CHAPTER 8

VISUAL IMPAIRMENT

This chapter contains two parts:

Part 8.1 —  Impairment of Visual Function

Part 8.2 —  Other Ocular Impairment

INTRODUCTION

Part 8.1 is to be applied to assess:

• any condition, such as refractive error, that is actually affecting visual function; and
• any condition, such as glaucoma or cataracts, that in the normal course of its progression would be likely to affect visual function.

Part 8.2 is to be applied to assess such conditions of the eye and the surrounding structures as may lead to discomfort or inconvenience, such as conjunctivitis and conditions of the eyelid, without actually or usually affecting visual function.

Loss of function

Visual function is to be measured by reference to:

• corrected visual acuity (Table 8.1.1 or Table 8.1.3); and
• visual field defects (Figures 8a and 8b); and
• miscellaneous function (Table 8.1.2).

The following steps take into account the fact that normal vision is a binocular function.

Follow the steps below to calculate the impairment rating due to accepted loss of visual function.

(Each step is elaborated in the following pages.)

All assessments of visual acuity are to be based on corrected visual acuity, that is, the visual acuity as measured when the veteran is wearing glasses or contact lenses correctly prescribed. No additional impairment rating is to be given for the need to wear corrective lenses.

A separate monocular assessment is to be determined for each eye.

If only one eye has a refractive error, or if only one eye is to be assessed, the monocular assessment of the eye is to be determined by applying Table 8.1.1 and the assessment for visual acuity for the other eye is to be taken as nil. (These assessments will ultimately be combined by applying Table 8.1.3.)

No age adjustment permitted for this table

Any condition (such as glaucoma) which could cause loss of visual field is to be assessed by measuring that loss. For glaucoma without field loss refer to Table 8.1.2.

Loss of visual field is to be measured either by a manual or a computerised method, using the Esterman grid (Figures 8A and 8B).

Methods of measuring visual field loss

If the field has been defined by a manual method such as a Bjerrum screen with a 5/1000 white target or a Humphrey bowl at 10dB or less, a transparency of the Esterman grid is placed over the map of the visual field. Those dots that fall wholly or partially within the area of field loss are counted, and the number of dots so counted is to be taken as the monocular assessment for the field loss of that eye.

If the field has been defined by the Humphrey computerised method, a transparency of the appropriate Esterman grid is placed over the graytone field map of the eye being assessed. The graytones represent varying degrees of diminished response to visual stimuli. Count those dots that fall wholly or partially within the area of the graytone field map corresponding to the three darkest intensities of the set of ten graytones in the key accompanying the field map. The number of dots so counted is to be taken as the monocular assessment of the field loss of that eye.

If the field has been defined by a computerised method other than the Humphrey method, a transparency of the appropriate Esterman grid is placed over the graytone field map of the eye being assessed. The graytones represent varying degrees of diminished response to visual stimuli. Count those dots that fall wholly or partly within the area of the graytone field map corresponding to the equivalent of 10dB or less of the intensities of the set of ten graytones in the key accompanying the field map. The number of dots so counted is to be taken as the monocular assessment of the field loss of that eye.

Only one criterion is to be selected from Table 8.1.2. If more than one criterion could be selected, the criterion resulting in the higher or highest monocular assessment is to be chosen. The single assessment is then included in both monocular assessments. (See below.)

As the criteria in Table 8.1.2 refer to binocular functions, the assessment is included in both monocular assessments. For example, the assessment for unilateral aphakia is to be included in both monocular assessments.

Having followed Steps 1, 2 and 3, up to three monocular assessments will have been obtained for each eye depending on the particular accepted visual conditions affecting the veteran.  

For example, there may be for the right eye:

• an assessment for corrected visual acuity;
• an assessment for a visual field defect; and
• an assessment for a miscellaneous visual defect.

For each eye separately, these three assessments are to be combined as if they were impairment ratings, by applying Chapter 18 (Combined Values Chart) in accordance with the steps in that chapter. The resulting value is to be rounded to the nearest multiple of 5. This is known as the combined monocular impairment rating for that eye.

Binocular impairment rating

After a combined monocular impairment rating has been made for each eye, the two ratings are to be combined by applying Table 8.1.3. The value obtained is known as the binocular impairment rating.

Figure 8a - ESTERMAN GRID: LEFT EYE

Figure 8b - ESTERMAN GRID: RIGHT EYE

No age adjustment permitted for this table

The combined monocular impairment ratings obtained in Step 4 are those values found in the shaded area of Table 8.1.3. The values for the better and worse eye are to be taken from the values in the shaded regions along the horizontal and vertical axes respectively.

For convenience, Table 8.1.3 incorporates Table 8.1.1 along both its axes. The figures in italics give the possible losses of visual acuity. The values in the shaded area immediately beside or above the figures in italics give the corresponding monocular assessment.

If the only condition affecting visual function is decreased visual acuity, the visual acuities for the better and the worse eye respectively can be read from the values in italics along the horizontal and vertical axes respectively.

Paired organs policy

If an accepted condition affects one eye only, the paired organs policy may apply (see Chapter 21).

Visual Impairment Worksheet

To ensure a consistent and clear record of the use of the tables, the Visual Impairment Worksheet (at page 141) should be used when assessing visual impairment.

A Visual Impairment Worksheet is used when assessing impairment involving visual field or miscellaneous visual conditions.

No age adjustment permitted for this table

Other Impairment

Table 8.2.1 lists impairment ratings for a variety of ocular conditions. The ratings are based on the presence of symptoms and of inconvenience. Ratings from Table 8.2.1 are not to be combined with ratings from Table 8.1.3 for the same condition.  If the same condition can be rated from both tables, the higher rating is to be chosen.

No age adjustment permitted for this table

CHAPTER 9

RENAL AND URINARY TRACT FUNCTION

This chapter contains two parts:

Part 9.1 — Renal Function

Part 9.2 — Lower Urinary Tract Function

INTRODUCTION

Renal function and urinary tract function are to be assessed separately. Only one rating is to be given for impairment of renal function. If appropriate, two ratings may be given for lower urinary tract conditions — one for conditions of urinary excretion and one for lower urinary tract infections.

Renal impairment is to be assessed under Tables 9.1.1 and 9.1.2. If an impairment may be assessed from both tables, the higher of the two is to be selected.

Loss of kidney function may also be assessed by applying Chapter 16 (Activities of Daily Living), which may sometimes be more appropriate than applying Table 9.1.1 and Table 9.1.2.

Follow the steps below to calculate the impairment rating due to an accepted loss of renal function.

(Each step is elaborated in the following pages.)

No age adjustment permitted for this table

Creatinine clearance may be estimated either by analysis of a 24 hour urine collection or from the serum creatinine level by applying the following formulae.

Males:

Females:

Direct measurements of creatinine clearance are more accurate than estimates of creatinine clearance by applying the appropriate formulae. If both measurements are available that which better reflects the current status of the veteran’s health during the period of assessment is to be used.

No age adjustment permitted for this table

A rating for urinary excretion and one for lower urinary tract infections may be determined under this Part.

Follow the steps below to calculate the impairment rating due to an accepted loss of lower urinary function.

(Each step is elaborated in the following pages.)

The ratings obtained in Steps 1 and 2 are not to be compared or combined at this stage but are to be included in the final combining of all ratings, except if the condition causes impairment of an intermittent nature.

If the condition does not cause impairment of an intermittent nature, the assessment of an impairment rating for the condition ceases at this point. If the condition causes impairment of an intermittent nature, proceed to Step 3.

If the rating obtained in Step 3 is higher than that obtained in Step 4, the impairment rating obtained in Step 1 and the impairment rating obtained in Step 2 are to be included in the final combining of all impairment ratings.

No age adjustment permitted for this table

No age adjustment permitted for this table

CHAPTER 10

SEXUAL FUNCTION, REPRODUCTION, AND BREASTS

This chapter contains three parts:

Part 10.1 — Sexual Function

Part 10.2 — Reproduction

Part 10.3 —  Breasts

INTRODUCTION

Each part of this chapter contains separate tables for males and females. Ratings may be obtained from one or more parts, depending on the conditions to be assessed.

Many conditions of the female reproductive system, such as premenstrual tension and dysmenorhoea, occur on a cyclical basis and should be rated by applying Chapter 15 (Intermittent Impairment). When such conditions are successfully controlled by use of the contraceptive pill, a rating of zero is to be given.

It is also recognised that servicewomen may use the contraceptive pill to free themselves from such cyclical problems. In itself this is not a condition. However, if the use of the contraceptive pill causes significant side effects and if these side effects are accepted as being war-caused or defence-caused conditions, they should be rated from whatever section applies to them according to their nature.

Some conditions related to the reproductive organs, or to the effects of the sexual hormones, or which are more common in one sex than the other (such as osteoporosis), are not specifically mentioned in this chapter. Such conditions should be rated from the relevant part of the Guide according to their nature.

Follow the steps below to calculate the impairment rating due to an accepted loss of sexual function.

(Each step is elaborated in the following pages.)

Although impotence may be a symptom or effect of more than one accepted condition, only one rating is to be given for impotence.

The rating from Table 10.1.1 is the final rating  for loss of sexual function in male veterans. The rating obtained from Table 10.1.1 is not to be compared or combined with any other rating at this stage, but is to be included in the final combining of all ratings.

No age adjustment permitted for this table

For the purposes of Table 10.1.1

“Impotence” means the persistent inability to attain an erection of sufficient strength to achieve intromission.

“Severe post-ejaculatory pain” means post-ejaculatory pain of such a degree as to cause complete or almost complete avoidance of sexual activity.

No age adjustment permitted for this table

For the purposes of Table 10.1.2:

“persistent inability” means  the woman is unable to participate in vaginal intercourse on most occasions because of physical obstruction of the vagina or its entrance or because of vaginismus or because of dyspareunia.

Ratings may be given from each of Tables 10.1.2 and 10.1.3 if appropriate. The rating obtained from Table 10.1.2 is not to be compared or combined with any other rating at this stage, but is to be included in the final combining of all ratings.

No age adjustment permitted for this table

Ratings may be given from each of Tables 10.1.2 and 10.1.3 if appropriate. The rating obtained from Table 10.1.3 is not to be compared or combined with any other rating at this stage, but is to be included in the final combining of all ratings.

Follow the steps below to calculate the impairment rating due to an accepted loss of reproductive function.

(Each step is elaborated in the following pages.)

For the purposes of this chapter:

“infertility” means:

 for females —

     the condition in which a woman is unable to achieve a pregnancy resulting in a viable infant because of a gynaecological condition that prevents her becoming pregnant or  maintaining a pregnancy to term; or

     the situation of a woman who has been given medical advice that she should not become pregnant and who consequently does not give birth to a viable child either because of risk to her life; or the danger of seriously compromising her health; or serious and significant risk to the potential child. (The latter circumstance may arise if the woman has had radiotherapy for a malignant condition.)

 for males —

     the condition in which a man is unable to achieve a pregnancy in a woman.

“reduced fertility” means:

 for females —

     the situation of a woman who has sought medical help in order to become pregnant and who has been given such help in the form of IVF, GIFT, or a similar procedure or hormonal stimuli and who as a result of such procedures does become pregnant; or

     the situation of a woman who has been advised that she is infertile and who, as a result, has adopted a child and who then, and only after that, has conceived.

 (A woman is to be taken to be infertile if, despite such procedures, she remains unable to become pregnant. She will also be taken to be infertile until such time as she gives birth to a viable infant.)

 for males —

     the situation of a man who has sought medical help in order to enable him to father a child as a result of conditions such as a low sperm count or impotence or other related condition and who, with his partner, has been given such help in the form of IVF, GIFT, or a similar procedure or hormonal stimuli and who as a result of such procedures does succeed in becoming the biological father of a viable infant; or

     the situation of a man who has been advised that he is infertile and who, as a result, with his partner, has adopted a child and who then, and only after that, has become the biological father of a viable infant in the normal way.

The impairment rating for reduced fertility is given to compensate veterans for the delay they and their partners will have incurred in starting their family as a result of waiting for investigations and in undergoing the procedures and for the stress of hormone therapy which places a considerable emotional stress on both partners and a specific physiological stress on the female.

The fertility problem should only be assessed as “infertility” under this Guide if it prevents the veteran from having children that the veteran would otherwise have had. It is for a medical practitioner to diagnose whether a fertility condition is present. The veteran must advise whether the fertility condition prevented the birth of a child that otherwise the veteran would have parented.

If the veteran is of the opinion that the fertility condition did not actually prevent the veteran from having a child, the condition is to be assessed at the same rate as reduced fertility.

Cervical incompetence is to be rated in the same way as are problems of fertility.

Step 1: (Omit this step if you are assessing an accepted condition of a female veteran.) Determine a functional impairment rating for loss of reproductive function in male veterans from Table 10.2.1.

No age adjustment permitted for this table

This is the final rating for loss of reproductive function in male veterans. The rating obtained from Table 10.2.1 is not to be compared or combined with any other rating at this stage, but is to be included in the final combining of all ratings.

While impotence would render it difficult for a man to father a child in the normal way, it would neither necessarily nor usually render him infertile.

No age adjustment permitted for this table

Amenorrhoea by itself is to be rated at 2 points. However amenorrhoea will generally be a symptom of some other condition, such as infertility, in which case a rating is to be given for infertility and that rating is to be compared with the rating for amenorrhoea. The higher rating is to be taken.

Endometriosis may be assessed by applying Table 10.2.2, or by assessment of its effect on fertility or sexual function, or by applying Chapter 15 (Intermittent Impairment). If ratings are given from both this chapter and Chapter 15, the ratings are to be compared and the higher is to be taken.

This is the final rating for loss of reproductive function in female veterans. The rating obtained from Table 10.2.2 is not to be compared or combined with any other rating at this stage, but is to be included in the final combining of all ratings.

For those conditions of the female reproductive system that occur on a cyclical basis, Chapter 15 (Intermittent Impairment) is to be applied.

A rating given for mastectomy under this Part is not the final rating for cancer of the breast. The steps to be followed in assessing cancer of the breast are given below, for convenience. In following these steps it is essential to apply both Chapter 14 and the tables in this Part.

Follow the steps below to calculate the impairment rating due to breast cancer.

Steps 2 to 6 are elaborated in Chapter 14 (Malignant Conditions).

No age adjustment permitted for this table

No age adjustment permitted for this table

CHAPTER 11

SKIN IMPAIRMENT

INTRODUCTION

This chapter is to be applied in assessing skin conditions. Chapter 17 (Disfigurement and Social Impairment) is also to be applied to the assessment of skin conditions if appropriate.

For any relatively minor skin condition, the major consideration is whether it occurs on a more or less permanent basis or whether it occurs intermittently. If the condition occurs on an intermittent basis, the application of Chapter 15 (Intermittent Impairment) is to be considered.

For a more noticeable skin condition, consideration must also be given to whether it affects function or causes disfigurement. If the skin condition is responsible for a discrete loss of function in another system, the appropriate system-specific table is to be applied. For example, if there were loss of hand function as the result of a skin condition, Chapter 3 (Spine and Limbs) is to be applied.

For very severe skin conditions, loss of function is generally measured by reference to the whole person and may need to be rated under Table 16.2 in Chapter 16 (Activities of Daily Living).

Other Impairment (Table 11.1)

Table 11.1 lists specific impairment ratings for a variety of skin conditions based on inconvenience. One rating only is to be made from this table for any combination of conditions. When more than one criterion is applicable, that associated with the higher rating is chosen.

Impairment ratings from Table 11.1 are not to be combined with ratings from tables for loss of function for the same condition. If ratings can be made from more than one table the higher rating is to be chosen.

Reference to disfigurement is found in Chapter 17 (Disfigurement and Social Impairment).

Follow the steps below to calculate the impairment rating from accepted skin conditions:

(Each step is elaborated in the following pages.)

Skin conditions may cause loss of function of hands by interfering with movement or sensation.  They may cause loss of function of joints as a result of scarring and contractions which may limit or interfere with the movement at the joint. Skin conditions may cause conditions of the eyelids (for example, ectropion or entropion, or difficulties in closing or opening the eyes).

If any such effect of the accepted skin condition exists, this should be confirmed before applying Table 11.1.

Depending on its nature and extent, functional loss may be assessed by:

• applying Chapter 16 (Activities of Daily Living);
• applying Chapter 15  (Intermittent Impairment), or
• applying one or more system specific tables.

The rating obtained from the table applied in assessing functional loss may need to be modified by:

• applying Chapter 19 (Partially Contributing Impairment) if there is some contribution from a non-accepted condition; or
• applying Chapter 20 (Apportionment) if there is some contribution from another accepted condition.

If ratings from Chapter 16, Chapter 15 and one or more system specific tables are possible, all three are not to be given. Instead, all attributable system specific ratings are to be combined and compared with any attributable rating from Chapter 16 and from Chapter 15. The veteran is to be given the highest of the attributable ratings from Chapter 16, Chapter 15 or the combined system specific ratings as the functional impairment rating for accepted skin conditions.

Only one rating is to be given from Table 11.1 for any condition or combination of conditions.

This step determines the final impairment rating for accepted skin conditions.

At Step 2 allowance was made for the effect of any non-accepted skin condition and of any accepted condition which is not a skin condition on the functional loss from the accepted skin conditions. Compare the result obtained in Step 2 with the result obtained in Step 3. Take the higher of the two ratings. This is the final impairment rating for the accepted skin condition.

No age adjustment permitted for this table

CHAPTER 12

ENDOCRINE AND HAEMOPOIETIC IMPAIRMENT

This chapter contains two parts:

Part 12.1 —  Loss of Endocrine Function

Part 12.2 —  Loss of Haemopoietic Function

INTRODUCTION

Part 12.1 is to be applied to assess loss of function of the endocrine system. The endocrine system consists of all the glands and tissues which secrete hormones and the mechanisms by which the secretion of those hormones is regulated.   The functions of the endocrine system are very diverse and include control of growth, of sexual function, of calcium metabolism and of the uptake of glucose by body cells.

Part 12.2 is to be applied to assess loss of haemopoietic function. The haemopoietic system consists of all the tissues, such as bone marrow and lymph nodes, that produce blood cells.

Many endocrine conditions will affect various other body systems. Hence, loss of endocrine function is established by assessing the effect of the condition on those other body systems. In very severe cases, where many body systems are affected, Table 16.2 in Chapter 16 (Activities of Daily Living) is to be applied to rate the loss of function.

In many cases, an endocrine condition will be under therapeutic control as a result of the use of continuous replacement therapy or the like. In these cases, the effect on other body systems may be minimal and the veteran’s principal inconvenience is that of undergoing the continuous therapy. This is to be assessed by applying the Other Impairment tables.

Follow the steps below to calculate the impairment rating due to accepted loss of endocrine function.

(Each step is elaborated in the following pages.)

Many of the effects of loss of endocrine function are separate and recognisable diseases. For example, diabetes mellitus may lead to ischaemic heart disease. Such diseases, though quite possibly a consequence of the loss of endocrine function, are to be separately assessed under this Guide and are not to be taken into account in the calculation of the impairment rating for loss of endocrine function.

Use the appropriate Functional Loss tables from other chapters in this Guide to determine the impairment rating.

There are two Other Impairment tables for loss of endocrine function. Table 12.1.1 is to be applied if assessing diabetes mellitus, while Table 12.1.2 is be applied if assessing any other endocrine condition. Both tables provide an impairment rating based on the type of treatment required by the veteran.

The rating obtained in Step 4 is to be included in the final combining of all ratings.

If recognisable episodes of increased impairment are superimposed on the underlying condition (for example, insulin-dependent diabetes with superimposed hypoglycaemic episodes), the endocrine condition is to be assessed under Chapter 15 (Intermittent Impairment). The rating from Chapter 15 and the rating obtained in Step 4 are to be included in the final combining of all ratings.

However, a rating from Chapter 15 is not to be combined with a rating from any other system-specific table for the same condition.

No age adjustment permitted for this table

For the purposes of Table 12.1.1, “Diabetes mellitus uncontrolled” means blood sugar level consistently 15 mmol/L or more, despite treatment.

No age adjustment permitted for this table

PART 12.2: THE HAEMOPOIETIC SYSTEM

Conditions of the haemopoietic system include anaemias, leukaemias and polycythaemia.

Haemopoietic conditions usually affect various other body systems, therefore loss of function for the condition is to be established by assessing the effect of the condition on those body systems. Some haemopoeitic conditions are also malignant conditions and may be assessed by applying Chapter 14 (Malignant Conditions). For very severe haemopoietic conditions, where many body systems are affected, Tables 16.1 and 16.2 in Chapter 16 (Activities of Daily Living) are also to be applied to rate the loss of function.

Many anaemias will respond adequately to replacement or supplemental therapy. For example, the hypochromic anaemia of iron deficiency will usually respond to dietary iron supplementation and pernicious anaemia will usually respond to parenteral Vitamin B12.

Follow the steps below to calculate the impairment rating due to accepted loss of haemopoietic function:

(Each step is elaborated on the following page.)

Haemopoietic conditions may affect the function of other body systems.  For example, refractory anaemia may result in reduced effort tolerance.

Apply the appropriate functional impairment table elsewhere in this Guide to assess the functional impairment arising from the haemopoietic condition. For example, in the case of refractory anaemia causing reduced effort tolerance, the reduced effort tolerance is to be assessed by use of the Effort Tolerance protocol in Chapter 1.

If non-accepted conditions have contributed to the impairment rating for any of the affected body systems, Chapter 19 (Partially Contributing Impairment) is to be applied.

The various functional impairment ratings are not combined at this stage but are to be included in the final combining of all impairment ratings.

The ratings obtained in Steps 2 and 3 are not to be combined at this stage but both are to be included in the final combining of all impairment ratings.

No age adjustment permitted for this table

Part B: Non-System Specific Assessment

CHAPTER 13

NEGLIGIBLE IMPAIRMENT

INTRODUCTION

As every accepted condition is to be assessed, Table 13.1 provides a convenient method of rating any accepted condition which causes negligible impairment. Table 13.1 is to be applied only to conditions that cannot be conveniently classified under other chapters of this Guide  and that would not attract a higher rating if they were classified under such chapters.

Follow the step below to calculate the negligible impairment due to an accepted condition.

No age adjustment permitted for this table

CHAPTER 14

MALIGNANT CONDITIONS

INTRODUCTION

Malignant conditions may affect one or more body systems.

Hence, any malignant condition can potentially be assessed by the following methods:

• by applying the system-specific tables contained in Chapters 1 to 12. A number of those tables may have to be consulted if the malignant condition causes multiple losses of function;
• by applying Chapter 14 which relates specifically to malignancies and which contains both a Functional Loss table and an Other Impairment table. These tables are designed to rate the malignant condition as a whole. The first table relates to loss of function in a general sense. The second table relates to reduced life expectancy which is regarded as an Other Impairment.

If the impairment rating from Chapter 14 is 70 points on the basis of either the malignant disorders functional table (Table 14.1) or the malignant disorders Other Impairment table (Table 14.2), there is no need to follow the steps set out in the following pages. If the rating from Chapter 14 is below 70 points, the steps are to be followed.

Follow the steps below to calculate the impairment due to an accepted malignant condition.

(Each of these steps is elaborated in the following pages.)

Before a malignant condition is assessed, information regarding the extent of the condition must be available. Such information includes the site of the primary, the sites of any secondaries, the effects of any surgery and the effects of any radiotherapy or chemotherapy.

From that information the affected body systems can be established and the applicable chapters of this Guide applied.

For example, in the case of an accepted carcinoma of the rectum, there may be surgical resection of the rectum with a colostomy, secondary spread of the cancer to the lungs and spine, and radiotherapy with some resultant digestive disturbances. In such a case, Chapters 1, 3, and 6 of this Guide will have to be applied in Step 1 to arrive at an appropriate functional impairment rating.

Depending on the body systems that are affected by the malignant condition and its treatment, each of the relevant chapters of the Guide is to be used and appropriate ratings obtained.

If other accepted or non-accepted conditions also affect any of the same body systems, Chapter 19 (Partially Contributing Impairment) or Chapter 20 (Apportionment) may have to be applied depending upon the circumstances.

The total combined impairment rating for the various body system impairments associated with the malignant condition is determined by combining the attributable impairment ratings by applying Chapter 18 (Combined Values Chart).

Unless the malignant condition is the only accepted condition, this combined rating is to be regarded as an intermediate rating only.

Apply Table 14.1 and find the relevant impairment rating for the entire set of effects which have arisen from the malignant disorder treatment, including surgical resection, chemotherapy and radiotherapy.

For the purposes of Table 14.1, “symptoms” encompasses the symptoms of both the malignant condition itself and the symptoms of the effects of its treatment.

If non-accepted conditions or accepted but non-malignant conditions have contributed to the impairment rating obtained from Table 14.1, Chapter 19 (Apportionment) or Chapter 20 (Partially Contributing Impairment) are to be applied depending on the circumstances of the case.

If an impairment rating has not been determined on any previous occasion by applying Table 14.2 (Life Expectancy) or its predecessor in an earlier edition of this Guide, a rating is to be obtained from Table 14.2. If a rating has been obtained from Table 14.2 or its predecessor in an earlier edition of this Guide, on a previous occasion, that same rating is to be applied again in all further assessments of the condition.

Whenever possible, the rating from Table 14.2 is to be based on an estimate from an oncologist or other treating specialist of the veteran’s survival. If such information is unavailable, data from standard reference texts is to be applied to provide an estimate. Such an estimate is to be based on malignancies of the same type and degree of spread as that affecting the veteran.

Estimated life expectancy is projected from the time of diagnosis, or from any subsequent major staging procedure or operation. Thus, once a rating from Table 14.2 has been made it is not to be changed, unless subsequent findings indicate that the earlier prognosis was based on incorrect clinical information.

If the assessment is made posthumously, the rating from Table 14.2 is not to be modified to reflect the actual duration for which the veteran survived after diagnosis. The table is only to be used for predicted probability of survival.

Ratings from Table 14.2 are not to be updated to account for the natural progression of the disease. However, it is expected that ratings from Table 14.2 will come to be exceeded by ratings from Table 14.1 during this time.

Ratings from Table 14.2 are not to be reduced because of favourable response to treatment, or because of better than expected survival. However, if the condition is being rated for the first time more than five years after diagnosis, and the disorder is in remission or appears to be cured, the impairment rating from this table is not to exceed ten.

If the veteran has more than one malignant condition accepted, Table 14.2 is to be applied to each condition. Table 14.2 is not to be applied to a recurrence of an old (already diagnosed) condition.

No age adjustment permitted for this table

No age adjustment permitted for this table

The higher of these two ratings will be the rating for the malignant condition on the basis of this chapter.

If the rating obtained in Step 3 is higher than that obtained in Step 6, go to Step 8.

If the rating obtained in Step 6 is higher than that obtained in Step 3, then the rating obtained in Step 6 becomes the final rating for the malignant condition and is to be included in the final combining of all ratings.

For example, in the case of an accepted carcinoma of the rectum postulated under Step 1, each of the ratings from Chapters 1, 3, and 6 of the Guide is to be separately included in the final combining of all impairment ratings.

CHAPTER 15

INTERMITTENT IMPAIRMENT

INTRODUCTION

Intermittent disorders are conditions:

• that remain at a low level of impairment between discrete episodes of increased impairment;

 or

• where there is one basic type of impairment on which is superimposed episodes of significantly greater impairment of another type.

A sufferer from epilepsy who remains well between “fits” exemplifies the first type of intermittent disorder. A sufferer from Menière’s disease whose condition is characterised by deafness and occasional episodes of vertigo exemplifies the second type of intermittent disorder. The deafness may be regarded as the basic type of impairment and the episodes of vertigo may be regarded as the superimposed intermittent impairment. Both elements of the condition are to be assessed.

In this chapter, “attacks” refers to the episode may increased or superimposed impairment. Attacks are to be categorised by reference to their severity, duration and frequency:

•    “severity of an attack” refers to the degree to which self-care and normal everyday activities are disrupted by the attack;
•    “duration of an attack” refers to the average length of time for which an attack lasts, that is, seconds, minutes, hours or days; and
•    “frequency of an attack” refers to the number of affected days in a year.

Intermittent disorders are also disorders that affect one or more body systems. For example, asthma is both an intermittent condition and a cardio-respiratory condition. Hence, potentially, any intermittent disorder can be assessed by either of two methods:

• by applying the system-specific tables contained in Chapters 1 to 12.  Several of those tables should be used if the intermittent disorder causes multiple losses of function; or
• by applying this chapter.

In practice, except where the intermittent nature of the condition clearly overwhelms its system specific effects or vice versa, both methods are to be applied for rating the intermittent condition and the higher of those two ratings taken as the final rating for the intermittent condition.

Follow the steps below to calculate the impairment rating due to an accepted intermittent condition:

(Each of these steps is elaborated in the following pages.)

Before an intermittent condition is assessed, information regarding the extent of the condition must be available. From that information, the affected body systems are to be established and the applicable chapters of this Guide applied.

Use the relevant chapters and determine the appropriate rating.

Chapter 19 (Partially Contributing Impairment) or Chapter 20 (Apportionment) may also have to be applied to allow for the effect of other accepted conditions or non-accepted conditions respectively.

Combine the attributable impairment ratings obtained in Step 2 by applying Table 18.1 (Combined Values Chart) in Chapter 18.

The combined value so obtained is for use only in Step 9.

If attacks vary in severity, duration or frequency, an average for each parameter is to be established except when the attacks fall naturally and very clearly into groups. In such cases separate the attacks into one or other of these groups. Determine the average severity, duration and frequency of the attacks in each group.

Perform the following four steps separately for each identified group of attacks.

No age adjustment permitted for this table

Ratings are based on the activities that the veteran is physically unable to perform. For conditions in which it is common practice to lie down during attacks, it may be inappropriate to rate at level III if symptoms are mild and cause little restriction to activity.

Attacks of some intermittent conditions necessitate hospital admission. Hospital admissions commonly, but not invariably, call for level V or VI rating. It is important to rate self-care capacity. To be rated at Level V severity, a condition must render the veteran incapable of caring for himself or herself.

Hospital admission for surgery is not to be used as a basis for ratings from Table 15.1.

Attacks that last for more than 24 hours are to be classified as prolonged for the purposes of Table 15.2. Because they affect the veteran for more than one day per attack, the number of affected days per year will be greater than the number of attacks.

No age adjustment permitted for this table

No age adjustment permitted for this table

Using the intermittent grading code determined in Step 7, determine the impairment rating appropriate to the intermittent grading code and frequency by applying Table 15.4.

No age adjustment permitted for this table

If the attacks were separated into groups in Step 4, a separate rating is to be obtained for each group of attacks.

Those ratings are not to be combined at this stage but are to be included in the final combining of all ratings.

If the attacks were separated into groups in Step 4, the ratings for the various groups of attacks are to be combined by applying Chapter 18 (Combined Values Chart) before being compared with the rating obtained in Step 3. The combined rating determined under Chapter 18 is to be used only for the purpose of this comparison.

If the combined rating determined under Chapter 18 is higher than the rating obtained in Step 3, then each of the separate ratings for the various groups of attacks is to be included in the final combining of all ratings.

Precluded activities refer to ordinary activities. Ratings are to be given on the basis of having to avoid, or of being precluded from undertaking, activities that are common for the veteran’s age group. Ratings are not to be given on the basis of having to avoid only relatively hazardous activities such as rock-climbing or acrobatics.

Table 15.5 is to be applied only if at least one attack of the condition of severity II or greater has occurred within the last two years.

No age adjustment permitted for this table

The rating obtained in Step 10 is not to be compared with the rating obtained in Step 9, nor are ratings to be combined at this stage. Irrespective of the outcome of Step 9 the rating obtained from Table 15.5 is to be included in the final combining of all ratings.

Intermittent Impairment Worksheets

A set of Intermittent Impairment Worksheets (pages 178 to 179) is designed to facilitate the calculation of intermittent impairment rating.

Intermittent Impairment Worksheet (1) is to be used in those cases where all the attacks are grouped into a single type of attack.

Intermittent Impairment Worksheet (2) is to be used in those cases where the attacks are grouped into two or three types.

No worksheet is provided for those cases where more than three types of attacks are involved.

CHAPTER 16

ACTIVITIES OF DAILY LIVING

INTRODUCTION

The Activities of Daily Living (ADLs) are a defined set of activities necessary for normal self-care. The activities are movement in bed, transfers, locomotion, dressing, personal hygiene, and feeding.

These six activities are defined as follows:

• “movement in bed” means sitting in, rising from, and moving around in, bed;
• “transfers” means moving from one seat to another, changing position from sitting to standing, and transferring to and from the toilet and bed;
• “locomotion” means walking on the level, on gentle slopes and down stairs;
• “dressing” means putting on socks, stockings, and shoes, as well as clothing the upper and lower trunk;
• “personal hygiene” means grooming, and washing of face, trunk, extremities and perineum;
• “feeding” means eating and drinking, but not the preparation of food.

“Effects on ADLs” is to be used to assess conditions for which criteria do not exist in the system specific tables of Chapters 1 to 12, or are inadequate, or for which the application of the tables in Chapter 14 (Malignant Conditions) or Chapter 15 (Intermittent Impairment) is inappropriate.

Table 16.3 (Other Impairment) covers such non-specific indicators of disease as pain, lethargy and prognosis.

This chapter is to be applied in the assessment of conditions that result in the veteran being bedfast, chairfast, housebound or nearly housebound. Such conditions include the effects of severe strokes, severe Parkinson’s disease, severe heart failure, severe respiratory disease, severe liver failure, severe kidney failure and some dementias.

ADLs may be used to rate a single condition if its effects are well-differentiated, or may be used to rate all conditions together if their effects are difficult to differentiate.

When ADLs are used to rate a single condition, an impairment rating or ratings from other chapters may be combined with a rating derived from Chapter 16 provided that the ratings relate to different conditions.

When ADLs are used to rate all conditions together, no ratings from other chapters are to be combined with the rating from Chapter 16.

Follow the steps below to calculate the impairment rating due to an accepted condition using the ADLs.

(Each step is elaborated in the following pages.)

From Table 16.1 obtain a separate grading code for:

• movement in bed;
• transfers;
• locomotion;
• dressing;
• personal hygiene; and
• feeding.

No age adjustment permitted for his table

Add up the 6 separate grading codes obtained from Table 16.1 for:

• movement in bed;
• transfers;
• locomotion;
• dressing;
• personal hygiene; and
• feeding.

Use the sum of the grading codes obtained in Step 2 to obtain an impairment rating from Table 16.2.

No age adjustment permitted for this table

Apply Chapter 19 (Partially Contributing Impairment) to make any necessary adjustment for non-accepted conditions.

Apply Chapter 18 (Apportionment) to make any necessary adjustment for accepted conditions (or groups of conditions) other than the ones that are being assessed by the application of the ADLs tables.

No age adjustment permitted for this table

The higher of the impairment ratings obtained in Steps 3 and 4 is the final impairment rating for the accepted conditions under assessment, based on ADLs.

CHAPTER 17

DISFIGUREMENT AND SOCIAL IMPAIRMENT

INTRODUCTION

This chapter is to be applied when assessing conditions that cause disfigurement and embarrassment.

Only one rating may be determined by applying this chapter for any condition or combination of conditions. The rating determined by applying this chapter is to be combined with any other ratings for the disfiguring condition or combination of conditions determined under other chapters.

Widespread skin conditions that cause avoidance of ordinary public places should also be assessed under Chapter 11 (Skin Impairment).

“Severe facial disfigurement” and “very severe facial disfigurement” are also mentioned in Chapter 24 (Degree Of Incapacity For Specific Disabilities).

Follow the steps below to calculate the impairment rating due to disfigurement.

(Each step is elaborated in the following pages.)

Step 1: Determine the impairment rating from Table 17.1 for the effect of all accepted conditions which cumulatively lead to disfigurement.

For the purposes of Table 17.1, the following definitions apply:

“disfiguring condition” means any noticeable condition that causes the sufferer embarrassment in ordinary public places and may include, but is not limited to, the following :

• facial scarring;
• exfoliative skin disorders;
• disorders of gait or posture;
• involuntary facial expressions, or unusual or grotesque involuntary bodily movements;
• disorders of speech;
• vile odours which cannot be overcome by the use of deodorants or the application of normal oral hygiene;
• deficits of the visual field which may cause the veteran to lurch into people through not seeing them;
• painful conditions which may cause the veteran to cry out involuntarily (for example, in response to a sudden pain in a joint); and
• severe pruritic conditions which cause the veteran to scratch even though normal behaviour in a public place would recommend restraint.

“ordinary public places” includes suburban streets, shopping centres, public transport, theatres, clubs and many sporting venues, but does not include places where a great part of the skin is customarily bared such as swimming pools and beaches.

“avoidance” means the veteran feeling obliged as a result of embarrassment to restrict his or her use of public places to hours when few people are about, or to avoid totally use of public places at certain times, for example, when school children are likely to be about.

No age adjustment permitted for this table

Both the objective and subjective components of a disfiguring condition are to be taken into account when applying Table 17.1. The objective component is the actual physical and/or temporal extent of the disfiguring condition as perceived by others. The subjective component is the veteran’s own emotional and behavioural reactions to the disfigurement.

The two components will generally be aligned with one another. If the veteran has a noticeable condition that is objectively disfiguring but does not embarrass the veteran to the extent to which an average person of the same age, occupational and residential circumstances would be embarrassed, the assessment should be based on the average person’s degree of embarrassment. The veteran’s denial of his or her condition should not be taken into account when applying Table 17.1.

If non-accepted conditions have contributed to the disfigurement, Table 19.1 in Chapter 19 (Partially Contributing Impairment) is to be applied to adjust the impairment rating for the accepted conditions.

The rating obtained in this step (or in Step 1 if partially contributing impairment is not applicable) is the final rating for disfigurement, and is to be included in the final combining of all impairment ratings.

Part C: Impairment Ratings: Combining, Apportioning, Partially Contributing

CHAPTER 18

COMBINED VALUES CHART

INTRODUCTION

After impairment ratings have been obtained for all accepted conditions they must be combined to a single value known as the combined impairment rating. The combining is not to be done by simple addition but is to be done by applying Table 18.1 (Combined Values Chart). The values in Table 18.1 (Combined Values Chart) are derived from the formula:

where “A” and “B” are the impairment ratings to be combined.

This formula embodies a principle of combining ratings. The principle derives from the concept of whole person impairment (see page X). The following example illustrates the combining principle:

Example

Suppose a veteran has three accepted conditions. If the first assessed condition attracts 60 points the veteran will get a rating of 60. This rating implies that the whole person is 60% impaired. That leaves 40% to be further apportioned among other conditions. If the second condition assessed attracts 30 points, the total impairment rating will not be 60 + 30 = 90, but 60 + 12 = 72. The 12 represents 30% of the 40 that remained of the whole person after the initial 60 was awarded. Now the whole person of the veteran is 72% impaired. If the third condition assessed attracts 10 points, the total impairment rating will be 60 + 12 + 3 = 75. The 3 represents 10% of the 28 that remained of the whole person after 72 was awarded for the first two conditions. Now the whole person of the veteran is 75% impaired.

Follow the steps below to combine two or more impairment ratings into a single value (the combined impairment rating).

Example

To combine 35 and 20, read down the extreme left hand side column of the chart in Table 18.1 until you come to the larger value, 35. In the very bottom row of the chart read from left to right until you come to 20. At the intersection of the row on which 35 is written, and the column above 20, is the number 48.

Therefore, 35 combined with 20 is 48. Due to the construction of this chart, the larger impairment value must be identified at the side of the chart.

Applying the formula to this example gives:

No age adjustment permitted for this table

No age adjustment permitted for this table

No age adjustment permitted for this table

CHAPTER 19

PARTIALLY CONTRIBUTING IMPAIRMENT

INTRODUCTION

Partially contributing impairment is to be applied whenever an impairment is not due solely to the effects of accepted conditions.

Follow the steps below to apply partially contributing impairment.

(Each step is elaborated in the following pages.)

Use relevant medical evidence to determine if any non-accepted conditions contribute to the impairment being assessed.

The judgement of the relative contributions should be based on proper medical advice.

The contribution should be expressed in the form:

‘The accepted condition contributes “not at all”, “about one quarter”, “about one third”, “about half”, etc’.

If more than one accepted condition contributes to the relevant impairment rating, the contribution of the accepted conditions is to be treated as a single entity.

If more than one non-accepted condition contributes to the relevant impairment rating, the contribution of the non-accepted conditions may be treated as a single entity.

Table 19.1 extracts the highlighted information in Table 19.2 and is provided for the convenience of users.

No age adjustment permitted for this table