Florida Impairment Guide

SECTION 5: NERVOUS SYSTEM

INTRODUCTION

1. Nervous system involvement may result in multiple impairments, which should be combined using the Combined Values Chart.

2. Sensory impairment rating utilizes the Grading Scheme on page 60 for calculation of percent of impairment.

3. Sensory impairment is measured for the digits using two-point discrimination or pain/temperature, and for other regions using pain/temperature testing.

4. Two-point discrimination testing of the digits uses a varied series of one or two points applied. If the subject is unable to distinguish between one point and two points at a distance of at least 10mm in two out of three applications, then sensation is impaired.

5. Motor impairment rating utilizes the Grading Scheme on page 60 for calculation of permanent impairment.

CENTRAL NERVOUS SYSTEM (BRAIN AND SPINAL CORD)

1. Language Disturbances

% Impairment of Whole Person

a. Minimal disturbances in comprehension or expression of language symbols for daily living, with minimal impairment in functional communication

15%

b. Moderate impairment in comprehension or expression of language symbols for daily living, with some useful functional communication

30%

c. Severe impairment in comprehension or expression of language symbols for daily living, with little functional communication

75%

d. Inability to comprehend or express language symbols sufficient for daily living, with no functional communication

95%

2. Disturbances of Consciousness and/or Complex Integrated Cerebral Function. (Determined by medical observation and psychometric testing, excluding functional overlay or primary psychiatric disturbances.)

Disturbances of complex integrated cerebral function, include defects in orientation, thinking, memory, judgment, ability to initiate and perform planned activity, and social behavior. Disturbances of consciousness include lethargy, clouding of consciousness, delirium, stupor, coma, and persistent vegetative state

% Impairment of Whole Person

a. Mild impairment of complex integrated cerebral function, able to live independently

15%

b. Mild impairment of complex integrated cerebral function, able to live independently, but requiring supervision with executive function

30%

c. Moderate impairment of complex integrated cerebral function, demonstrated by psychometric testing, with mild disturbance of consciousness, but able to perform all activities of daily living with supervision on a daily basis

50%

d. Moderately severe impairment of complex integrated cerebral function or moderate disturbance of consciousness, requiring supervision for activities of daily living

75%

e. Severe impairment of complex integrated cerebral function or delirium, requiring assistance as well as supervision for activities of daily living

95%

f. Stupor, coma, or persistent vegetative state

99%

3. Emotional Disturbances (organic dysfunction documented by medical observation, supported by psychometric testing. Not primary psychiatric disturbances.)

% Impairment of Whole Person

a. Intermittent mild to moderate emotional disturbance under unusually stressful situations

15%

b. Mild to moderate emotional disturbance under ordinary stresses of daily living

30%

c. Moderate to severe emotional disturbance under ordinary stresses of daily living, requiring sheltered living

75%

d. Severe emotional disturbance that continually endangers self or others, requiring continuous supervision or protected care

95%

4. Episodic Neurological Disorders

% Impairment of Whole Person

a. Slight severity and under such control that most of the activities of daily living can be performed

10%

b. Of such severity as to interfere moderately with activities of daily living

30%

c. Of such severity and constancy as to limit activities to supervised or protected care or confinement in an institution

75%

d. Of such severity and constancy as to totally incapacitate the individual in terms of daily living

95%

5. Sleep and Arousal Disorders

% Impairment of Whole Person

a. Reduced daytime alertness due to sleepiness or sleep episodes or disturbed nocturnal sleep affecting complex cerebral functions, but ability remains to carry out most activities of daily living

15%

b. Reduced daytime alertness due to sleepiness or sleep episodes or disturbed nocturnal sleep affecting complex cerebral functions, requiring some supervision to carry out activities of daily living

30%

c. Reduced daytime alertness due to sleepiness or sleep episodes or disturbed nocturnal sleep that significantly limits activities of daily living, requiring supervision by caretakers

75%

d. Such a severe reduction of daytime alertness due to sleepiness or sleep episodes or disturbed nocturnal sleep so that activities of daily living are severely limited, individual is unable to care for self in any situation or manner

95%

6. Station and Gait/Mobility

% Impairment of Whole Person

a. Able to rise to standing position and walk, with or without assistive devices, independent at community level, except for difficulty with elevations, grades, stairs, and distances

10%

b. Able to rise to standing position and walk with or without assistive devices, and is independent at household but not community level

20%

c. Supervised standing and ambulation at household level

30%

d. Assisted ambulation, household level

40%

e. Nonambulatory, uses manual wheelchair, community level

65%

f. Nonambulatory, uses manual wheelchair, household level only

75%

g. Nonambulatory, uses power wheelchair only

85%

h. Nonambulatory, not able to use mobility device

95%

7. Use of the Upper Extremities

Preferred Extremity

Nonpreferred Extremity

Both Extremities

a. Can use the involved extremity for self-care, grasping and holding, but with difficulty with digital dexterity

10%

15%

b. Can use the involved extremity for some self-care activities and can grasp and hold objects, with difficulty but without digital dexterity

30%

15%

50%

c. Can use the involved extremity for few self-care activities, with difficulty

40%

30%

70%

d. Unable to use involved extremity for any self-care activities

60%

40%

90%

8. Respiration

% Impairment of Whole Person

a. Capable of spontaneous respiration, with difficulty in activities of daily living that require exertion

20%

b. Capable of spontaneous respiration but to a degree that restricts functions such as standing, ambulation, and upper-extremity use

50%

c. Capable of spontaneous respiration, but to a degree that results in bed confinement

90%

d. No capacity for spontaneous respiration, requires a ventilator

95%

9. Urinary Bladder Function (organic bladder disorder)

% Impairment of Whole Person

a. Impairment in form of urgency

1 - 10%

b. Good reflex activity without voluntary control

11 - 20%

c. Poor reflex activity and no voluntary control

21 - 30%

d. No reflex or voluntary control

31 - 40%

10. Anorectal/Bowel Function (organic disorder)

% Impairment of Whole Person

a. Mild fecal incontinence

1 - 5%

b. Moderate but partial fecal incontinence

6 - 15%

c. Complete fecal incontinence

16 - 25%

11. Sexual Function (organic dysfunction)

% Impairment of Whole Person

a. Sexual function is possible, but with some degree of difficulty for erection or ejaculation in males, or awareness due to sensory loss in either sex.

10%

b. Reflex sexual function is possible, but without awareness due to sensory loss

20%

c. No capacity for sexual function

30%

SKULL DEFECTS

Unfilled Skull Defects

% Impairment of Whole Person

a. Up to 5 sq cm

b. 6 – 10 sq cm

c. 11 – 16 sq cm

d. 17 – 26 sq cm

10%

e. 27 – 42 sq cm

15%

f. 43 or more sq cm

20%

SKULL DEFECTS

% Impairment of Whole Person

Skull fractures

HEADACHES

% Impairment of Whole Person

Vascular, tension, or combination (if associated with neurologic or musculoskeletal condition of the head or neck, the primary condition may be ratable.)

CRANIAL NERVES

1. Olfactory

% Impairment of Whole Person

a. Complete unilateral loss

b. Complete bilateral loss

2. Optic

% Impairment of Whole Person

a. Complete unilateral loss

24%

b. Complete bilateral loss

85%

3, 4, 5. Oculomotor, Trochlear, Abducens (alone or in combination)

% Impairment of Whole Person

Complete loss of ability to perceive single image but correctable by covering one eye

24%

6. Trigeminal

% Impairment of Whole Person

a. Complete unilateral sensory loss

10%

b. Complete bilateral sensory loss

35%

c. Intractable typical trigeminal neuralgia or tic douloureux

50%

d. Atypical facial neuralgia

20%

e. Complete unilateral motor loss

f. Complete bilateral motor loss

30%

7. Facial

% Impairment of Whole Person

a. Complete loss of taste

b. Complete unilateral paralysis

15%

c. Complete bilateral paralysis

45%

8. Auditory (See ENT Section)

9, 10. Glossopharyngeal or Vagus

% Impairment of Whole Person

a. Mild dysphagia with minimal modification of diet

10%

b. Moderate dysphagia with restriction to pureed food or liquid diet

30%

c. Feeding gastronomy or tube feeding required

50%

d. Dysarthria (See ENT Section)

11. Accessory (See spinal nerve affecting head and neck)

12. Hypoglossal

% Impairment of Whole Person

a. Unilateral paralysis

b. Bilateral paralysis (see scale above for impaired swallowing)

1. Mild dysphagia with minimal modification of diet

2. Moderate dysphagia with restriction to pureed food and/or thickened liquids

10%

3. Feeding gastronomy or tube feeding required

30%

4. Dysarthria (See ENT Section)

50%

SPINAL NERVE IMPAIRMENT AFFECTING HEAD AND NECK

Nerve

% Impairment of the Whole Person

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Loss of Strength

Greater occipital

Lesser occipital

Greater articular

Spinal accessory

10% unilateral

20% bilateral

(See Determination Procedures at the end of this section for grading schemes to determine whole-person impairment due to motor or sensory loss.)

THORACIC NERVES

Nerve

% Impairment of the Whole Person

Unilateral Involvement

Bilateral Involvement

Any 2 thoracic nerves

10%

Any 2 – 5 thoracic nerves

10%

20%

Any 5 or more thoracic nerves

30%

50%

SPINAL NERVES AFFECTING INGUINAL REGION AND PERINEUM

Nerve

% Impairment of the Whole Person

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Loss of Strength

Iliohypogastric

Ilioinguinal

Pudendal (unilateral)

Pudendal (bilateral)

20%

Coccygeal

(See Determination Procedures at the end of this section for grading schemes to determine whole-person impairment due to motor or sensory loss.)

UNILATERAL SPINAL NERVE ROOT AFFECTING THE UPPER EXTREMITY

Nerve Root Impaired

% Impairment of the Whole Person

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Motor Deficit or Loss of Power

C-5

30%

C-6

35%

C-7

35%

C-8

45%

T-1

20%

(See Determination Procedures at the end of this section for grading schemes to determine the percentage of upper extremity. Convert upper-extremity impairment to whole-person only when all upper-extremity impairments have been combined.)

UNILATERAL BRACHIAL PLEXUS DISORDERS

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Motor Deficit or Loss of Power

Brachial Plexus

100%

Upper Trunk (C-5, C-6) (Duchenne-Erb)

25%

70%

Middle Trunk (C-7)

35%

Lower Trunk (C-8, T-1) (Klumpke-Dejerine)

20%

70%

SPECIFIC UNILATERAL SPINAL NERVE AFFECTING THE UPPER EXTREMITY

Nerve

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Motor Deficit or Loss of Power

Anterior thoracic (pectoral)

Axillary (circumflex)

35%

Dorsal scapular

Long thoracic (posterior thoracic n., external respiratory n. of Bell, n. to serratus anterior)

15%

Medial antebrachial cutaneous

Medial brachial cutaneous

Median (above mid-forearm)

40%

55%

Median (below mid-forearm)

40%

35%

Branch to radial side of thumb

Branch to ulnar side of thumb

11%

Branch to radial side of index finger

Branch to ulnar side of index finger

Branch to radial side of middle finger

Branch to ulnar side of middle finger

Branch to radial side of ring finger

Musculocutaneous

25%

Radial (musculospiral) (upper arm with loss of triceps) wrist placed in position of function

55%

Radial (musculospiral) (with sparing of triceps) wrist placed in position of function

40%

Subscapular (upper and lower)

Suprascapular

15%

Thoracodorsal (long subscapular; nerve to latissimus dorsi)

10%

Ulnar (above mid-forearm)

10%

35%

Ulnar (below mid-forearm)

10%

25%

Branch to ulnar side of ring finger

Branch to radial side of little finger

Branch to ulnar side of little finger

UPPER EXTREMITY DUE TO ENTRAPMENT NEUROPATHY

UNILATERAL SPINAL NERVE ROOT AFFECTING THE LOWER EXTREMITY

Nerve Root Impaired

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Loss of Strength

L-3

20%

L-4

34%

L-5

37%

S-1

20%

(See Determination Procedures at the end of this section for grading schemes to determine the percentage of lower extremity. Convert lower-extremity impairment to whole-person only when all lower-extremity impairments have been combined.)

UNILATERAL LUMBOSACRAL PLEXUS

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Loss of Strength

Lumbosacral Plexus

40%

50%

SPECIFIC UNILATERAL SPINAL NERVE AFFECTING THE LOWER EXTREMITY

Nerve

Maximum % Loss of Function Due to Sensory Deficit, or Pain

Maximum % Loss of Function Due to Motor Deficit or Loss of Power

Femoral (anterior crural)

35%

Femoral (anterior Crural) (below iliacus nerve)

30%

Genitofemoral (genito crural)

Inferior gluteal

25%

Lateral femoral cutaneous

10%

N. to obturator internus muscle

N. to piriformis muscle

10%

N. to quadratus femoris muscle

N. to superior gemellus muscle Obturator

10%

Posterior cutaneous of thigh

Superior gluteal

20%

Sciatic (above hamstring innervation)

25%

75%

Common peroneal (lateral, or external popliteal)

35%

Deep (above mid-shin)

Deep (below mid-shin)

25%

Anterior tibial

Superficial

10%

Tibial nerve (medial, or internal popliteal)

Above knee

15%

35%

Posterior tibial (mid-calf and knee)

15%

25%

Below mid-calf

15%

Lateral plantar branch

Medial plantar branch

Sural (external Saphenous)

DETERMINATION OF PAIN OR LOSS OF SENSATION

Grading Scheme

Description ... Grade

1. No loss of sensation or no spontaneous abnormal sensations ... 0%

2. Impaired sensation with or without pain, which does not interfere with activity ... 1—15%

3. Impaired sensation with or without pain, which interferes with activity ... 16—30%

4. Impaired sensation with or without pain, which may prevent activity ... 31—60%

5. Impaired sensation with or without severe pain, which prevents activity ... 61—90%

6. Impaired sensation with or without pain, which prevents all activity ... 91—100%

Procedure for determining Impairment Due to Sensory Involvement

1. Identify area of involvement using appropriate anatomical chart.

2. Identify the nerve(s) or root level(s) for the involved area.

3. Find the value for the maximum loss of function of the nerve(s) or root(s), due to pain or loss of sensation, using the appropriate table.

4. Grade the degree of impaired sensation or pain according to the Grading Scheme.

5. Multiply the value of the nerve or root by the degree of impaired sensation or pain.

DETERMINATION OF STRENGTH (POWER) AND/OR MOTOR DEFICIT

Grading Scheme

Description ... Grade

1. Range of motion against gravity and full resistance (normal strength) ... 0%

2. Range of motion against gravity and some resistance, or reduced fine movements and motor control, may include abnormalities documented by electrophysiological studies (good strength) ... 1 – 40%

3. Range of motion against gravity, but without resistance (fair strength) ... 41 – 60%

4. Range of motion with gravity eliminated (poor strength) ... 61 – 75%

5. Slight palpable muscle contraction (trace strength) ... 76 – 99%

6. No contractibility and no muscle function (zero strength) ... 100%

Procedure for determining Impairment Due to Motor Involvement

1. Identify the motion involved

2. Identify the muscle(s) performing the function

3. Determine the nerve(s) that innervate the involved muscle(s) and find the value for maximum percentage loss due to loss of strength or power, according to the appropriate table.

4. Grade the degree of loss of strength or power according to the Grading Scheme.

5. Multiply the value of the nerve by the degree of loss of strength or power.

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