Rating Schedule

INTRODUCTION

This section includes impairment determination for hearing, equilibrium (vertigo), the face (cosmetic deformity), respiration (air passage defects), mastication and deglutition, olfactory and taste, speech (dysarthria), and temporomandibular joint.

If there is more than one category of impairment, use the Combined Values Chart to determine total impairment.

HEARING LOSS

For objective techniques to determine hearing impairment, take the following steps.

a. Test each ear separately with a pure-tone audiometer and record the hearing levels at 500Hz, 1,000 Hz, 2,000 Hz, and 3,000 Hz. It is necessary that the hearing level for each frequency be determined in every patient.

The following rules apply for extreme values.

1. If the hearing level at a given frequency is greater than 100dB or is beyond the range of the audiometer, the level shall be taken as 100dB.

2. If the hearing level for a given frequency is better than normal, the level shall be taken as 0 dB.

b. Total these four decibel values for each ear separately. Hearing levels are determined in dB according to ANSI-1969 standards.

c. Consult Table 1 for percentage of monaural hearing impairments(s). "DSHL" is the decibel sum of the hearing threshold levels at 500, 1,000, 2,000 and 3,000 Hz, and is equated to percent of monaural hearing impairment.

d. Consult Table 3 to determine percent of binaural hearing impairment.

e. Consult Table 2 to determine impairment of the whole person.

EQUILIBRIUM

Equilibrium or orientation in space is maintained by the visual, kinesthetic, and vestibular mechanisms.

Vertigo, or vestibular dysequilibrium, is a sense movement that is perceived by the patient as “subjective,” in the case of movement of self, or as “objective,” in the case of movement of the environment.

The movements may be described as a sense of spinning, pulsion, or tilting of the visual environment with change of head position.

This section is primarily concerned with permanent impairment resulting from defects of the vestibular (labyrinthine) mechanisms and its central connections. The defects are evidenced by loss of equilibrium produced by: (1) loss of vestibular function; or (2) disturbances of vestibular function. (Lightheadedness and abnormalities of gait not associated with vertigo are not considered.)

Class 1—Impairment of the Whole Person, 0%

A patient belongs in Class 1 when (a) signs of vestibular dysequilibrium are present without supporting objective findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living can be performed without assistance.

Class 2—Impairment of the Whole Person, 5 - 10%

A patient belongs in Class 2 when (a) signs of vestibular dysequilibrium are present with supporting objective findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living are performed without assistance, except for complex activities such as bike riding, or certain activities related to the patient’s work, such as walking on girders or scaffolds.

Class 3—Impairment of the Whole Person, 11 - 30%

A patient belongs in Class 3 when (a) signs of vestibular dysequilibrium are present with supportive objective findings (e.g., nystagmus, ataxia); and (b) the patient’s usual activities of daily living cannot be performed without assistance, except such simple activities as self care, some household duties, walking on the street, and riding in a motor vehicle operated by another person.

Class 4—Impairment of the Whole Person, 31 - 60%

A patient belongs in Class 4 when (a) signs of vestibular dysequilibrium are present with supportive objective findings (e.g., nystagmus, ataxia); and (b) usual activities of daily living cannot be performed without assistance, except for self care.

Class 5—Impairment of the Whole person, 61 - 95%

A patient belongs in Class 5 when (a) signs of vestibular dysequilibrium are present with supportive objective findings (e.g., nystagmus, ataxia); and (b) the usual activities of daily living cannot be performed without assistance, except self-care not requiring ambulation; and (c) confinement to the home or premises is necessary.

DISORDERS OF THE FACE

In evaluating permanent impairment from a disorder of the face, functional capacity as well as structural integrity are considered. Impairment in this section is limited to abnormality in structural integrity only. (For loss of function, refer to sections regarding specific anatomical areas). Loss of structural integrity can result from cutaneous disfigurement, such as that due to abnormal pigmentation or scars, or from loss of supporting structures, such as soft tissue, bone, or cartilage of the facial skeleton.

Class 1—Impairment of the Whole Person, 1 - 5%

A patient belongs in Class 1 when the facial abnormality is limited to a disorder of the cutaneous structures, such as visible scars and abnormal pigmentation.

Class 2—Impairment of the Whole Person, 6 - 10%

A patient belongs in Class 2 when there is loss of supporting structures of part of the face, with or without cutaneous disorder. Depressed cheek, nasal, or frontal bones constitute a Class 2 impairment.

Class 3—Impairment of the Whole Person, 11 - 15%

A patient belongs in Class 3 when there is absence of a normal anatomical area of the face. Loss of an eye (see Section 10) or loss of part of the nose with the resulting cosmetic deformity constitute a Class 3 impairment.

Class 4—impairment of the Whole Person, 16 - 35%

A patient belongs in Class 4 when facial disfigurement is so severe that it precludes social acceptance. Massive distortion of normal facial anatomy constitutes a Class 4 impairment.

RESPIRATION

Air passage defects may result in permanent impairment. The following provides a rating classification system for air passage defects (excluding larynx air ways and lung parenchyma). Permanent impairment from obstructive sleep apnea should be evaluated using the neurologic section.

Classes of Air Passage Defects

Class 1—Impairment of the Whole Person, 0 - 10%

A recognized air passage defect exists.

Dyspnea does not occur at rest.

Dyspnea is not produced by walking or climbing stairs freely, performance of other usual activities of daily living, stress, prolonged exertion, hurrying, hill climbing, or recreation* requiring intensive effort or similar activity.

Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx, upper trachea (to 4th ring), lower trachea, bronchi, or complete obstruction of the nose (bilateral), or nasopharynx.

*prophylactic restriction of activity such as strenuous competitive sports does not exclude patient from Class 1.

NOTE: Patients with successful permanent tracheostomy or stoma should be rated at 25% impairment of the whole person.

Class 2—Impairment of the Whole Person,11 - 30%

A recognized air passage defect exists.

Dyspnea does not occur at rest.

Dyspnea is not produced by walking freely on the level, climbing at least one flight of ordinary stairs, or the performance of other usual activities of daily living.

Dyspnea is produced by stress, prolonged exertion, hurrying, hill climbing, recreation except sedentary forms, or similar activity.

Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx, upper trachea (to 4th ring), lower trachea, bronchi, or complete obstruction of the nose (bilateral) or nasopharynx.

Class 3—Impairment of the Whole Person, 31 - 50%

A recognized air passage defect exists.

Dyspnea does not occur at rest.

Dyspnea is produced by walking more than one or two blocks on the level, climbing one flight of ordinary stairs even with periods of rest, performance of other usual activities of daily living, stress, hurrying, hill climbing, recreation, or similar activity.

Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx, upper trachea (to 4th ring), lower trachea, or bronchi.

Class 4—Impairment of the Whole Person, 51 -75%

A recognized air passage defect exists.

Dyspnea occurs at rest, although patient is not necessarily bedridden.

Dyspnea is aggravated by the performance of any of the usual activities of daily living beyond personal cleansing, dressing, grooming or its equivalent.

Examination reveals one or more of the following: partial obstruction of oropharynx, laryngopharynx, larynx, upper trachea (to 4th ring), lower trachea, or bronchi.

MASTICATION AND DEGLUTITION

Numerous conditions of non-gastrointestinal origin may interfere with these functions and dietary restrictions may result. If these restrictions are permanent, impairment may be determined as follows:

Restriction ... Impairment of the Whole Person

• Mild dysphagia with minimal modification of diet ... 10%
• Moderate dysphagia with restriction of pureed or liquid diet ... 30%
• Feeding gastrostomy or tube feeding required ... 50%

OLFACTION AND TASTE

(See neurologic impairment rating section.)

DYSARTHRIA

Impairment rating in this section is concerned with voice production and articulate speech. Language content and receptive speech disorders are considered in the section on impairment rating of neurologic disorders.

A classification chart, oral reading paragraph, and examining procedures for use in estimating speech impairment are described below.

Classification Chart Judgments as to the amount of impairment should be made with reference to the classes, percentages, and examples provided in the Speech Classification Chart (on page 98-99). The fifteen categories of the chart suggest activities or situations with different levels of impairment. Data gathered from direct observation of the patient or from interviews should be compared with these categories, and values should be assigned considering the specific impairments that are present.

Oral Reading Paragraph The paragraph of 100 words, entitled, “The Smith House,” composed of 10 sentences, provides a uniform means of comparing a speech example of the patient with the performance of normal speakers. The phonetic elements of the paragraph are selected particularly for their relevance to intelligibility of speech.

Examining Procedures

General Orientation The examining physician should have normal hearing as defined in the earlier section on Hearing.

The setting of the examination should be a reasonably quiet office that approximates the noise level conditions of everyday living. The examiner should base judgments of impairment on two kinds of evidence: (1) Direct observation of the patient’s speech in the office; for example, during conversation, during the interview, and while reading and counting aloud; and (2) reports pertaining to the patient’s performances in situations of everyday living. The reports or the evidence should be supplied by observers who know the patient well.

The standard of evaluation is the concept of a normal speaker’s performance in average situation of everyday living. It is assumed in this context that an average speaker usually can perform as follows: (1) Talk in a loud voice when the occasion demands it. (2) Sustain phonation for at least 10 seconds in one breath. (3) Complete at least a 10 word sentence in one breath. (4) Form all of the phonetic units of American speech, and join them together intelligibly. (5) Maintain a rate of at least 75 to 100 words per minute, and sustain a flow of speech for a reasonable length of time.

Specific Procedures

a. Place the patient approximately 8 feet from the examiner.

b. Interview the patient. This will permit observation of the patient’s speech in ordinary conversation while obtaining information pertinent to his or her history.

c. Listen to the patient’s speech as the patient reads aloud the short paragraph, “The Smith House.” For this exercise, seat the patient with the back towards the physician; maintaining a separation of 8 feet. Instruct the patient as follows: “You are to read this passage so that I can hear you plainly. Be sure to speak so that I can understand you”.

d. If additional reading procedures are required, simple prose paragraphs from a magazine may be used. A nonreader may be requested to give name, address, the days of the week, the months of the year, etc. Additional evidence regarding the patient’s rate of speech and ability to sustain it may be obtained by noting the time required to count to 100 by ones. Completion of the latter task in 60 to 75 seconds is accepted as normal.

e. Record judgment of the patient’s speech capacity with regard to each of the three sections of the Speech Classification Chart.

f. The degree of impairment of the speech function is equivalent to the greatest percentage of impairment recorded in any one of the three sections of the classification chart.

SPEECH CLASSIFICATION CHART

Audibility

Intelligibility

Functional Efficiency

TEMPOROMANDIBULAR JOINT DISORDERS

For permanent impairment of disorders of the temporomandibular joint consider range of motion, arthoplasty, and permanent dietary restrictions. If more than one category is used, the values should be combined using the Combined Values Chart.

Range of Motion

Only vertical opening of the jaw is measured and considered in determining impairment. Normal- 50mm opening ( from incisal edge of maxillary teeth to incisal edge of mandibular teeth)