Impairments: Row 4 Columns 2 and 3

Musculocutaneous 0 0a 0a 1 1 1 14 14 16 17 19

Mild sensory deficit or Severe motor
mild CRPS II (objectively deficit
verified)
18 20 22 23 25
12233
Very severe
Moderate sensory defi- motor deficit
cit or moderate CRPS II
(objectively verified)

33444

Severe sensory deficit
or severe CRPS II (objec-
tively verified)

44444

Very severe sensory def-
icit or very severe CRPS II
(objectively verified)

0a 2 3 5 6

Mild motor deficit

7 8 10 11 13

Moderate motor deficit

22 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 446, Left Column, Paragraph 2 Page 446, Right Column, Paragraph 3

Threshold values for latency and conduction velocity Latencies and conduction velocities that are slower
for specific nerves are provided in Appendix 15-B. than those in Appendix 15-B qualify as conduction
The values necessary to qualify for a diagnosis of a delay for the purpose of impairment rating. Upper
specific focal nerve compromise are conservative. The limb temperature must be stated in the report and must
criteria in Appendix 15-B must be met to make the be at least 32°C.
diagnosis of focal neuropathy for impairment rating
purposes. Page 447, Left Column, Paragraph 1

Page 446, Right Column, Paragraph 2 latencies for the nerve supplying that muscle suggests
misinterpretation of the potentials seen on EMG. It
Test Findings. Normal electrodiagnostic tests fail to is, therefore, not sufficient for the diagnosis of a focal
meet the definitions necessary to permit a diagnosis neuropathy syndrome for the purpose of impairment
of focal nerve compromise for the purpose of impair- rating.
ment rating (Appendix 15-B). Electromyographers
use different, nonstandardized definitions of normal.
A physician may for treatment purposes, choose to
accept an electromyographer’s report interpreting a
study as abnormal and consistent with focal neuropa-
thy. However, unless the study meets the criteria listed
in Appendix 15-B, it is considered a normal study for
the purpose of impairment rating. The interpretation
of findings for specific entrapment syndromes is pro-
vided in Appendix 15-B, Electrodiagnostic Evaluation
of Entrapment Syndromes.

Page 449, Partial Table 15-23, Row 3, Column 2

HISTORY Asymptomatic Mild intermittent Significant inter- Constant NA

symptoms mittent symptoms symptoms

Page 450, Right Column, Paragraph 5 Page 456, Table 15-27

For ulnar nerve entrapment, test findings are grade TABLE 15-27
modifier 2 (conduction block), history is constant
symptoms, but only conduction block is present on Level of Amputation
nerve conduction testing, so grade 2 is the highest
permitted grade. Physical findings are grade modi- Upper Whole
fier 2 (decreased sensation). The grade modifiers
total 6 (2 + 2 + 2) and average 2. Therefore, grade Amputation Level (%) Hand Extremity Person
modifier 2 is selected with a default of 5% UEI. The
QuickDASH is 32 (mild), therefore, for grade modi- Metacarpal ray loss – CMC 42 38 23
fier the lowest value for that grade is selected and thumb
the impairment is 4% UEI for the ulnar nerve.
Distal half of index or 21 19 11
Page 451, Right Column, Paragraph 6 middle metacarpal

The steps in assessing CRPS type 1 impairment are as CMC of index or middle ray 22 20 12
follows:
Distal half of ring or little 12 11 7
metacarpal

CMC of ring or little ray 13 12 7

Note: CMC indicates carpometacarpal.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 23

Page 458, Right Column, Example 15-22 Page 464, Right Column, Paragraph 1

At the time of current evaluation, the patient has a The actual measured goniometer readings or linear
neuroma in the distribution of the ulnar digital nerve measurements are rounded to end in 0 and are then
of the little finger; grip strength is decreased. recorded.

Page 459, Left Column, Example 15-22, Page 466, Right Column, Paragraph 5
Continued
The relative value of this functional unit is 45% of the
Impairment Rating: Per Figure 15-10, an amputation thumb. The normal range of opposition is from 0 to 8
through the metacarpal shaft of the little finger cm. However, in smaller hands, the normal distance of
opposition can be slightly smaller. Both sides are mea-
Comment: An alternative is to not rate the neuroma, sured and compared. If the contralateral “normal” hand
but rather to rate the amputation from Table 15-29 with opposition distance is smaller by 2 cm (total distance
adjustments. 6 cm or less), the impairment value corresponding to
the uninvolved side (assuming no prior injury of that
Page 459, Left Column, Paragraph 6 side) serves as a baseline, and 5% thumb impairment is
subtracted from the impairments listed in Figure 15-20.
rologic loss cannot exceed 100% of the hand. Upper This adjustment should be stated in the report.
extremity impairments determined by combining
impairments for amputation, loss of motion, and neuro-
logic loss cannot exceed 100% of the upper extremity.

Page 459, Right Column, Example 15-23,
last line

these 2 values is still 92% UEI or 55% WPI.

Page 470, Partial Table 15-31, Finger Range of Motion: Row 10, Columns 4 and 5

PIP 80% Finger Ն100º ϭ 0% 90º ϭ 6% DI 20º to 40º ϭ Յ10º ϭ Ϫ40º ϭ 50% DI
Flexion Ն0º ϭ 0% 50º to 80º ϭ
Motionº ϭ 21% DI 42% DI 54% DI ϩ10º to Ϫ10º or Ϫ50º to
Extension % Digit Ϫ70º ϭ 60% DBI
Impairment Ϫ10º lag ϭ
(% DI) 3% DI Նϩ20º or ՅϪ80º ϭ 80% DI

Ϫ20º to Ϫ50º ՆϪ60º lag ϭ
lag ϭ 14% DI 58% DI

Page 471, Right Column, Paragraph 5 Page 472, Right Column, Paragraph 11

Normal range of forearm motion is from 70° of supi- Shoulder Internal and External Rotation
nation to 80° of pronation. The position of function is Normal range of shoulder motion is from 80° of
20° of pronation. The relative value of this motion unit internal rotation to 60° of external rotation.
is 28% of upper extremity function.

Page 472, Right Column, Paragraph 6

Shoulder Abduction and Adduction
Normal range of shoulder motion is from 170° of
abduction to 40° of adduction. The positions of func-

24 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 473, Partial Table 15-32, Wrist Range of Motion

Joint 70% Wrist Ն60º ϭ 0% 30º to 50º ϭ 20º ϭ 7% UEI Յ10º ϭ 9% UEI Ϫ10º to ϩ 10º ϭ 21% UEI
Wrist Ն60º ϭ 0% 3% UEI
Flexion Motionº ϭ ϩ20º to ϩ40º or Ϫ20º to
% Upper 30º to 50º ϭ Ϫ40º ϭ 25% UEI
Extension Extremity 3% UEI
Wrist Impairment Նϩ50º or ՅϪ50º ϭ 40%
Radial (% UEI) UEI
Deviation
20º ϭ 7% UEI Յ10º ϭ 9% UEI
Ulnar
Deviation 30% Wrist

Ն20º ϭ 0% 10º ϭ 2% UEI 0º ϭ 4% UEI Ն10º ulnar 0º to 10º ulnar deviation ϭ
deviation ϭ 9% UEI
12% UEI
10º radial deviation or 20º
Motionº ϭ ulnar deviation ϭ 14% UEI
% Upper
Extremity Ն20º radial deviation or
Impairment Ն30º ulnar deviation ϭ
(% UEI) 18% UEI

Ն30º ϭ 0% 20º ϭ 2% UEI 10º to 0 º ϭ Ն10º radial
4% UEI deviation ϭ
12% UEI

Page 474, Partial Table 15-33, Elbow/Forearm Range of Motion: Row 10, Columns 3 and 4

Forearm 40% Elbow Ն80º ϭ 0% 70º to 50º ϭ 40º to 20º ϭ Յ10º ϭ 20º pronation ϭ 8% UEI
Pronation Ն70º ϭ 0%
Motionº ϭ 1% UEI 3% UEI 10% UEI 30º to 60º pronation or
Supination % Upper 10º pronation to 20º supi-
Extremity nation ϭ 15% UEI
Impairment
(% UEI) Ն70º pronation or Ն30º
supination ϭ 25% UEI

60º to 50º ϭ 40º to 20º ϭ Յ10º ϭ

1% UEI 2% UEI 10% UEI

Page 474, Right Column, Paragraph 1 Page 476, Right Column, Paragraph 1

ference between the range of motion grade modifier and the net modifier 2, the increase is 10% (net modifier)
the functional history grade modifier. times 10% (impairment), or a 1% increase, which
should be added to the 10% impairment rating for a
Page 474, Right Column, Paragraph 3 final 11% upper extremity impairment. Note that 10%
history net modifier times 10% times the total motion is not an add-on of 10%, rather it is a multiplier used
impairment. With the above example, if the range of in conjunction with the functional history net modifier
motion impairment was 10% upper extremity impair- and the total impairment.
ment (class 1), the functional history grade (class 3) and

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 25

Page 475, Partial Table 15-34, Shoulder Range of Motion, Row 9, Column 7

Shoulder 30% Shoulder
Abduction
Ն170º ϭ 0% 90º to 160º ϭ 20º to 80º ϭ Յ10º ϭ 20º to 50º of abduction ϭ
Adduction 9% UEI
Motionº ϭ 3% UEI 6% UEI 10% UEI
% Upper Յ10º or Ն60º abduction ϭ
Extremity 16% UEI
Impairment
(% UEI) Ն40º ϭ 0% 10º to 30º ϭ 0º to 30º Ն40º abduc-
1% UEI tion ϭ
abduction ϭ 10% UEI
2% UEI

Page 477, Example 15-24, Continued, Left Page 497, Right Column, Paragraph 5
Column
This process is repeated for each separate diagnosis
Physical Exam: Examination is only remarkable in each limb involved. In most cases, only 1 diagnosis
for her motion deficits secondary to the scarred in a region (ie, hip, knee and/or foot/ankle) will be
digits; thumb and index. She retains protective sen- appropriate. If a patient has 2 significant diagnoses, for
sation in these digits. Thumb - IP joint ankylosed instance, ankle instability and posterior tibial tendonitis,
at 20°; MCP - flexion to 40° and extension to -30°; the examiner should use the diagnosis with the highest
CMC joint opposition at 4cm, radial abduction to impairment rating in that region that is causally-related
20° and adduction to 5cm. Index finger DIP anky- for the impairment calculation. If an examiner is rou-
losed at 30°; DIP ankylosed at 20° of flexion; PIP tinely using multiple diagnoses without objective sup-
ankylosed at 60° of flexion; MCP flexion limited porting data, the validity and reliability of the evaluation
to 70° and extension limited to 0°. Motion defi- may be questioned.
cits were reproducible and consistent with other
documentation. Page 499, Right Column, Paragraph 2

Chapter 16 Selecting the optimal diagnosis requires judgment and
experience. If assignment to a class is determined by
Page 493, New Insert, Left Column, bottom severity of ROM deficit (ie, normal, mild, moderate,
of page severe, very severe), this severity is determined using
Sec. 16.7 ROM Impairment. If more than 1 diagnosis
Note: All references to “radiographic” are to be in a region (ie, hip, knee and/or foot/ankle) can be used,
inclusive of other “imaging” studies. the 1 that provides the most clinically accurate and
causally-related impairment rating should be used; this
Page 496, Left Column, Paragraph 1 will generally be the more specific diagnosis. Typically,
1 diagnosis will adequately characterize the impair-
• Grade modifier 0: no demonstrable interference ment and its impact on ADLs. Certain diagnoses may
with function. span more than 1 class; therefore, these diagnoses are
associated with specific objective findings on physical
• Grade modifier 1: interference with the vigorous examination or clinical studies to ensure placement in
or extreme use of the limb only. the appropriate class.

• Grade modifier 2: antalgic limp that limits ambula-
tion distance; or regularly uses orthotic device (at
least ankle-foot orthosis).

• Grade modifier 3: an antalgic limp; routine use of
2 canes, or 2 crutches, or knee-ankle-foot orthosis.

• Grade modifier 4: non-ambulatory.

26 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 500, Left Column, Paragraph 1

When this is the case, those same findings may not
be used as grade modifiers to adjust the rating. Range
of motion will, in some cases, serve as an alternative
approach to rating impairment. It is not combined with
the diagnosis-based impairment, and stands alone as an
impairment rating.

Page 508, Partial Table 16-2 (continued) Foot and Ankle Regional Grid – Lower Extremity
Impairments: Rows 7 and 8, Columns 4, 5, and 6

Ankle 7 8 10 12 13 16 18 20 22 24 26 28 30 32 34 52 56 60 64 68
Subtalar Neutral position
Mild Moderate Severe malalign-
7 8 10 12 13 malalignment malalignment ment (plantar
Neutral position (dorsiflexion (dorsiflexion flexion varus
(equal to oppo- 10–19°, plantar Ͼ19°, plantar position >19°,
site normal side) flexion 10–19°, flexion 20–29°, valgus position
varus position varus position >19°, internal
5–9°, valgus posi- 10–19°, valgus malrotation >29°,
tion 5–9°, internal position 10-19°, or external mal-
malrotation 0–9°, internal malrota- rotation >39°)
or external mal- tion 10–29°, or or infected non-
rotation 15–19°) external malrota- union
tion 20–39°) or
non-union 52 56 60 64 68

16 18 20 22 24 26 28 30 32 34 Severe malalign-
ment (varus posi-
Mild malalign- Moderate mala- tion, Ͼ6° greater
ment (varus lignment (varus than the opposite
position, 1°–3° position, 4°–6° normal or valgus
greater than the greater than the Ͼ14° greater)
opposite normal opposite normal
or valgus 5–9° or valgus 10–14°
greater) greater)

Page 509, Partial Table 16-3 Knee Regional Grid – Lower Extremity Impairments: Row 11, Column 3

LIGAMENT / Do not use with PE Do not use with
BONE / JOINT stability PE stability

Meniscal 1 2 22 3 19 20 22 24 25
injury Partial (medial or lat- Total (medial and
eral) meniscectomy,
meniscal tear, or lateral)
meniscal repair

5 6 78 9
Total meniscectomy
(medial or lateral) or
meniscal transplant
(allograft)

7 8 10 12 13
Partial (medial and
lateral)

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 27

Page 510, Partial Table 16-3 (continued) Knee Regional Grid – Lower Extremity Impairments:
Rows 13 and 15, Columns 4 and 5

Supracondylar 0 3 4 56 7 19 20 22 24 25 31 34 37 40 43 52 56 60 64 68
or intercondy- 10°–19° angulation Non-union and/or
lar fracture Non-displaced, Non-displaced with 20°ϩ angulation infected
with no signifi- abnormal examina- or Ͼ 2 mm articu-
Patellar cant objective tion findings lar surface step off 52 56 60 64 68
fracture abnormal find- Non-union and/or
ings at MMI 7 8 10 12 13 infected, or severe
Tibial plateau comminuted,
fracture 5°–9° angulation displaced

0 5 6 78 9 14 15 16 17 18

Non-displaced, Non-displaced with Displaced with
with no signifi- abnormal examina- nonunion
cant objective tion findings
abnormal find-
ings at MMI 7 8 10 12 13

Articular surface dis-
placed 3 mm or less

0 3 4 56 7 19 20 22 24 25 31 34 37 40 43

Non-displaced, Non-displaced with 10°–19° angulation 20°ϩ angulation
with no signifi- abnormal examina- or Յ2 mm articular or Ͼ 2 mm articu-
cant objective tion findings surface step off lar surface step off
abnormal find-
ings at MMI 7 8 10 12 13

Ͻ 9° angulation

Page 513, Partial Table 16-4 (continued), Hip Regional Grid – Lower Extremity Impairments:
Row 7, Columns 3, 4 and 5

Avascular 7 8 10 12 13 14 15 16 17 18 26 28 30 32 34
necrosis
Avascular necrosis Avascular necrosis Avascular necrosis
of hip with mild of hip with mod- of hip with severe
range of motion erate range of range of motion
deficit motion deficit deficit

Page 515, Partial Table 16-4 (continued), Hip Regional Grid – Lower Extremity Impairments:
Row 7, Columns 1 and 4

Partial or total 21 23 25 25 25 31 34 37 40 43 59 63 67 71 75
hip replacement
Good result Fair result (fair Poor result (poor
(good position, position, mild position, mod-
stable, functional) instability and/ erate to severe
or mild motion instability, and/
deficit) or moderate to
severe motion
deficit)

67 71 75 79 83

Poor result with
chronic infection

Page 516, Right Column, Paragraph 1 Page 517, Left Column, Paragraph 2

the examiner in defining the grade for functional his- each specific ratable condition. If a physical finding,
tory and does not serve as a basis for defining further for example, range of motion, has been used to deter-
impairment nor does the score reflect an impairment mine class placement, that specific finding should not
percentage (see Table 16-6). be used to select a grade modifier. If physical exami-
nation findings are determined to be unreliable or
inconsistent, or they are for conditions unrelated to the
condition being rated, they

28 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 517, Partial Table 16-7, Physical Examination Adjustment – Lower Extremities: Row 5, Column 6

KNEE Grade 1 Grade 2 Lachman’s test; Grade 3 Multi-
Lachman’s moderate laxity patellar Lachman’s directional
test; slight mechanism test; severe instability
laxity patellar laxity patellar
mechanism mechanism

Page 518, Left Column, Paragraph 1 Page 518, Left Column, Paragraph 4

The total values for the foot/ankle, knee, or hip are it with the opposite side. Teleroentgenography is
compared to the criteria in Section 16-7, Range of recommended. If surface measurements with a tape
Motion Impairment, to define the range of motion measure from the anterior superior iliac spine to
grade modifier. Range of motion impairment is not medial malleolus are used, they should be repeated
combined with the diagnosed-based impairment. 3 times and averaged to reduce measurement error.

Page 518, Left Column, Paragraph 3 Page 518, Left Column, Paragraph 5

patella and compared a similar measure on the other must be reliable and pertinent. For adjustment pur-
thigh. Calf circumference is compared at the level poses, findings at MMI are used.
of maximum circumference bilaterally. Neither limb

Page 519, Partial Table 16-8, Clinical Studies Adjustment – Lower Extremities: Rows 5 and 6,
Columns 3, 4, and 5

ARTHRITIS Cartilage interval Cartilage interval Cartilage interval No cartilage inter-
Note: Do not normal or less than present; however, present; however, val; radiographic
use when 25% loss compared 25% to 50% loss Ͼ50% lost com- evidence of severe
X-ray carti- to opposite unin- compared to oppo- pared to opposite posttraumatic
lage interval jured side; cystic site uninjured side; uninjured side; arthrosis or avascu-
is used in changes on 1 side cystic changes on radiographic evi- lar necrosis
diagnostic of joint; loose body both sides of joint; dence of moder-
impairment Ͻ5 mm loose body 5 mm or ate posttraumatic
definition greater or multiple arthrosis or avascu-
loose bodies; radio- lar necrosis
STABILITY graphic evidence of
Foot/Ankle mild posttraumatic
Note: Do not arthrosis or avascu-
use when lar necrosis
X-ray stress
opening AP stress radio- AP stress radio- AP stress radio-
is used in graph: 2- to 3-mm graph: 4- to 6-mm graphs: Ͼ6-mm
diagnostic excess opening or excess translation excess translation or
impairment 5°–9° varus opening or 10–15° varus Ͼ15° varus opening
definition compared to normal opening compared compared to normal
opposite side to normal opposite opposite side
side
Lateral stress radio-
Lateral stress radio- graph: anterior
graph: anterior drawer Ͼ6-mm
drawer 4- to 6-mm excess translation
excess translation compared to nor-
compared to normal mal side
side

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 29

Page 523, Example 16-3, Ankle Instability: Page 525, Example 16-8, Meniscal Tear:
Impairment Rating Clinical Studies

value of 5% LEI. Adjustment grids: Functional Clinical Studies: MRI showed medial meniscal tear,
history: Grade modifier 1; Physical exam: grade and mild patellofemoral chondromalacia.
1, either by tenderness or by instability; Clinical
studies: not applicable, used in class assignment. Page 526, Example 16-8, Meniscal Tear
Net adjustment compared to diagnostic class is 0, (continued): Impairment Rating
remains grade C. Therefore remains at the default of
5% LEI or 2% WPI. Grade modifier 0; Clinical studies: Grade 1 (chon-
dromalacia). With 2 grade modifier 0, adjustments
Page 524, Partial Example 16-5: Ankle moved 2 to the left of midrange default resulting in
Arthritis, Clinical Studies grade A and final rating of 1% LEI and converts to 1%
WPI.
Clinical Studies: X rays reveal total loss of the ankle
joint space interval on the right with a normal 4 mm Page 526, Example 16-10: Subluxing Patella:
joint space interval on the left. History and Physical Exam

Page 524, Partial Example 16-5: Ankle History
Arthritis, Impairment Rating knee hurts in the front most of the time, especially
when climbing stairs. She has an antalgic limp despite
findings consistent with moderate to severe motion use of a patellar tracking brace.
deficits and/or moderate malalignment, refer to Table
16-22, Ankle Motion Impairments and Table 16-25,

Page 525, Example 16-6: S/P Total Ankle Physical Exam
Replacement With Poor Result the knee flexed. No effusion is palpable. There is 2.5
cm of thigh atrophy.
History
and regular use of a cane.
Physical Exam
She has 3.5 cm atrophy of her right calf compared
with the left. The ankle is stable without deformity.
Clinical Studies: X rays show ankle replacement
in good position, but heterotopic bone which limits
ankle motion.
Comment: For ankle replacement the class is
determined by findings of position (good), stabil-
ity (normal), and range of motion (moderately
reduced), which results in a poor result, and a class
4 assignment.
Impairment Rating: Class 4 results in a midrange
default impairment value of 67% LEI. Since class
4 is being used, each adjustment is increased by +1.
Adjustments: Functional history; regular use of a cane
is grade 2, which is increased to grade 3. Physical
exam: Range of motion is the same as in Example
16-5, but was used in class placement. Calf atrophy is
grade 2, which is increased to grade 3. Clinical stud-
ies: X ray at MMI showing heterotopic bone limit-
ing motion is grade 3, which is increased to grade 4.
Numerical adjustment: –2. Moved 2 positions to the
left (grade A). Regional impairment: 59% LEI or
24% WPI.

30 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 526, Partial Example 16-9: S/P Anterior Page 527, Example 16-10: Subluxing Patella
Cruciate Reconstruction and Medial Meniscus (continued): Impairment Rating
Repair
Adjustment grids: Function: Grade 2 (antalgic limp
Physical Exam: 5° flexion contracture, normal flexion despite bracing); Exam: Grade 2 (atrophy); Clinical
and no effusion. “Give way” weakness of his quadri- studies: Grade 2 (chondromalacia). Adjustments are
ceps and no atrophy. There is mild laxity of the ACL. consistent with the class 2 assignment for diagnoses,
His gait was unremarkable when exiting the examina- midrange default used resulting in final rating of 16%
tion room. LEI which converts to 6% WPI.

Clinical Studies: Current weight-bearing X rays show Page 527, Partial Example 16-11: S/P Total
bioabsorbable fixation of the ACL in good position Knee Replacement, With Apportionment:
with a normal 5 mm joint space in all 3 compartments. Left Column

Comment: The methodology requires the examiner to Physical Exam: Weight is 101.2 kg (225 lb) and height
pick one diagnosis for the region. The anterior instabil- is 157.5 cm (5 ft 2 in). She can flex her right knee to 80°
ity diagnosis was chosen, and the effect of the meniscal and has an extension lag of 5°. Her right knee is stable,
tear is reflected in the adjustments. quadriceps strength is 4+/5 and there is 2 cm atrophy
of the quadriceps on the right compared with the left.
Impairment Rating: Diagnosis: “cruciate or collateral Exam of the left knee is normal.
ligament injury” with mild instability assigned to class
1 with a default value of 10% LEI. Functional history Clinical Studies: X rays on the right show a well-
judged unreliable in the presence of only mild instabil- aligned knee replacement without loosening. X rays
ity and no atrophy, and thus not used in rating. Physical performed on the left at the time of the examination
exam instability not used as a grade modifier since sta- revealed 2 mm cartilage interval.
bility was used in class assignment. No atrophy would
be grade 0, but 5° flexion contracture would be rated
at 10% LEI by Table 16-23, and Table 16-25 indicates
a 10% LEI rating would be a mild degree of problem,
or a grade 1 modifier from Table 16-7. The anterior
cruciate reconstruction, in good position without joint
space narrowing on current weight-bearing X rays, by
itself would be a grade 1, mild pathology adjustment.
The presence of the meniscal tear and subsequent
repair (documented in the operation report) would jus-
tify moving up a grade to grade 2 for the final clinical
studies adjustment. The net adjustment is +1, so class 1,
grade D, or 12% LEI is the final rating.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 31

Page 527, Partial Example 16-11: S/P Total Page 528, Partial Example 16-12: Knee
Knee Replacement, With Apportionment, Arthritis, Physical Exam
Right Column
There is 4/5 weakness on extension of the knee and 3
Impairment Rating: Right Knee: Regional impair- cm atrophy of the left thigh compared to the right.
ments: Diagnosis “s/p total knee replacement” and
per criteria of “fair result” assigned to class 3 with Page 528, Partial Example 16-12: Knee
midrange default value of 37% LEI. Adjustment grids: Arthritis, Impairment Rating
Functional history: Grade modifier 2 difficulty on
stairs; Physical examination: Grade modifier 1 (based Impairment Rating: Regional impairment:
on either atrophy or weakness; ROM would be grade Diagnosis: “arthritis” and per criteria of “no cartilage
modifier 2, but motion was used in assigning class); interval” assigned to class 4 with midrange default
Clinical studies: Grade modifier 2 (implant in good value of 50% LEI. Adjustment grids: Functional his-
position). Net adjustment is minus 4, thus, grade A. tory grade 2 modifier (frequent use of cane), with +1
Regional impairment 31% LEI. added since class is 4. Physical exam grade modifier 3
(range of motion is grade 3, atrophy is grade 2, weak-
Left knee: Regional Impairments: Diagnosis: “knee ness is grade 1) with +1 added because class 4 impair-
arthritis” and per criteria of “2 mm cartilage interval” ment. Clinical studies not applicable, used in class
assigned to class 2 with midrange default value of assignment. Numerical adjustment: –1 position moved
20% LEI. Adjustment grids: Functional history: Grade 1 to the left, at grade B; however, the minimum LEI
modifier 1; Physical examination: Grade modifier 0; for class 4 is 50% (see grid) and therefore impairment
Clinical studies: Not applicable, used to assign class. is unchanged. Regional impairment: 50% LEI or 20%
Net adjustment compared to diagnostic class 2 is Ϫ3 WPI.
(ie, functional history was 1 less than the diagnosis
class 2, physical examination was 2 less, and clinical Class 4 Example Calculation
studies not applicable). Therefore, moved 2 to the left
resulting in 16% LEI or 6% WPI. CDX GMFH GMPE GMCS
N/A
434

Apportionment: Using the left knee as her normal, (3 Ϫ 4)ϭ Ϫ1
the 16% LEI is subtracted from the right knee impair- (4 Ϫ 4)ϭ 0
ment of 31% LEI resulting in 15% LEI, which is attrib-
uted to her work-related injury. This converts to 6% Net adjustment ϭ Ϫ1
WPI.
Adjustment of Ϫ1 equals 1 position to the left of
default grade C resulting in grade B

Class 4, grade B ϭ 50%

Class 3 Example Calculation

CDX GMFH GMPE GMCS

3212 Page 532, Left Column, Paragraph 4

Right knee Sensory deficits can be challenging to grade, since the
clinical examination is based on subjective reports by
(2 Ϫ 3) Ϫ1 the patient. Grading is based on the results of sensibil-
ϩ (1 Ϫ 3) Ϫ2 ity testing by light touch and sharp/dull discrimination.
ϩ (2 Ϫ 3) Ϫ1
Page 532, Left Column, Paragraph 5
Net adjustment ϭ Ϫ4
moving or constant. Instruments designed to control
Adjustment of Ϫ4 results in default grade A the force and velocity of two-point or monofilament
application and of other stimuli are not yet available.
Class 3, grade A ϭ 31% The examiner’s experience, attention to detail, and
adherence to methods of administration can minimize
CDX GMFH GMPE GMCS the effects of the above variables.

2 1 0 N/A

Left knee (1 Ϫ 2) Ϫ1

ϩ (0 Ϫ 2) Ϫ2

Net adjustment ϭ Ϫ3

Adjustment of Ϫ3 equals 2 positions to the left of the
default grade C which equals grade A

Class 3, grade A ϭ 16%

Apportionment: 31% (right knee) Ϫ 16% (left knee)
ϭ 15%

32 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 532, Right Column, Paragraphs 1-4 Page 533, Left Column, Paragraph 1, 1st line

All clinical studies used to examine the degree of bility is normal. Individuals with severe deficits have
functional loss of sensibility are related to cutaneous decreased protective sensibility, which is defined as a
touch-pressure sensation. The examiner’s fingertip or conscious appreciation of pain, temperature, or pres-
a cotton tipped applicator can be used to assess light sure before tissue damage results from the stimulus.
touch. Sharp/dull recognition and protective sensation Individuals with very severe or complete deficit have
can be assessed using a disposable pin. The pinprick no protective sensibility.
test can be useful to determine whether protective sen-
sation is intact and to identify discrepancies between
dermatomal findings and reported symptoms. More
accurate assessment is obtained by using the sharp
and dull sides of the pin at random. Vibration test-
ing has yet to be associated with functional levels of
sensibility.

The sensory exam results should conform to the cuta-
neous distribution of a peripheral nerve, or a branch
of a peripheral nerve. The sensory exam should be
classified into one of five categories. Severity grade 0
is normal sensibility and sensation. Severity grade 1
is subjectively altered sensory perception but retained
light touch and sharp/dull recognition. In this grade the
patient correctly reports each time he/she is touched,
but stimuli are perceived as subjectively abnormal
(paresthesia-like), but in only the distribution of a par-
ticular cutaneous nerve. Severity grade 2 is impaired
light touch, but retained sharp/dull recognition. This
means several of the light touch stimuli are not felt by
the patient, but sharp and dull stimuli are consistently
recognized correctly. Severity grade 3 is impaired
sharp/dull recognition, but retained protective sensibil-
ity. In this grade. light touch recognition is severely
impaired, and sharp/dull discrimination is absent, but
the sharp side of the pin is recognized as touching
the patient, and protective sensation is still present, as
recognized by the absence of blisters, burns, abrasions,
scars, etc from unrecognized trauma or repetitive
activity. Severity grade 4 sensation is absent sensa-
tion and no protective sensibility. There should be no
recognition of light touch and no recognition of touch
with the sharp side of the pin, and there will usually be
signs of skin injury (blisters, scars, burns, abrasions,
etc).

If nerve conduction testing has been done, there should
be at least major sensory conduction block if the physi-
cal exam is consistent with sensory severity grade 3,
and there should be axon loss or no recordable sensory
nerve action potential (SNAP) if the physical exam is
consistent with sensory grade 4 severity.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 33
Page 533, Partial Table 16-11, Sensory and Motor Severity, Row 3, Columns 3-6

Sensory Deficit Normal sen- Subjectively altered Impaired light touch, Impaired Absent sensation and
sibility and sensory perception but retained sharp/ sharp/dull no protective sensibility
sensation but retained light dull recognition recognition,
Normal touch and sharp/dull but retained
monofilament recognition protective
and normal sensibility
2-point
discrimination

Page 534, Partial Table 16-12, Peripheral Nerve Impairment – Lower Extremity Impairments, Row 1

Note: Classification of degree of deficit must be based on results of specific evaluation as explained in Section 16.4b and
the use of Table 16.11 Sensory and Motor Severity. The examiner must document specific results of sensory testing (sen-
sibility and two point discrimination) and motor assessment.

Page 534, Partial Table 16-12, Peripheral Nerve Impairment – Lower Extremity
Impairments: Row 12, Column 3

Obturator 0 0 1 1 22

No objective Mild motor or
motor deficits sensory deficit

2 3 3 34

Moderate motor
or moderate or
greater sensory
deficit

4 4 5 55

Severe motor
deficit

6 6 7 77

Very severe
motor deficit

34 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 535, Partial Table 16-12 (continued), Peripheral Nerve Impairment – Lower Extremity
Impairments: Rows 5, 7, and 9, Columns 3 and 5

Row 5 0 1 3 5 79 14 14 14 17 19 28 30 33 35 37

Inferior Gluteal No objective Mild motor Moderate motor Very severe
motor deficits deficit deficit motor deficit

19 21 23 25 25

Severe motor
deficit

Row 7 0 1 1 1 22 14 14 14 17 19 28 30 33 35 37

Femoral No objective Sensory deficit Moderate motor Very severe
sensory or motor or CRPS II (objec- deficit motor deficit
deficits tively verified)
19 21 23 25 25
1 3 5 79
Severe motor
Mild motor deficit
deficit

Row 9 0 1 2 3 45 14 15 16 19 21 26 26 26 29 32

Common No objective Sensory deficit Moderate motor Severe motor
Peroneal sensory or motor or mild CRPS II deficit deficit
deficits (objectively
verified) 33 35 37 39 42

Very severe
motor deficit

Page 538, Partial Example 16-16: Femoral Page 540, Left Column, Paragraph 2
Neuropathy, Physical Exam and Impairment The steps in assessing CRPS type I impairment are:
Rating
Page 541, Table 16-15, Row 3, Column 2
Physical Exam: Decreased light touch perception
in leg in the distribution of the saphaneous nerve 0% LE
(the distal sensory branch of the femoral nerve) with
intact sharp/dull perception. The area of skin along Page 542, Right Column
the medial leg has retained sharp/dull perception. Amputation impairment is based on the level of the
Blisters on the medial malleolus from his shoe rubbing amputation with adjustments for proximal problems
on the area where the skin has decreased sensation. reflected by functional history, physical examina-
Quadriceps strength is grade 4/5. tion, and clinical studies, unless the proximal prob-
lems qualify for separate impairments (diagnosis,
(Impairment Rating) range of motion, or nerve injury). Table
and sensory. For sensory deficit the impairment is 2%
LE and for the motor deficit the impairment is 7% LEI. assignment to grade D or grade E. These adjust-
The combined impairment is 9% LEI which is equiva- ments are performed as outlined in Section 16.3.
lent to 4% WPI. The amputation impairment may be combined with
proximal diagnosed-based impairments or proximal
(Class 1 Example Calculation Box, last three lines) range of motion impairments; the examiner must
Class 1, grade D = 2% sensory deficit explain the rationale for combining. Impairment for
Motor deficit = 7% amputation can never exceed 100% lower extremity.
7% + 2% = 9%

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 35

Page 544, Left Column Paragraph 4 Page 548, Left Column, Paragraph 1
Both extremities should be compared. If the contra-
lateral joint is uninjured it may serve as defining the increase is 2 (net modifier) 10% (modification per-
centage) ϫ 10% LEI (the calculated range of motion
Page 544, Right Column Paragraph 2 impairment) or 1% LEI.

motion in the lower extremity. The ranges listed in Page 548, Left Column, Number 2
Tables 16-18 to 16-24 define the severity of impair-
ment (mild, moderate, severe) for lower extremity 2. Compare results to criteria in Tables 16-18 to

Page 544, Right Column Paragraph 4 Page 549, Table 16-24, Hip Motion
Impairments – Lower Extremity Impairment,
1 or 2. The impairment is increased by multiplying Row 9, Column 1
the functional history net modifier 10% by the total
motion impairment. With the above example, if the Adduction
range of motion impairment was 10% LEI (class 1),
the functional grade (class 3) and the net modifier 2,

Page 550, Table 16-25 Range of Motion ICF Classification: Rows 4-9
Note: Rows were removed to simplify this Table and to provide consistency with the Upper Extremity.

LESSER TOE 0 246
No motion deficits
LEI based on Table
16-18

GREATER TOE 0 257
No motion deficits
LEI based on Table
16-19

HINDFOOT 0 2457 14 17 19 24 25 27 30 32 50 52 55 57
No motion deficits
LEI based on Table LEI based on Table LEI based on Table LEI based on Table
16-20 and Table 16-20 and Table 16-20 and Table 16-20 and Table
16-21 16-21 16-21 16-21

ANKLE 0 7 12 15 19 24 25 27 30 42 45 50 52 55 57 62
No motion deficits 65 80 87
LEI based on Table LEI based on Table LEI based on Table
16-21 and 16-22 16-21 and 16-22 16-21 and 16-21 LEI based on Table
16-21 and 16-22

KNEE 0 10 20 30 35 40 45 50 55 60 65
No motion deficits 70 75 80 85
LEI based on Table LEI based on Table LEI based on Table
16-23 16-23 16-23 90 95

LEI based on Table
16-23

HIP 0 5 10 15 20 25 30 35 40 45 50 55 60 65

No motion deficits LEI based on Table LEI based on Table LEI based on Table 70 75 80 85
90 95
16-24 16-24 16-4

LEI based on Table

16-24

Page 563, Right column, Paragraph 1 states where apportionment is appropriate, 1% impair-
ment would have preexisted the new injury and 2%
of 1% or 2% WPI would not be added to increase the would be related to the new injury. A person who has a
impairment beyond maximum impairment assigned grade C or 2% WPI who sustains a new injury, and still
for grade E in that diagnostic impairment class. Thus, falls in grade A, B, or C, still has a 2% WPI, meaning
a person with a grade B or 1% impairment who there is no new impairment (0%) for the new injury.
sustains a similar, subsequent injury that is rated as
grade D or 3% WPI would then have a 3% WPI. In

36 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Chapter 17

Page 564, TABLE 17-2, Cervical Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–8% 9%–14% 15%–24% 25%–30%
RATING (WPI %)

SOFT TISSUE AND NON- SPECIFIC CONDITIONS

Non-specific 0 11233
chronic, or
chronic recur- Documented Documented history
rent neck pain history of of sprain/strain-type
(also known as sprain/strain- injury with contin-
chronic sprain/ type injury, ued complaints of
strain, symp- now resolved, axial and/or non-
tomatic degen- or occasional verifiable radicular
erative disc complaints complaints; similar
disease, facet of neck pain findings docu-
joint with no mented on mul-
pain, chronic objective tiple occasions (see
whiplash, etc) findings on Section 17.2 General
examination Considerations)

MOTION SEGMENT LESIONS

Intervertebral 0 45678 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
disc herniation
and/or AOMSIa Imaging Intervertebral Intervertebral disk Intervertebral disk Intervertebral disk
findings of disk herniation(s) herniation and/or herniations or herniation(s) or
Note: AOMSI intervertebral or documented AOMSI at a single AOMSI at multiple AOMSI, with medi-
includes insta- disk hernia- AOMSI at a single level with medically levels, with medi- cally documented
bility (specifi- tion without level or multiple documented find- cally documented findings; with or
cally as defined a history levels with medi- ings; with or with- findings; with or without surgery
in the Guides), of clinically cally documented out surgery without surgery
arthrodesis, correlating findings; with or and
failed arthro- radicular without surgery and and
desis, dynamic symptoms with documented
stabilization or and with documented with or without signs of residual
arthroplasty, residual radiculopa- documented bilateral or
or combina- for disk thy at the clinically signs of residual multiple-level
tions of those in herniation(s) appropriate level radiculopathy at radiculopathy at
multiple-level with documented present at the time a single clinically the clinically appro-
conditions resolved radicu- of examination (see appropriate level priate levels pres-
lopathy or non- Table 17-7 to grade present at the time ent at the time of
verifiable radicular radiculopathy) of examination (see examination (see
complaints at the Table 17-7 to grade Table 17-7 to grade
clinically appropri- radiculopathy) radiculopathy)
ate level(s) pres-
ent at the time of
examinationb

Pseudarthrosis 0 45678 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30

Note: Only Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis
applies after (post surgery) (post surgery) at (post surgery) at (post surgery) at (post surgery) at
spinal surgery with no resid- a single level or a single level with multiple levels with multiple levels with
intended for ual signs or multiple levels with medically docu- medically docu- medically docu-
fusion with symptoms medically docu- mented findings mented findings mented findings
resultant docu- mented findings
mented motion and and and
(not necessarily and
AOMSI by defini- with documented with or without with documented
tion provided in with documented radiculopathy at documented signs of bilateral
footnote) with resolved radicu- the clinically appro- radiculopathy at or multiple-level
consistent radio- lopathy or non- priate level pres- a single clinically radiculopathy at
graphic findings verifiable radicular ent at the time of appropriate level the clinically appro-
or hardware complaints at the examination (see present at the time priate levels pres-
failure; with or clinically appropri- Table 17-7 to grade of examination (see ent at the time of
without surgery ate level present radiculopathy) Table 17-7 to grade examination (see
to repair at the time of radiculopathy) Table 17-7 to grade
examination radiculopathy)

a See footnote a on page 571.
b Or AOMSI in the absence of radiculopathy, or with documented resolved radiculopathy or nonverifiable radicular complaints
at the clinically appropriate levels present at the time of examination.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 37

Page 565, Table 17-2 (continued) Cervical Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–8% 9%–14% 15%–24% 25%–30%
RATING (WPI %)

Spinal Stenosis 0 45678 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
(may include
AOMSI)a Cervical Cervical stenosis Cervical stenosis at Cervical stenosis at Cervical stenosis at
stenosis at at a single level or a single level with multiple levels with multiple levels with
Note: AOMSI 1 or more multiple levels with or without AOMSI or without AOMSI or without AOMSI
includes insta- levels with or without AOMSI with medically doc- with medically doc- with medically doc-
bility (specifi- or without with medically doc- umented findings; umented findings; umented findings;
cally as defined AOMSI with umented findings; with or without with or without with or without
in the Guides), axial pain with or without surgery surgery surgery
arthrodesis, medically surgery
failed arthro- documented and and and
desis, dynamic symptoms, and
stabilization or resolved with documented with or without with documented
arthroplasty, without with documented radiculopathy at documented resid- signs of residual
or combina- residual com- resolved radicu- the clinically appro- ual radiculopathy bilateral or
tions of those in plaints or lopathy or non- priate level pres- at a single clinically multiple-level
multiple-level findings verifiable radicular ent at the time of appropriate level radiculopathy at
conditions complaints at clini- examination (see present at the time the clinically appro-
cally appropriate Table 17-7 to grade of examination (see priate levels pres-
level(s) present radiculopathy)b Table 17-7 to grade ent at the time of
at the time of radiculopathy)b examination (see
examination Table 17-7 to grade
radiculopathy)b

FRACTURES/DISLOCATIONS OF THE SPINE

Compression f 0 22468 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
Fractures of 1 or
more vertebral Single- or Single- or multiple- Single- or multiple- Single- or multiple- Single- or multiple-
bodies multiple-lev- level fractures with level fractures with level fractures with level fractures with
els fractures Ͻ25% compression 25%–50% compres- Ͼ50% compres- Ͼ50% compression
and/or with no or of any vertebral sion of any verte- sion of 1 vertebral of 1 vertebral body;
minimal com- body; with or bral body; with or body; with mod- with or without
Fracture of pos- pression of without minimal without moderate erate to severe moderate to severe
terior element any vertebral bony retropulsion, bony retropulsion; bony retropulsion; bony retropulsion;
(pedicle, lam- body; with with or without with or without with or without with or without
ina, articular or without pedicle and/or pedicle and/or pedicle and/or pedicle and/or
process, trans- pedicle and/ posterior element posterior element posterior element posterior element
verse process) or posterior fracture (Յ5-mm fracture (Ͼ5-mm fracture (Ͼ5-mm fracture (Ͼ5-mm
element frac- displacement) displacement) displacement) displacement)
and/or ture (Ͻt5-mm
displacement) Healed, with or Healed, with or Healed, with or Healed, with or
burst fracture without surgery without surgery without surgical without surgical
(including ver- (including vertebro- intervention; with intervention; with
Healed with tebroplasty or plasty or kypho- residual deformity residual deformity
or without kyphoplasty) plasty) with resid-
surgical inter- ual deformity and and
vention; with and
no residual and may have radicul- may have docu-
signs or may have docu- opathy at a single mented signs
symptoms mented resolved may have docu- clinically appropri- of bilateral or
radiculopathy or mented radiculopa- ate level present multiple-level
nonverifiable radic- thy at the clinically at the time of radiculopathy at
ular complaints at appropriate level examination (see the clinically appro-
clinically appropri- present at the time Table 17-7 to grade priate levels pres-
ate level(s)b of examination (see radiculopathy)b ent at the time of
Table 17-7 to grade examination (see
radiculopathy)b Table 17-7 to grade
radiculopathy)b

a See footnote a on page 571.
b With signs of spinal cord injury or myelopathy: see Chapter 13, The Central and Peripheral Nervous System, for calculating
additional impairment

38 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 566, Table 17-2 (continued) Cervical Spine Regional Grid: Spine Impairments:
Row 3, Columns 3, 4, 5, 6

Dislocations/ 0 22468 9 10 11 12 14 15 17 19 21 23 25 27 28 29 30
fracture-
dislocation Dislocation Single-level disloca- Single-level disloca- Multiple-level Multiple-level
or fracture- tion with or with- tion with or with- dislocation with dislocation with
dislocation out fracture out fracture or without surgi- or without surgi-
with no or cal intervention, cal intervention,
minimal com- Healed, with or Healed, with or including fusion including fusion
pression of without surgery without surgi-
any vertebral cal intervention, and and
body; with and including fusion
or without may have docu- may have signs of
pedicle and/ with documented and mented radicul- bilateral or multi-
or posterior resolved radicu- opathy at a single ple-level radiculop-
element frac- lopathy or non- may have docu- clinically appropri- athy at the clinically
ture (Ͻ5-mm verifiable radicular mented radiculopa- ate level present appropriate levels
displacement) complaints at clini- thy at the clinically at the time of present at the time
cally appropriate appropriate level examination (see of examination (see
Healed, with level(s)b present at the time Table 17-7 to grade Table 17-7 to grade
or without of examination (see radiculopathy)b radiculopathy)b
surgical inter- Table 17-7 to grade
vention; with radiculopathy)b
no residual
signs or
symptoms

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 39
Page 567, Table 17-3 Thoracic Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–6% 7%–11% 12%–16% 17%–22%
RATING (WPI %)

Non-specific 0 11233
chronic, or
chronic recur- Documented Documented his-
rent thoracic history of tory of sprain/
spine pain sprain/strain- strain type injury
(also known as type injury, with continued
chronic sprain/ now resolved, complaints of
strain, etc) or occasional axial and/or non-
continued verifiable radicular
complaints complaints and
of mid-back similar findings
pain with documented on
no objective multiple occa-
findings on sions in previous
examination examinations and
present at the time
of evaluation (see
Sec. 17.2 General
Considerations)

MOTION SEGMENT LESIONS

Intervertebral 0 23456 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
disk herniation
and/or AOMSIa Imaging Intervertebral Intervertebral Intervertebral disk Intervertebral disk
findings of disk herniation(s) disk herniation or herniation(s) or herniation(s) or
Note: AOMSI intervertebral or documented AOMSI at a single AOMSI at multiple AOMSI, at multiple
includes insta- disk hernia- AOMSI, at a single level, with medi- levels with medi- levels, with medi-
bility (specifi- tion without or multiple levels, cally documented cally documented cally documented
cally as defined a history with medically doc- findings; with or findings; with or injury; with or
in the Guides), of clinically umented findings; without surgery without surgery without surgery
arthrodesis, correlating with or without
failed arthro- radicular surgery; findings and and and
desis, dynamic symptoms
supral sta- and with documented with documented with documented
bilization or residual radicul- signs of residual signs of residual
arthroplasty, with for disk opathy at the clini- radiculopathy at bilateral or
or combina- herniation(s) cally appropriate a single clinically multiple-level
tions of those in with documented level present at appropriate level radiculopathy
multiple-level resolved radicu- the time of exami- present at the time at the clinically
conditions lopathy or non- nation (see Table of examination (see appropriate levels
verifiable radicular 17-7, Examination Table 17-7 to grade present at the time
complaints at clini- Adjustment, radiculopathy) of examination (see
cally appropriate to grade Table 17-7 to grade
level(s), present radiculopathy) radiculopathy)
at the time of
examinationb

Pseudarthrosis 0 23456 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22

Note: Only Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis
applies after (post surgery) (post surgery) at (post surgery) at (post surgery) at (post surgery) at
spinal surgery with no resid- a single level or a single level with multiple levels with multiple levels with
intended for ual signs or multiple levels with medically docu- medically docu- medically docu-
fusion with symptoms medically docu- mented findings mented findings mented findings
resultant docu- mented findings
mented motion and and and
(not necessarily and
AOMSI by defi- may have docu- may have docu- may have docu-
nition provided may have docu- mented radiculopa- mented radicul- mented signs
in footnote) mented resolved thy at the clinically opathy at a single of bilateral or
with consistent radiculopathy or appropriate level clinically appropri- multiple-level
radiographic nonverifiable radic- present at the time ate level present radiculopathy
findings or hard- ular complaints at of examination (see at the time of at the clinically
ware failure; the clinically appro- Table 17-7 to grade examination (see appropriate levels
with or without priate level(s) pres- radiculopathy) Table 17-7 to grade present at the time
surgery to repair ent at the time of radiculopathy) of examination (see
examination Table 17-7 to grade
radiculopathy)

a See footnote a on page 571.
b Or AOMSI in the absence of radiculopathy, or with documented resolved radiculopathy or nonverifiable radicular complaints
at the clinically appropriate levels present at the time of examination..

40 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 568, Table 17-3 (continued) Thoracic Spine Regional Grid: Spine Impairments

FRACTURES/DISLOCATION OF THE SPINE

Compression 0 23456 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
Fractures of 1 or
more vertebral Resolved with Single- or multiple- Single- or multiple- Single- or multiple- Single or multiple-
bodies includ- or without level fracture(s) level fractures with level fractures level fractures
ing compression surgery, with with Ͻ25% com- 25%–50% compres- with Ͼ50% com- with Ͼ50% com-
fractures, no residual pression of any ver- sion of any vertebral pression of any pression of any
signs or tebral body; with body; with or with- vertebral body; vertebral body;
and/or symptoms or without minimal out moderate bony with or without with or without
bony retropulsion retropulsion into the moderate to severe moderate to severe
fracture of pos- into the canal, canal, pedicle and/ bony retropulsion bony retropulsion
terior element pedicle and/or or posterior element into the canal, into the canal,
(pedicle, lam- posterior element fracture (Ͼ5-mm pedicle and/or pedicle and/or
ina, articular fracture (Ͻ5-mm displacement) posterior element posterior element
process, trans- displacement) fracture (Ͼ5-mm fracture (Ͼ5-mm
verse process) Healed, with or displacement) displacement)
Healed, with or without surgery
and/or without surgery (including ver- Healed with or Healed with or
(includes ver- tebroplasty or without surgery without surgery
and burst frac- tebroplasty or kyphoplasty) with (including ver- (including ver-
ture of 1 or kyphoplasty) or without residual tebroplasty or tebroplasty or
more vertebral deformity kyphoplasty) with kyphoplasty) with
bodies and or without residual or without residual
and deformity deformity
may have docu-
mented resolved may have docu- and and
radiculopathy mented radiculopa-
or nonverifiable thy at the clinically may have docu- may have docu-
radicular com- appropriate level mented radicul- mented signs of
plaints at clinically present at the time opathy at a single bilateral or multi-
appropriate level, of examination (see clinically appropri- ple-level radiculop-
present at the time Table 17-7 to grade ate level present athy at the clinically
of examination radiculopathy) at the time of appropriate levels
examination (see present at the time
With signs of spinal Table 17-7 to grade of examination (see
cord injury or myel- radiculopathy) Table 17-7 to grade
opathy: see Chapter radiculopathy)
13, The Central and With signs of
Peripheral Nervous spinal cord injury With signs of spinal
System, for calcu- or myelopathy: see cord injury or myel-
lating additional Chapter 13 for cal- opathy: see Chapter
impairment culating additional 13 for additional
impairment impairment

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 41

Page 569, Table 17-3 (continued) Thoracic Spine Regional Grid: Spine Impairments, Rows 1, 2, and 3

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–6% 7%–11% 12%–16% 17%–22%
RATING (WPI %)

Dislocations/ 0 23456 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22
fracture-
dislocation Resolved with Single- or multiple- Single-level Multiple-level Multiple-level
or without level dislocation dislocation with or dislocation with or dislocation with or
surgery, with with or without without fracture without fracture without fracture
no residual fracture
signs or Healed, with or Healed with or Healed with or
symptoms Healed, with or without surgi- without surgi- without surgi-
without surgery cal intervention, cal intervention, cal intervention,
including fusion including fusion including fusion
and
and and and
may have docu-
mented resolved may have docu- may have docu- may have docu-
radiculopathy or mented radiculopa- mented radicul- mented signs
nonverifiable radic- thy at the clinically opathy at a single of bilateral or
ular complaints at appropriate level clinically appropri- multiple-level
clinically appropri- present at the time ate level present radiculopathy
ate level(s) of examination (see at the time of at the clinically
Table 17-7 to grade examination (see appropriate levels
With signs of spinal radiculopathy) Table 17-7 to grade present at the time
cord injury or myel- radiculopathy) of examination (see
opathy: see Chapter With signs of Table 17-7 to grade
13, The Central and spinal cord injury With signs of radiculopathy)
Peripheral Nervous or myelopathy: see spinal cord injury
System, for calcu- Chapter 13 for cal- or myelopathy: see With signs of spinal
lating additional culating additional Chapter 13 for cal- cord injury or myel-
impairment impairment culating additional opathy: see Chapter
impairment 13

42 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 570, Table 17-4 Lumbar Spine Regional Grid: Spine Impairments

SOFT TISSUE AND NON-SPECIFIC CONDITIONS

Non-specific 0 01233
chronic, or
chronic recur- Documented Documented history
rent low back history of sprain/strain type
pain (also of sprain/ injury with contin-
known as: strain-type ued complaints of
chronic sprain/ injury, now axial and/or non-
strain, symptom- resolved, or verifiable radicular
atic degenera- occasional complaints and sim-
tive disc disease, complaints ilar findings on mul-
facet joint of back pain tiple occasions (see
pain, SI joint with no Sec. 17.2, General
dysfunction, etc) objective Considerations)
findings on
examination

MOTION SEGMENT LESIONS

Intervertebral 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
disk herniation
and/or AOMSIa Imaging find- Intervertebral Intervertebral disk Intervertebral disk Intervertebral disk
ings of inter- disk herniation(s) herniation and/or herniations and/or herniations and/or
Note: AOMSI vertebral disk or documented AOMSI at a single AOMSI at multiple AOMSI, at multiple
includes herniation AOMSI, at a single level with medically levels, with medi- levels, with medi-
instability without a level or multiple documented find- cally documented cally documented
(specifically history of levels with medi- ings; with or with- findings; with or findings; with or
as defined in clinically cally documented out surgery without surgery without surgery
the Guides), correlating findings; with or
arthrodesis, radicular without surgery and and and
failed arthro- symptoms
desis, dynamic and with documented with or without with documented
stabilization or residual radicul- documented resid- signs of residual
arthroplasty, with documented opathy at the clini- ual radiculopathy bilateral or
or combina- resolved radicul- cally appropriate at a single clinically multiple-level
tions of those in opathy at clinically level present at the appropriate level radiculopathy
multiple-level appropriate level(s) time of examina- present at the time at the clinically
conditions or nonverifiable tion (see Physical of examination (see appropriate levels
radicular com- Examination Table 17-7 to grade present at the time
plaints at clinically adjustment grid in radiculopathy) of examination (see
appropriate level(s), Table 17-7 to grade Table 17-7 to grade
present at the time radiculopathy) radiculopathy)
of examinationa

Pseudarthrosis 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33

Note: Only Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis Pseudarthrosis
applies after (post surgery) at (post surgery) at a (post surgery) at a
spinal surgery (post surgery) (post surgery) at a single level with multiple levels with multiple levels with
intended for medically docu- medically docu- medically docu-
fusion with with no resid- a single level or mented findings mented findings mented findings
resultant docu-
mented motion ual signs or multiple levels with and and and
(not necessarily
AOMSI by defi- symptoms medically docu- may have docu- may have docu- may have docu-
nition provided mented signs of mented radicul- mented signs of
in footnote) mented findings radiculopathy at opathy at a single bilateral or multiple
with consistent the clinically appro- clinically appropri- level radiculopathy
radiographic and priate level pres- ate level present at the clinically
findings or hard- ent at the time of at the time of appropriate levels
ware failure; with documented examination (see examination (see present at the time
with or without resolved radicu- Table 17-7 to grade Table 17-7 to grade of examination (see
surgery to repair lopathy or non- radiculopathy) radiculopathy) Table 17-7 to grade
verifiable radicular radiculopathy)
complaints at the
clinically appropri-
ate level(s) pres-
ent at the time of
examination

a Or AOMSI in the absence of radiculopathy, or with documented resolved radiculopathy or nonverifiable radicular complaints
at the clinically appropriate levels present at the time of examination.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 43

Page 571, Table 17-4 (continued) Lumbar Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–9% 10%–14% 15%–24% 25%–33%
RATING (WPI %)

Spinal stenosisa 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
(may include
AOMSI) Lumbar steno- Lumbar stenosis, Lumbar stenosis, Lumbar stenosis, Lumbar stenosis,
at a single level at multiple levels at multiple levels
Note: AOMSI sis at 1 or at a single level with or without with or without with or without
includes insta- AOMSI with medi- AOMSI with medi- AOMSI with medi-
bility (specifi- more levels or multiple levels, cally documented cally documented cally documented
cally as defined findings; with or findings; with or findings; with or
in the Guides), with axial pain (with or without without surgery without surgery without surgery
arthrodesis, (decompression) (decompression) (decompression)
failed arthro- only AOMSI) with medi-
desis, dynamic and and and
stabilization or cally documented
arthroplasty, documented inter- documented neuro- severe neurogenic
or combina- findings; with or mittent neurogenic genic claudication, claudication and
tions of those in claudication (see walking limited to inability to ambu-
multiple-level without surgery Table 17-7 to grade <10 minutes (see late without assis-
conditions radiculopathy, but Table 17-7 to grade tive devices
(decompression) not claudication) radiculopathy, but
not claudication) may have docu-
or may have docu- mented signs of
mented signs of may have docu- bilateral or multi-
with resolved radiculopathy at mented signs of ple-level radiculop-
previously docu- the clinically appro- radiculopathy at athy at the clinically
mented neurogenic priate level pres- a single clinically appropriate levels
claudication ent at the time of appropriate level present at the time
examination present at the time of examination
and of examination
with signs of cauda with signs of cauda
may have docu- equina syndrome: with signs of cauda equina syndrome:
mented resolved use Chapter 13 to equina syndrome: use Chapter 13 to
radiculopathy at calculate additional use Chapter 13 to calculate additional
clinically appropri- impairment calculate additional impairment
ate level(s) or non- impairment
verifiable radicular
complaints at clini-
cally appropriate
level(s), present
at the time of
examination

SPONDYLOLISTHESIS

Spondylolisthesis 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33

Spondylolysis Spondylolisthesis Spondylolisthesis Spondylolisthesis Spondylolisthesis
with medically with medically with medically
or spondylolis- with medically documented injury; documented injury; documented injury;
with or without with or without with or without
thesis at one or documented injury; surgery at a single surgery at multiple surgery at multiple
level levels levels (including
more levels on with or without AOMSI)
and and
imaging stud- surgery and
with documented with documented
ies with axial and signs of radiculopa- signs of radicul- with documented
pain only thy at the clinically opathy at a single signs of bilateral
appropriate level clinically appropri- or multiple-level
with documented present at the time ate level present radiculopathy
of examination (see at the time of at the clinically
resolved radicu- Table 17-7 to grade examination (see appropriate levels
radiculopathy) Table 17-7 to grade present at the time
lopathy or non- radiculopathy) of examination (see
Table 17-7 to grade
verifiable radicular radiculopathy)

complaints at clini-

cally appropriate

level, present

at the time of

examination

a Note: The following applies to the cervical, thoracic, and lumbar spine grids: 1) Intervertebral disk herniation excludes
annular bulge, annular tear and disk herniation on imaging without consistent objective findings of radiculopathy at the
appropriate level(s) when most symptomatic. 2) When AOMSI is the diagnosis being rated, imaging is not included in the Net
Adjustment Calculation, because imaging is used to confirm the diagnosis.

44 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 572, Table 17-4 (continued) Lumbar Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–9% 10%–14% 15%–24% 25%–33%
RATING (WPI %)

Degenerative 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
spondylolisthesis
with or without Degenerative Degenerative spon- Degenerative spon- Degenerative Degenerative spon-
spinal stenosis spondylolis- dylolisthesis, at a dylolisthesis at a spondylolisthesis at dylolisthesis is at
thesis at one single or multiple single level, with multiple levels with multiple levels with
or more lev- levels, with medi- medically docu- medically docu- medically docu-
els with axial cally documented mented injury; with mented injury; with mented injury; with
pain only injury; with or or without surgery or without surgery or without surgery
without surgery
previously docu- and and and
mented neurogenic
claudication documented inter- documented neuro- severe neurogenic
mittent neurogenic genic claudication, claudication and
and claudication (see walking limited to inability to ambu-
table 17-7 to grade <10 minutes (see late without assis-
may have docu- radiculopathy, but Table 17-7 to grade tive devices
mented resolved not claudication) radiculopathy, but
radiculopathy or not claudication) may have docu-
nonverifiable radic- may have with doc- mented signs of
ular complaints at umented radiculop- may have docu- bilateral or multi-
clinically appropri- athy at the clinically mented radicul- ple-level radiculop-
ate level(s), pres- appropriate level opathy at a single athy at the clinically
ent at the time of present at the time clinically appropri- appropriate levels
examination of examination ate level present present at the time
at the time of of examination
examination
with signs of cauda
with signs of cauda equina syndrome:
equina syndrome: use Chapter 13 to
use Chapter 13 to calculate additional
calculate additional impairment
impairment

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 45

Page 573, Table 17-4 (continued) Lumbar Spine Regional Grid: Spine Impairments

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–9% 10%–14% 15%–24% 25%–33%
RATING (WPI %)

FRACTURES/DISLOCATIONS OF THE SPINE

Fractures of 1 or 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
more vertebral
bodies Resolved Single- or multiple- Single- or multiple- Single- or multiple- Single- or multiple-
with or with- level fractures with level fractures level fractures with level fractures with
including com- out surgery, Ͻ25% compression with 25%–50% Ͼ50% compression Ͼ50% compression
pression frac- with no of any vertebral compression of any of any vertebral of any vertebral
tures, fracture residual signs body; with or with- vertebral body; with body; with or body; with or
of posterior ele- or symptoms out retropulsion; or without retropul- without retropul- without retropul-
ment (pedicle, with or without sion; pedicle and/or sion into the canal; sion; pedicle and/or
lamina, articular pedicle and/or posterior element pedicle and/or posterior element
process, trans- posterior element fracture (Ͼ5-mm posterior element fracture (Ͼ5-mm
verse process) fracture (Ͻ5-mm displacement) fracture (Ͼ5-mm displacement)
displacement) displacement)
and Healed, with or Healed, with or
Healed, with or without surgery Healed, with or without surgery
burst fracture of without surgery (including ver- without surgery (including ver-
1 or more verte- (includes ver- tebroplasty or (including ver- tebroplasty or
bral bodies tebroplasty or kyphoplasty) with tebroplasty or kyphoplasty) with
kyphoplasty) or without residual kyphoplasty) with or without residual
deformity or without residual deformity
and deformity
and and
may have docu- and
mented resolved may have docu- may have signifi-
radiculopathy at mented radiculopa- may have signifi- cant radiculopathy
clinically appro- thy at the clinically cant radiculopathy bilaterally or at
priate level(s) or appropriate level at a single clinically multiple clinically
documented non- present at the time appropriate level appropriate levels
verifiable radicular of examination (see present at the time present at the time
complaints (with- Table 17-7 to grade of examination (see of examination (see
out radiculopathy) radiculopathy) Table 17-7 to grade Table 17-7 to grade
at clinically appro- radiculopathy) radiculopathy)
priate level(s), pres- with signs of cauda
ent at the time of equina syndrome: with signs of cauda with signs of cauda
examination use Chapter 13 to equina syndrome: equina syndrome:
calculate additional use Chapter 13 to use Chapter 13 to
with signs of cauda impairment calculate additional calculate additional
equina syndrome: impairment impairment
use Chapter 13 to
calculate additional
impairment

46 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 574, Table 17-4 (continued) Lumbar Spine Regional Grid: Spine Impairments, Row 3

CLASS CLASS 0 CLASS 1 CLASS 2 CLASS 3 CLASS 4

IMPAIRMENT 0 1%–9% 10%–14% 15%–24% 25%–33%
RATING (WPI %)

Dislocations/ 0 56789 10 11 12 13 14 15 17 19 21 23 25 27 29 31 33
fracture-
dislocation Resolved Single- or multiple- Single-level disloca- Multiple-level dis- Multiple-level dis-
without sur- level dislocations tion with or with- location with or location with or
gery with no (with or without out fracture without fracture without fracture
residual signs fractures)
or symptoms healed, with or healed, with or healed, with or
healed, with or without surgi- without surgi- without surgi-
without surgery cal intervention, cal intervention, cal intervention,
including fusion including fusion including fusion
and
and and and
may have docu-
mented resolved may have docu- may have docu- with documented
radiculopathy or mented radiculopa- mented radicul- signs of bilateral
nonverifiable radic- thy at the clinically opathy at a single or multiple level
ular complaints at appropriate level clinically appropri- radiculopathy
clinically appropri- present at the time ate level present at the clinically
ate level(s), pres- of examination (see at the time of appropriate levels
ent at the time of Table 17-7 to grade examination (see present at the time
examination radiculopathy) Table 17-7 to grade of examination (see
radiculopathy) Table 17-7 to grade
with signs of cauda with signs of cauda radiculopathy)
equina syndrome: equina syndrome: with signs of cauda
use Chapter 13 to use Chapter 13 to equina syndrome: with signs of cauda
calculate additional calculate additional use Chapter 13 to equina syndrome:
impairment impairment calculate additional use Chapter 13 to
impairment calculate additional
impairment

Page 579, Figure 17-5, Loss of Motion Page 579, Right Column, Paragraph 2
Segment Integrity, Translation
Electrodiagnostic studies should be performed only
B by a licensed physician who is qualified by education,
A training, and experience in these procedures. Typically,
these studies are performed by board certified neurolo-
A dot is placed at the posterior superior corner of the gists and physical medicine specialists. Others duly
lower vertebra, and a separate dot is placed at the pos- recognized by an appropriate jurisdiction may perform
terior-inferior corner of the upper vertebra. The distance such studies within their applicable scope of practice
(A) is measured as illustrated by the figure, using two and field of expertise. The studies must be performed
parallel lines. Measurements are obtained in flexion and in accordance with established standards. The quality
extension. Measure the A-P sagittal plane diameter at the of the test and interpretation of the results depend on
midlevel of the superior vertebra (B). Distance A is then the skill and knowledge of the individual performing
compared to distance B; determine % or distance in mm the study. The technique and documentation of the
as specified for each region (see Section 17.3) AOMSI is electromyographer may be considered in assessing
established if the regional criteria are met. “EMG evidence” and validity. The EMG/NCV is con-
sidered to be an extension of the history and physical
examination, and interpretation should correlate with
the clinical findings.

Page 580, Figure 17-6, legend, last sentence

Therefore (ϩ8) Ϫ (Ϫ18) ϭ 26° and would qualify for loss
of structural integrity at any lumbar level.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 47

Page 583, Boxed Example: Lumbar Diskecto- Diagnosis: Status post herniated nucleus pulposus and
my With Residual Radiculopathy, last line anterior cervical diskectomy and fusion at C5-6 with
persistent left arm pain.
the default rating (C) for the diagnosis; that is, it would
remain at 12% whole person impairment (WPI). Impairment Rating: Regional Impairment: Diagnosis
is consistent with “Intervertebral disk herniation and/
Page 583, Left Column, Insert New Paragraph or documented AOMSI at a single level with medically
3, Continue into Right Column, Paragraph 1 documented findings; with or without surgery, and
with documented resolved radiculopathy
Regional Impairment
Page 585, Example 17-3: Intervertebral
In some instances, the evaluator may be asked to Disk Herniation or AOMSI at a Single Level
express an impairment rating in terms of the involved (continued)
spine region, rather than the whole person. This is
done by dividing the WPI estimate by the % of spine or non-verifiable radicular complaints at the clinically
function that has been assigned to that region. The appropriate level present at the time of examination,”
conversion factors used in the DBI method are the and therefore, assigned to class 2. Adjustment Grids:
same as those used for the DRE method in the Fifth Functional History: Grade modifier 1 based on both
Edition. For the purposes of the DBI method, the con- functional symptoms and PDQ. Physical Examination:
version factors are: 0.35 for the cervical spine, 0.20 for Grade modifier 2 based on motor strength. Clinical
the thoracic spine, and 0.75 for the lumbar spine. Studies: Grade modifier 2 based on imaging studies.
Net adjustment is Ϫ1 and the impairment is class 2
Page 584, Example 17-2, Intervertebral Disk grade B. Impairment is 11% WPI.
Herniation, Impairment Rating
Class 2 Example Calculation
Left Column
Impairment Rating: Regional Impairment: Diagnosis CDX GMFH GMPE GMCS
is consistent with “Intervertebral disk herniation and/or
documented AOMSI at a single or multiple levels with 2122
medically documented findings; with or
Net adjustment
Right Column
however, this is 2 or more points higher than the grade (GMFH Ϫ CDX) (1 Ϫ 2) ϭ Ϫ1
modifier for clinical studies and therefore discounted.
Physical Exam: + (GMPE Ϫ CDX) (2 Ϫ 2) ϭ 0

Page 584, Right Column, Insert before + (GMCS Ϫ CDX) (2 Ϫ 2) ϭ 0
Example 17-3
Net adjustment ϭ Ϫ1
CLASS 2
9% to 14% Whole Person Impairment Result is class 2 with an adjustment Ϫ1; therefore,
this impairment is class 2, grade B, which equals 11%
Page 584, Example 17-3: Intervertebral Disk
Herniation or AOMSI at a Single Level impairment
Current Symptoms: Resolution of neck pain and per-
sistent pain in the left arm. Symptoms occur only with Note: CDX indicates class of diagnosis; GMFH, grade modifier
strenuous activity. for Functional History; GMPE, grade modifier for Physical
Examination; and GMCS, grade modifier for Clinical Studies.
Physical Exam: Slightly decreased range of motion
of the cervical spine and slight weakness of wrist Page 585, Example 17-4: Intervertebral
extensors on the left, diminished light touch in C6 Disk Herniation or AOMSI at a Single Level,
distribution. History and Physical Exam
History: The patient sustained a blow to the posterior
aspect of his neck from a machine support that slipped.
Studies revealed a C7-T1 disk herniation. He

Physical Exam:
has decreased finger flexion strength (3/5), and
decreased sensation in ring and little fingers.

48 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 586, Example 17-5: Intervertebral Disk Page 586, Example 17-6: Vertebral Fractures
Herniation or AOMSI at Multiple Levels, at Multiple Levels, Right Column, Impairment
Physical Exam Rating

Physical Exam: Slight loss of cervical spine motion. Impairment Rating: Regional Impairment: Diagnosis
Neurologic examination reveals diminished light touch is consistent with “Single or multiple level fractures
on the right in the distribution of C6 and decreased with >50% compression of one vertebral body; with
brachioradialis reflex, right. or without moderate to severe bony retropulsion; with
or without pedicle and/or posterior element fracture
Page 586, Example 17-5: Intervertebral Disk (>5mm displacement). Healed; with or without surgi-
Herniation or AOMSI at Multiple Levels, cal intervention; with residual deformity and may have
Impairment Rating documented multiple level radiculopathy at the clini-
cally appropriate levels present at the time of examina-
not applicable, define class. Net adjustment is Ϫ1, tion,” and is therefore assigned to class 4. Adjustment
resulting in class 3, grade B. Impairment is 17% WPI. Grids: Functional History: Grade modifier 4 based on
pain/symptoms at rest and PDQ. Physical Examination:
Class 3 Example Calculation Grade modifier 2 based on atrophy, noting the 4/5
weakness would have resulted in grade modifier 1.
CDX GMFH GMPE GMCS Clinical Studies: not applicable, used to determine
class. Since the diagnostic class is 4, the net adjustment
3 3 2 n/a calculation requires that +1 be added to each grade
modifier to calculate the net adjustment. Net adjust-
Net adjustment ment compared with diagnostic class is 0, resulting in
class 4, grade C. Impairment is 28% WPI.
(GMFH Ϫ CDX) (3 Ϫ 3) ϭ 0

ϩ (GMPE Ϫ CDX) ϩ (2 Ϫ 3) ϭ Ϫ 1

Net adjustment ϭ Ϫ 1

Result is class 3 with an adjustment Ϫ 1 from the default Class 4 Example Calculation
value C, which equals class 3, grade B ϭ 17% impairment.

Note: CDX indicates class of diagnosis; GMFH, grade modifier CDX GMFH GMPE GMCS
for Functional History; GMPE, grade modifier for Physical
Examination; and GMCS, grade modifier for Clinical Studies. 4 4 (ϩ1 for class 4) ϭ 5 2 (ϩ1 for class 4) ϭ 3 n/a

Net adjustment

(GMFH Ϫ CDX) (5Ϫ 4) ϭ 1

ϩ (GMPE Ϫ CDX) ϩ (3 Ϫ 4) ϭ Ϫ 1

Net adjustment ϭ 0

Result is class 4 with an adjustment of 0. Therefore,
this impairment is class 4, grade C, which equals 28%
impairment.

Note: CDX indicates class of diagnosis; GMFH, grade modifier
for Functional History; GMPE, grade modifier for Physical
Examination; and GMCS, grade modifier for Clinical Studies.