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Chapter 111.1 History1.2 Impairment, Disability, and Handicap1.3 The Organ System and Whole BodyApproach to Impairment1.4 Philosophy and Use of the Combined Values Chart1.5 Incorporating Science with ClinicalJudgment1.6 Causation, Apportionment Analysis, and Aggravation1.7 Use of the Guides1.8 Impairment Evaluations in Workers’Compensation1.9 Employability Determinations1.10 Railroad and Maritime Workers1.11 The Physician’s Role Based on the Americans with Disabilities Act (ADA)1.12 Summary1.1 HistoryThe Guides was first published in book form in 1971in response to a public need for a standardized,objective approach to evaluating medical impair-ments. Sections of the first edition of the Guideswere originally published in the Journal of theAmerican Medical Association, beginning in 1958and continuing until August 1970.1 Since then, theGuides has undergone four revisions, culminating inthe current, fifth edition. The purpose of this fifthedition of the Guides is to update the diagnostic cri-teria and evaluation process used in impairmentassessment, incorporating available scientific evi-dence and prevailing medical opinion. Chapterauthors were encouraged to use the latest scientificevidence from their specialty and, where evidencewas lacking, develop a consensus view. This chapterwas revised from the earlier edition in response tospecific requests from user groups concerning thedefinitions, appropriate use, and scope of applicationof the Guides.Philosophy, Purpose, andAppropriate Use of the GuidesChapter 1Chapter 1The fifth edition includes most of the common con-ditions, excluding unusual cases that require individ-ual consideration. Since this edition encompasses themost current criteria and procedures for impairmentassessment, it is strongly recommended that physi-cians use this latest edition, the fifth edition, whenrating impairment.1.2 Impairment, Disability, and Handicap1.2a ImpairmentThe Guides continues to define impairment as “a loss, loss of use, or derangement of any bodypart, organ system, or organ function.” 2 This defi-nition of impairment is retained in this edition. Amedical impairment can develop from an illness orinjury. An impairment is considered permanent whenit has reached maximal medical improvement(MMI), meaning it is well stabilized and unlikely tochange substantially in the next year with or withoutmedical treatment. The term impairment in theGuides refers to permanent impairment, which isthe focus of the Guides.An impairment can be manifested objectively, forexample, by a fracture, and/or subjectively, throughfatigue and pain.3 Although the Guides emphasizesobjective assessment, subjective symptoms areincluded within the diagnostic criteria. According tothe Guides, determining whether an injury or illnessresults in a permanent impairment requires a medicalassessment performed by a physician. An impair-ment may lead to functional limitations or the inabil-ity to perform activities of daily living. Table 1-1, adapted from a report by the AMACouncil on Scientific Affairs, lists various definitionsof impairment and disability used by four mainauthorities: the AMA Guides, the World HealthOrganization, the Social Security Administration,and a state workers’ compensation statute.4 Althougha nationally accepted definition for impairment doesnot exist, the general concept of impairment is simi-lar in the definitions of most organizations. Severalterms used in the AMA definition, and their applica-tion throughout the Guides, will be discussed in thischapter and Chapter 2. Loss, loss of use, or derangement implies a changefrom a normal or “preexisting” state. Normal is arange or zone representing healthy functioning andvaries with age, gender, and other factors such asenvironmental conditions. For example, normal heartrate varies between a child and adult and accordingto whether the person is at rest or exercising.Multiple factors need to be considered when assess-ing whether a specific or overall function is normal.A normal value can be defined from an individual orpopulation perspective.When evaluating an individual, a physician has twooptions: consider the individual’s healthy preinjuryor preillness state or the condition of the unaffectedside as “normal” for the individual if this is known,or compare that individual to a normal value definedby population averages of healthy people. TheGuides uses both approaches. Accepted populationvalues for conditions such as extremity range-of-motion or lung function are listed in the Guides; it isrecommended that the physician use those values as detailed in the Guides when applicable. In other cir-cumstances, for instance, where population valuesare not available, the physician should use clinicaljudgment regarding normal structure and functionand estimate what is normal for the individual basedon the physician’s knowledge or estimate of the indi-vidual’s preinjury or preillness condition.2 Guides to the Evaluation of Permanent ImpairmentChapter 1Philosophy, Purpose, and Appropriate Use of the Guides 3Chapter 1Guides to the Evaluationof Permanent Impairment(5th ed, 2000)A loss, loss of use, orderangement of any bodypart, organ system, ororgan function.An alteration of an individual’s capacity tomeet personal, social, oroccupational demandsbecause of an impairment.Determine impairment,provide medical informa-tion to assist in disabilitydetermination.An impaired individualmay or may not have adisability.World HealthOrganization (WHO)(1999)Problems in body functionor structure as a signifi-cant deviation or loss.Impairments of structurecan involve an anomaly,defect, loss, or other sig-nificant deviation in bodystructures.Activity limitation (formerly disability) is adifficulty in the perform-ance, accomplishment, orcompletion of an activityat the level of the person.Difficulty encompasses allof the ways in which thedoing of the activity maybe affected.Not specifically defined;assumed to be one of thedecision-makers in deter-mining disability throughimpairment assessment.Emphasis is on the importance of functionalabilities and defining context-related activitylimitations.Social SecurityAdministration (SSA)(1995)An anatomical, physiolog-ical, or psychologicalabnormality that can beshown by medicallyacceptable clinical andlaboratory diagnostictechniques.The inability to engage inany substantial, gainfulactivity by reason of anymedically determinablephysical or mental impair-ment(s), which can beexpected to result indeath or which has lastedor can be expected to lastfor a continuous period ofnot less than 12 months.Determine impairment;may assist with the dis-ability determination as aconsultative examiner.Physicians and nonphysi-cians need to worktogether to define situa-tional disabilities.State Workers’Compensation Law (typical)5“Permanent impairment”is any anatomic or func-tional loss after maximalmedical improvement hasbeen achieved and whichabnormality or loss, med-ically, is considered stableor nonprogressive at thetime of evaluation.Permanent impairment isa basic consideration inthe evaluation of perma-nent disability and is acontributing factor to, butnot necessarily an indica-tion of, the entire extentof permanent disability.(Idaho Code section 72-422)“Temporary disability”means a decrease inwage-earning capacitydue to injury or occupa-tional disease during aperiod of recovery. (IdahoCode section 72-102[10]“Permanent disability”results when the actual orpresumed ability toengage in gainful activityis reduced or absentbecause of permanentimpairment and no funda-mental or marked changein the future can be rea-sonably expected. (IdahoCode section 72-423)“Evaluation (rating) ofpermanent impairment” isa medical appraisal ofwith immunity-suppressing pharma-ceuticals or persons treated with anticoagulants, thepharmaceuticals themselves may lead to impair-ments. In such an instance, the physician should usethe appropriate parts of the Guides to evaluateimpairment related to pharmaceutical effects. Ifinformation in the Guides is lacking, the physicianmay combine an estimated impairment percent basedon the severity of the effect, with the primary organsystem impairment, by means of the CombinedValues Chart (p. 604).A patient may decline surgical, pharmacologic, ortherapeutic treatment of an impairment. If a patientdeclines therapy for a permanent impairment, thatdecision neither decreases nor increases the esti-mated percentage of the individual’s impairment.However, the physician may wish to make a writtencomment in the medical evaluation report about thesuitability of the therapeutic approach and describethe basis of the individual’s refusal. The physicianmay also need to address whether the impairment isat maximal medical improvement without treatmentand the degree of anticipated improvement that couldbe expected with treatment.20 Guides to the Evaluation of Permanent ImpairmentChapter 22.5h Changes in Impairment from PriorRatingsAlthough a previous evaluator may have considereda medical impairment to be permanent, unanticipatedchanges may occur: the condition may have becomeworse as a result of aggravation or clinical progres-sion, or it may have improved. The physician shouldassess the current state of the impairment accordingto the criteria in the Guides. If an individual receivedan impairment rating from an earlier edition andneeds to be reevaluated because of a change in themedical condition, the individual is evaluatedaccording to the latest information pertaining to thecondition in the current edition of the Guides.Valid assessment of a change in the impairment esti-mate would depend on the reliability of the previousestimate and the evidence upon which it was based.If a prior impairment evaluation was not performed,but sufficient historical information is available tocurrently estimate the prior impairment, the assess-ment would be performed based on the most recentGuides criteria. However, if the information is insuf-ficient to accurately document the change, then thephysician needs to explain that decision and shouldnot estimate a change.If apportionment is needed, the analysis must con-sider the nature of the impairment and its relation-ship to each alleged causative factor, providing anexplanation of the medical basis for all conclusionsand opinions. (Apportionment and causation are con-sidered more fully in Chapter 1 and are brieflydefined in the Glossary.) For example, in apportion-ing a spine impairment, first the current spineimpairment rating is calculated, and then an impair-ment rating from any preexisting spine problem iscalculated. The value for the preexisting impairmentrating can be subtracted from the present impairmentrating to account for the effects of the interveninginjury or disease. Using this approach to apportion-ment requires accurate information and data to deter-mine both impairment ratings. If different editions ofthe Guides are used, the physician needs to assesstheir similarity. If the basis of the ratings is similar, asubtraction is appropriate. If they differ markedly,the physician needs to evaluate the circumstancesand determine if conversion to the earlier or latestedition of the Guides for both ratings is possible. Thedetermination should follow any state guidelines andshould consider whichever edition best describes theindividual’s impairment.2.6 Preparing ReportsA clear, accurate, and complete report is essential tosupport a rating of permanent impairment. The fol-lowing elements in bold type should be included inall impairment evaluation reports. Other elementslisted in italics are commonly found within an IMEor may be requested for inclusion in an impairmentevaluation.2.6a Clinical Evaluation2.6a.1 Include a narrative history of the medicalcondition(s) with the onset and course of the condi-tion, symptoms, findings on previous examination(s),treatments, and responses to treatment, includingadverse effects. Include information that may be rele-vant to onset, such as an occupational exposure orinjury. Historical information should refer to any relevant investigations. Include a detailed list of prior evaluations in the clinical data section.2.6a.2 Include a work history with a detailed,chronological description of work activities, specifictype and duration of work performed, materials usedin the workplace, any temporal associations with themedical condition and work, frequency, intensity,and duration of exposure and activity, and any pro-tective measures.2.6a.3 Assess current clinical status, includingcurrent symptoms, review of symptoms, physicalexamination, and a list of contemplated treatment,rehabilitation, and any anticipated reevaluation.2.6a.4 List diagnostic study results and outstand-ing pertinent diagnostic studies. These may include laboratory tests, electrocardiograms, exercise stressstudies, radiographic and other imaging studies,rehabilitation evaluations, mental status examina-tions, and other tests or diagnostic procedures.2.6a.5 Discuss the medical basis for determiningwhether the person is at MMI. If not, estimate anddiscuss the expected date of full or partial recovery.Practical Application of the Guides 21Chapter 22.6a.6 Discuss diagnoses, impairments.2.6a.7 Discuss causation and apportionment, ifrequested, according to recommendations outlined in Chapters 1 and 2.2.6a.8 Discuss impairment rating criteria,prognosis, residual function, and limitations.Include a discussion of the anticipated clinical courseand whether further medical treatment is anticipated.Describe the residual function and the impact of themedical impairment(s) on the ability to performactivities of daily living and, if requested, complexactivities such as work. List the types of affectedactivities (see Table 1-2). Identify any medical con-sequences for performing activities of daily living.If requested, the physician may need to analyze differ-ent job tasks to determine if an individual has theresidual function to perform that complex activity.The physician should also identify any medical con-sequence of performing a complex activity such aswork.2.6a.9 Explain any conclusion about the need forrestrictions or accommodations for standard activitiesof daily living or complex activities such as work.2.6b Calculate the Impairment RatingCompare the medical findings with the impair-ment criteria listed within the Guides and calculatethe appropriate impairment rating. Discuss how spe-cific findings relate to and compare with the criteriadescribed in the applicable Guides chapter. Refer toand explain the absence of any pertinent data andhow the physician determined the impairment ratingwith limited data.2.6c. Discuss How the Impairment RatingWas Calculated2.6c.1 Include an explanation of each impairmentvalue with reference to the applicable criteria of theGuides. Combine multiple impairments for a wholeperson impairment.2.6c.2 Include a summary list of impairments andimpairment ratings by percentage, including calcula-tion of the whole person impairment.On the following two pages is a standard form that theevaluator may use to ensure that all essential elementsare included in the impairment evaluation report. Theform may be reproduced without permission from theAmerican Medical Association. Most chapters includea summary form that identifies the salient, specific features to consider for each category of organ systemimpairment.22 Guides to the Evaluation of Permanent ImpairmentChapter 2Practical Application of the Guides 23Chapter 2Identifiers:Patient name: ______________________________________________________________________________________________________________Address:___________________________________________________________________________________________________________________Claim #: ___________________________________________________________________________________________________________________Date of birth: ______________________________________________________________________________________________________________Date of injury or illness: ______________________________________________________________________________________________________Sample Report for Permanent Medical ImpairmentExamination date:_________________________________________________________________________________________________________________Dates of care by examining physician: ______________________________________________________________________________________________Examination location: _____________________________________________________________________________________________________________Examining physician: ______________________________________________________________________________________________________________Introduction: Purpose (impairment or IME evaluation, personal injury, workers’ compensation) and procedures (who performed the exam, patientconsent, location of examination)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Narrative history: Chief complaints, history of injury or illness, occupational history, past medical history, family history, social history, review of systems______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medical record review: Chronology of medical evaluation, diagnostic studies, and treatment for the injury or illness______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Physical examination: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________24 Guides to the Evaluation of Permanent ImpairmentChapter 2Diagnostic studies:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Diagnoses and Impairments: (If requested, discuss work relatedness, causation, apportionment, restrictions , accommodations, assistive devices)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Work ability, work restrictions (If requested, review abilities and limitations in reference to essential job activities):______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Impairment Rating Criteria: MMI residual function, limitations of activities of daily living, prognosis______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Impairment Rating and Rationale Organ system and whole person impairmentBody part or system Chapter No. Table No. % Impairment of the Whole Persona.b.c.d.Calculated total whole person impairment:_________%. Discussion of rationale of impairment rating and any possible inconsistencies in the examination:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations: Further diagnostic or therapeutic follow-up care______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Chapter 3253.1 Principles of Assessment3.2 Valvular Heart Disease3.3 Coronary Heart Disease3.4 Congenital Heart Disease3.5 Cardiomyopathies3.6 Pericardial Heart Disease3.7 Arrhythmias3.8 Cardiovascular Impairment Evaluation SummaryIntroductionThis chapter provides criteria for evaluating perma-nent impairments of the cardiovascular system andtheir effects on an individual’s ability to perform theactivities of daily living. The cardiovascular systemconsists of the heart, the aorta, the systemic arteries,and the pulmonary arteries. Impairment of the heartis the focus of this chapter; impairment of diseases ofthe aorta, the systemic arteries, and pulmonary arter-ies (including coronary and peripheral circulation)are included in Chapter 4.The following sections have been revised from thefourth edition: (1) information about valvular heartdisease reflecting newly published guidelines fromthe American Heart Association and AmericanCollege of Cardiology; (2) information about coro-nary artery disease reflecting the important prognos-tic impact of left ventricular function on impairmentin individuals with coronary artery disease, and theinclusion of silent ischemia and coronary arteryspasm with regard to impairment; and (3) informa-tion about cardiomyopathy, including the impact ofHIV-related conditions that affect cardiac function.The Cardiovascular System:Heart and AortaChapter 3Chapter 33.1 Principles ofAssessmentBefore using the information in this chapter, theGuides user should become familiar with Chapters 1and 2 and the Glossary. Chapters 1 and 2 discuss theGuides’ purpose, applications, and methods for per-forming and reporting impairment evaluations. TheGlossary provides definitions of common terms usedby many specialties in impairment evaluation.3.1a Interpretation of Symptoms and SignsSome impairment classes refer to limitations in theability to perform daily activities because ofsymptoms. When this information is subjective andpossibly misinterpreted, it should not serve as thesole criterion upon which decisions aboutimpairment are made. Rather, the examiner shouldobtain objective data about the extent of thelimitation and integrate the findings with thesubjective data to estimate the degree of permanentimpairment. See the functional classifications ofcardiac disease in Table 3-1.Exercise TestingWhen feasible, the physician should attempt to quan-tify limitations due to symptoms by observing theindividual during exercise.2 A motor-driven treadmillwith varying grades and speeds is the most widelyused device for standardized exercise protocols. Theprotocols vary slightly, but they all attempt to relatethe exercise to excess energy expended and to func-tional class. The excess energy expended is usuallyexpressed in terms of the “MET,” which representsthe multiples of resting metabolic energy used forany given activity. One MET is considered to be 3.5 mL (kg/min). The 70-kg man who burns 1.2kcal/min while sitting at rest uses approximately 3METS when walking 4 km/h.Table 3-2 displays the relationship of excess energyexpenditures in METS to functional class accordingto the protocols of several investigators. With all pro-tocols, the exercise periods last for 2 or 3 minutes;the time periods are represented in the table by boxeswith numbers giving the estimated METS involved.26 Guides to the Evaluation of Permanent ImpairmentChapter 3I Individual has cardiac disease but no resulting limitationof physical activity; ordinary physical activity does notcause undue fatigue, palpitation, dyspnea, or anginalpain.II Individual has cardiac disease resulting in slight limitationof physical activity; is comfortable at rest and in the per-formance of ordinary, light, daily activities; greater thanordinary physical activity, such as heavy physical exertion,results in fatigue, palpitation, dyspnea, or anginal pain.III Individual has cardiac disease resulting in marked limitation of physical activity; is comfortable at rest; ordinary physical activity results in fatigue, palpitation,dyspnea, or anginal pain.IV Individual has cardiac disease resulting in inability tocarry on any physical activity without discomfort; symp-toms of inadequate cardiac output, pulmonary conges-tion, systemic congestion, or anginal syndrome may bepresent, even at rest; if any physical activity is under-taken, discomfort is increased.*Adapted from: Criteria Committee of the New York Heart Association. Diseases of theHeart and Blood Vessels: Nomenclature and Criteria for Disease. 6th ed. Boston, Mass:Little Brown & Co; 1964. This well-established classification is preferred over the newerclassification introduced in the 7th edition.1Table 3-1 NYHA Functional Classification of Cardiac Disease*Class DescriptionThe Cardiovascular System: Heart and Aorta 27Chapter 3Treadmill testsEllestadMiles per hour 1.7 3.0 4.0 5.0% grade 10 10 10 10BruceMiles per hour 1.7 2.5 3.4 4.2% grade 10 12 14 16BalkeMiles per hour 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4% grade 2 4 6 8 10 12 14 16 18 20 22 24 26BalkeMiles per hour 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0% grade 0 2.5 5 7.5 10 12.5 15 17.5 20 22.5NaughtonMiles per hour 1.0 2.0 2.0 2.0 2.0 2.0 2.0% grade 0 0 3.5 7 10.5 14 17.5Clinical statusSymptomatic patientsDiseased, recoveredSedentary healthyPhysically activeFunctional classTable 3-2 Relationship of METS and Functional Class According to Five Treadmill Protocols*METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16METS 1.6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16������������ � �IV III II I and Normal*Adapted from: Fox SM III, Naughton JP, Haskell WL. Physical activity and the prevention of coronary heart disease. Ann Clin Res. 1971;3:404-432.3*Source: American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. Philadelphia, Pa: Lea and Febiger; 1975:17.kg (lb) 75 150 300 450 600 750 900 1050 1200 1350 1500 1650 1800)(12) (25) (50) (75) (100) (125) (150) (175) (200) (225) (250) (275) (300)20 (44) 4.0 6.0 10.0 14.0 18.0 22.030 (66) 3.4 4.7 7.3 10.0 12.7 15.3 17.9 20.7 23.340 (88) 3.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.050 (110) 2.8 3.6 5.2 6.8 8.4 10.0 11.5 13.2 14.8 16.3 18.0 19.6 21.1)60 (132) 2.7 3.3 4.7 6.0 7.3 8.7 10.0 11.3 12.7 14.0 15.3 16.7 18.0)70 (154) 2.6 3.1 4.3 5.4 6.6 7.7 8.8 10.0 11.1 12.2 13.4 14.0 15.7)80 (176) 2.5 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0)90 (198) 2.4 2.9 3.8 4.7 5.6 6.4 7.3 8.2 9.1 10.0 10.9 11.8 12.6)100 (220) 2.4 2.8 3.6 4.4 5.2 6.0 6.8 7.6 8.4 9.2 10.0 10.8 11.6)110 (242) 2.4 2.7 3.4 4.2 4.9 5.6 6.3 7.1 7.8 8.5 9.3 10.0 10.7)120 (264) 2.3 2.7 3.3 4.0 4.7 5.3 6.0 6.7 7.3 8.0 8.7 9.3 10.0)Table 3-3 Energy Expenditure in METS During Bicycle Ergometry*Body Weight Work Rate on Bicycle Ergometer, kg m—1 min—1 (Watts)A major problem with the use of any exercise-testingtechnique to attempt to quantify an individual’s func-tional capacity is the marked variability in people’sefforts and abilities. Therefore, while measuring themaximum oxygen consumption response, the healthcare professional should estimate and note the indi-vidual’s cooperation and effort during the test; eg,some will continue longer than they should, whileothers will stop after minimal effort because theyfeel fatigued.Functional CapacityThe functional capacity of an individual depends onage, gender, and level of training. The functionalclass determined by means of Tables 3-2 and 3-3may not be applicable to people at the ends of theage spectrum, such as a 20-year-old athlete or aninactive 70-year-old woman. Therefore, it may beuseful to calculate a “percentage functional aerobiccapacity” that is achieved on an exercise test.Standard charts are available for the various exerciseprotocols that determine the percentage functionalaerobic capacity based on total exercise duration,age, gender, and level of training.4Left Ventricle FunctionKnowledge of the status of the left ventricle is impor-tant to assess in the examination and evaluation of anindividual with cardiac disease. Two phases of leftventricular (LV) function contribute to the person’ssymptoms and condition: systolic function, which isthe ability of the heart to pump out blood during con-traction; and diastolic function, the process by whichthe heart fills with blood during relaxation of themyocardium and a passive filling phase.5Ejection FractionA clinically used measure of systolic function is the“ejection fraction” (EF), the percentage of blood theheart is able to eject during one beat. Echocardiogra-phy, radionuclide angiography, and left ventriculog-raphy are commonly used to measure the EF. Anormal EF is greater than to 0.50; EFs of 0.40 to0.50 indicate mild systolic dysfunction; 0.30 to 0.40,moderate systolic dysfunction; and3-1 category I of the NYHA systemis represented in the corresponding class 1 on Table3-5. The classes listed in Tables 3-5 through 3-11apply the NYHA functional classification to specificdisease conditions. The percentages of impairmentreflect the severity of the condition and the extent towhich the condition limits the abilities to do activi-ties of daily living.In the illustrative examples of impairment in thischapter, any historic, physical examination, or labo-ratory information or data not described should beconsidered to be within normal limits.In summary, an evaluation of the cardiovascular system that falls within normal range reflects anindividual who performs all activities of daily livingwithout cardiovascular symptoms, has some reservecapacity that allows comfortable exercise without the development of major cardiovascular symptoms,has an LV ejection fraction that falls within normallimits, and completes at least 80% of age- and gender-predicted functional aerobic capacity duringexercise stress testing.28 Guides to the Evaluation of Permanent ImpairmentChapter 33.2 Valvular HeartDiseaseCongenital, rheumatic, infectious, or traumatic fac-tors or a combination of those factors may causevalvular heart disease. Valvular disease may result in(1) pressure hypertrophy of the left or right ventricle(RV), causing elevated filling pressures, myocardialischemia, and eventual LV dysfunction with signsand symptoms of congestive heart failure (CHF); (2) volume hypertrophy of the LV or RV, causingventricular dilatation and eventual irreversiblemyocardial dysfunction with signs and symptoms ofCHF; (3) inflow obstruction to the ventricles causingcongestion of organs, even in the absence of ventric-ular dysfunction; or (4) decreased cardiac output.5Valvular heart disease can be detected and its sever-ity assessed by means of a thorough history andphysical examination and should be confirmed byeither Doppler echocardiography or cardiac catheter-ization.8 A valve gradient measures the pressure dropacross a stenotic valve and is proportional to theseverity of obstruction. Since the valve gradient isinfluenced by the cardiac output, the valve gradientcalculates a valve area that takes into considerationboth the pressure gradient and the cardiac output.There may be technical limitations to these derivedvariables. Their correlation with the severity of thestenosis is shown in Table 3-4.* Severity of stenosis also may be indexed to body surface area.The severity of a regurgitant valve lesion is more dif-ficult to assess than that of a stenotic lesion. Physicalexamination and Doppler echocardiography mayprovide a qualitative assessment. Although Dopplerechocardiography may help the physician determinea mild or severe regurgitant valve lesion, this tech-nique’s inherent limitations preclude an accurateassessment of intermediate grades of severity.Cardiac catheterization may be required for a semi-quantitative estimate of the valve lesion’s severity; itcan provide a view of the contrast medium’s inten-sity as it crosses the regurgitating valve into thereceiving heart chamber. To assess the severity ofaortic valve regurgitation, obtain the estimate withaortic root angiography; to assess the severity ofmitral valve regurgitation, obtain the estimate withleft ventriculography.Catheter-based interventional procedures, operativerepair, or prosthetic valve replacement can reduce theseverity of, but not fully repair, valvular heart dis-ease. After any of these procedures, allow sufficienttime to elapse from the date of surgery for maximum recovery and reconditioning of the heart,lungs, and other organs before estimating permanent impairment.In addition, because medication may affect the sever-ity of valvular heart disease, especially limitationsdue to symptoms, allow sufficient time for medica-tion to be introduced and adjusted and to take effectbefore estimating permanent impairment.The Cardiovascular System: Heart and Aorta 29Chapter 3Aortic valveMild 1.5Moderate 25-50 1.0-1.5Severe >50 1.5Moderate 5-10 1.0-1.5Severe >10 7;TMET [Bruce protocol] >6 min)and in the individual who has recov-ered from valvular heart surgery,all above criteria are metEvidence by physical examina-tion or laboratory studies ofvalvular heart disease, and nosymptoms in performance ofdaily activities, but symptomsdevelop on moderately heavyphysical exertion (functionalclass II)orrequires moderate dietaryadjustment or drugs to preventsymptoms or to remain free ofsigns of CHF or other conse-quences of valvular heart dis-ease, such as syncope, chestpain, and embolior signs or laboratory evidence ofcardiac chamber dysfunctionand/or dilation, severity of steno-sis or regurgitation estimated tobe moderate, and surgical cor-rection not feasible or advisable;METS >5 but 3 minor has recovered from valvularheart surgery and meets criteriafor functional class IISigns of valvular heart diseaseand slight to moderate sympto-matic discomfort during per-formance of ordinary dailyactivities (functional class III)and dietary therapy or drugs do notcompletely control symptoms orprevent CHFand signs or laboratory evidence ofcardiac chamber dysfunction ordilation, severity of stenosis orregurgitation estimated to bemoderate or severe, and surgicalcorrection not feasible; METS >2but 1 min butthen estimate valvedisorder impairment at 1% to 9%, depending onthe severity of the abnormality. If aortic regurgita-tion murmur but no symptoms or signs of cardiacenlargement and CHF, then estimate is lower. LV size and function may be present; assess with 2-dimensional echocardiography (2DE) orradionuclide angiography to rule out significantLV dilation or dysfunction.Example 3-20% to 9% Impairment Due to Valvular Heart DiseaseSubject: 38-year-old-woman.History: Systolic murmur on insurance physicalexam. Played collegiate sports. Marathon runner.Current Symptoms: Denies dyspnea, angina, palpi-tations, or fatigue.Physical Exam: Blood pressure (BP): normal; pulserate (PR): 52 BPM; mid-peaking systolic ejectionmurmur.Clinical Studies: Echocardiogram: bicuspid aorticvalve; mean gradient of 22 mm Hg; valve area 1.5cm2. ECG: tall R-waves and slight ST depressionin precordial leads V5and V6in excess of 25 mm.Chest roentgenogram: normal.Diagnosis: Asymptomatic mild aortic stenosis sec-ondary to a bicuspid aortic valve with electrocar-diographic evidence of LV hypertrophy.Impairment Rating: 1% to 9% impairment of thewhole person.Comment: Antibiotic prophylaxis before dental orsurgical procedure to minimize risk of bacterialendocarditis. Periodic cardiac follow-up for pro-gression of aortic stenosis. Aortic valve surgerynecessary later in life.Class 10%-9% Impairment of the Whole PersonEvidence by physical examination or laboratory studies of valvularheart diseaseandno symptoms in the performance of ordinary daily activities(functional class I; 5 METS; Table 3-2) or with moderately heavyexertion (7 to 10 METS)anddoes not require continuous treatment, except for intermittentprophylactic antibiotics for surgical or dental procedure to reducerisk of bacterial endocarditisandno evidence of CHFandno signs of ventricular dysfunction or dilation, and severity ofstenosis or regurgitation estimated to be mild (METS >7; TMET[Bruce protocol] >6 min)andin the individual who has recovered from valvular heart surgery, all of above criteria are metThe Cardiovascular System: Heart and Aorta 31Chapter 3Example 3-310% to 29% Impairment Due to Valvular Heart DiseaseSubject: 66-year-old woman.History: Progressive HF; culminated in several syn-copal episodes 3 years ago. Severe calcific steno-sis of the aortic valve; depressed systolic function.Aortic valve replacement with large St. Jude’sbileaflet prosthesis.Current Symptoms: Returned to normal life; walks2 miles daily. Maintenance: oral anticoagulants.Prothrombin time level every 3 weeks. Antibioticsbefore dental or operative procedures; no othermedication.Physical Exam: BP and PR: normal. No signs ofHF. Slightly sustained apical impulse. 1/6 earlysystolic murmur in first right intercostal space. S1: normal; S2: crisp, closing click of the pros-thetic valve.Clinical Studies: ECG: rhythm, QRS pattern nor-mal; low T waves in I, L, V5, and V6. Chestroentgenogram: slight prominence heart apex;prosthesis properly positioned: no evidence ofpulmonary congestion. Echocardiogram: normalsize ventricles; thickening of LV wall; prosthesisproperly positioned, mean gradient 10 mm Hgacross the prosthesis; slight regurgitation. LV sys-tolic function mildly depressed; 0.45 LVEF.Diagnosis: Calcific aortic stenosis, probably relatedto congenital bicuspid aortic valve, and valvereplacement.Impairment Rating: 20% impairment of the wholeperson.Comment: Impairment greater if (1) a diastolicdecrescendo murmur; (2) the systolic gradientacross the prosthesis > Doppler-derived normalvalues for the type of prosthesis; or (3) mildrecurrent dyspnea. Cardiac catheterization notnecessary for estimate.Example 3-410% to 29% Impairment Due to Valvular Heart DiseaseSubject: 63-year-old man.History: Mild CHF and aortic regurgitation 5 yearsago. Restricts salt intake; no cardiac medications.Golfs regularly.Current Symptoms: None.Physical Exam: BP: 160/50 mm Hg; PR: 70 BPM;bounding peripheral pulses, lungs clear, apeximpulse slightly lateral to midclavicular line(MCL); S1and S2normal; 3/6 harsh aortic ejectionmurmur; 3/6 long decrescendo diastolic murmur.Clinical Studies: ECG: borderline voltage for leftventricular hypertrophy (LVH). Chestroentgenogram: no cardiomegaly or pulmonarycongestion. Echocardiogram: normal size aorticroot; trileaflet aortic valve; fluttering anteriorleaflet of the mitral valve; normal LV systolicfunction with moderate dilation. Doppler: moder-ately severe aortic regurgitation; no stenosis.Diagnosis: Moderately severe aortic regurgitation ofuncertain cause.Impairment Rating: 20% to 29% impairment of thewhole person.Comment: Asymptomatic but impaired. Higher esti-mate if LV systolic dysfunction. Cardiac catheter-ization, angiography were not necessary forestimate. Elevated BP needs treatment. If eleva-tion of BP persists after treatment, then estimateimpairment due to hypertension per Table 4-2.Class 210%-29% Impairment of the Whole PersonEvidence by physical examination or laboratory studies of valvularheart disease, and no symptoms in performance of daily activities,but symptoms develop on moderately heavy physical exertion(functional class II)orrequires moderate dietary adjustment or drugs to prevent symptoms or to remain free of signs of CHF or other con-sequences of valvular heart disease, such as syncope, chest pain,and emboliorsigns or laboratory evidence of cardiac chamber dysfunctionand/or dilation, severity of stenosis or regurgitation estimated tobe moderate, and surgical correction not feasible or advisable;METS >5 but 3 minorhas recovered from valvular heart surgery and meets criteria forfunctional class II32 Guides to the Evaluation of Permanent ImpairmentChapter 3Example 3-530% to 49% Impairment Due to Valvular DiseaseSubject: 71-year-old man.History: Nonresponsive thrombocytopenia. Moderateexertional dyspnea for 2 years despite diureticsand digoxin.Current Symptoms: Comfortable at rest; becomesshort of breath (SOB) when climbing to secondfloor. Sleeps on two pillows; has not awakenedSOB since diuretic increase 1 year earlier. Lies flatcomfortably.Physical Exam: BP: 110/80 mm Hg; PR: irregular—84 BPM. Venous pressure (VP): normal; noedema. Harsh breath sounds at each base; no rales.Apical impulse: large, hyperdynamic, displaced tothe anterior axillary line. Slight parasternal heave.S1, S2: loud; 4/6 holosystolic murmur at lower ster-nal border, apex, and left axilla. Audible S3.Clinical Studies: ECG: atrial fibrillation; irregularventricular response 80/min. Low T waves; QRSpattern normal. Chest roentgenogram: car-diomegaly; large LA. Upper lobes vasculatureprominent. Echocardiogram: 2DE: flail mitralleaflet. Doppler: Severe mitral regurgitation; esti-mated peak systolic pulmonary arterial pressure(PAP) 50 mm Hg. Mild LV and moderate LAenlargement; hyperdynamic systolic function.Diagnosis: Severe mitral regurgitation due to mitralvalve prolapse with a flail leaflet. Atrial fibrillationwith a controlled ventricular response at rest.Impairment Rating: 40% to 49% impairment of thewhole person.Comment: Greater exercise tolerance and less car-diomegaly for lower impairment. If reduced sys-tolic function, increase impairment. Cardiaccatheterization not necessary for estimate.Consider surgical treatment.Example 3-630% to 49% Impairment Due to Valvular Heart DiseaseSubject: 60-year-old woman.History: Seamstress; surgical replacement of aorticand mitral valves 1 year earlier. Little staminadespite oral anticoagulants, digoxin, diuretics, saltrestrictions. Tired easily; rested each afternoon.Sometime ankle edema resolved after extradiuretic.Current Symptoms: No nocturnal dyspnea; sleepswith one pillow. Light housework possible; notwell enough to returnto work. Weight 6.8 kg (15 lb) below preoperative weight.Physical Exam: Comfortable lying flat. BP: 110/70 mm Hg; PR: irregular—80 BPM.Venous pressure: normal; no edema. Lungs: clear.Clinical Studies: Apical impulse: enlarged, sus-tained through systole at anterior axillary line; noparasternal heave; normal prosthetic valve sounds;1/6 early systolic murmur in first right intercostalspace, along the left sternal border. ECG: atrialfibrillation; irregular ventricular response 80/min.Completes stage I Bruce protocol on treadmill;fatigue and SOB at stage II (5 METS). Chestroentgenogram: cardiomegaly; LV, LA enlarge-ment. Upper lobes vasculature prominent.Echocardiogram: no prosthetic valve malfunctionor displacement. Ventricles, LA slightly enlarged.LV systolic function normal.Diagnosis: Aortic and mitral valve disease, probablyrheumatic in origin; surgical replacement ofvalves.Impairment Rating: 40% to 49% impairment of thewhole person.Comment: Bruce protocol: class I if exertion > 6 minutes; class II if 3 to 6 minutes; class III if1 to 3 minutes; and class IV if 2 but 1 min butRating PermanentImpairment Due to Coronary Heart DiseaseImpairment criteria for CHD are given in Table 3-6.The Cardiovascular System: Heart and Aorta 35Chapter 3Chapter 336 Guides to the Evaluation of Permanent ImpairmentBecause of serious implicationsof reduced coronary blood flow,it is not reasonable to classifydegree of impairment as 0%through 9% in anyone who hassymptoms of CHD corroboratedby physical examination or labo-ratory tests; this class of impair-ment should be reserved forindividuals with equivocal histo-ries of angina pectoris on whomcoronary angiography is per-formed, or for those on whomcoronary angiography is per-formed for other reasons and inwhom less than 50% reductionin cross-sectional area of coro-nary artery is found with a nor-mal EF; METS determination isnot applicableHistory of MI or angina pectorisdocumented by appropriate lab-oratory studies, but at time ofevaluation, no symptoms whileperforming ordinary daily activi-ties or even moderately heavyphysical exertion (functionalclass I)andmay require moderate dietaryadjustment or medication toprevent angina or to remain freeof signs and symptoms of CHFand able to walk on treadmill or bicy-cle ergometer and obtain HR of90% of predicted maximum HR(see Table 3-6b) without devel-oping significant ST-segmentshift, VT, or hypotension; ifuncooperative or unable to exer-cise because of disease affectinganother organ system, thisrequirement may be omitted;METS >7orhas recovered from coronaryartery surgery or angioplasty,remains asymptomatic duringordinary daily activities, and ableto exercise as outlined above; iftaking a beta-adrenergic block-ing agent, should be able towalk on treadmill to level esti-mated to cause energy expendi-ture of at least 7 METS assubstitute for HR targetHistory of MI documented byappropriate laboratory studies,or angina pectoris documentedby changes on resting or exer-cise ECG or radioisotope studysuggestive of ischemiaor either fixed or dynamic focalobstruction of at least 50% ofcoronary artery, angiography,and function testingand requires moderate dietaryadjustment or drugs to preventfrequent angina or to remainfree of symptoms and signs ofCHF, but may develop anginapectoris after moderately heavyphysical exertion (functionalclass II); METS >5 butHistory: Service station attendant; acute MI 8months earlier. Hospitalized for 10 days; serialECGs: classic changes of an inferior wall infarc-tion. Post-MI echocardiography: inferior wallmotion abnormalities; 0.55 EF.Current Symptoms: After recovery, returned towork. Follows diet to maintain weight of 72 kg(160 lb)—11 kg (24 lb) less than 1 year before.Asymptomatic; no medication.Clinical Studies: Chest roentgenograms: normal.ECG: Q and flat T waves in 2, 3, and F. Duringexercise, HR: 152 BPM; BP: adequate rise. ECG: no pattern changes to indicate ischemia orarrhythmias.Diagnosis: Recent inferior-wall MI.Impairment Rating: 10% to 19% impairment of thewhole person.Comment: Greater impairment for uncomplicatedrecovery from anterior wall infarction, especiallyif LV systolic dysfunction.Example 3-1210% to 29% Impairment Due to Coronary Heart DiseaseSubject: 52-year-old woman.History: Service specialist for an insurance firm;coronary artery bypass surgery for angina relief 6 months earlier. Vein grafts in LAD, RCA.Preoperative coronary angiography: no signifi-cant obstruction in circumflex coronary artery;normal EF.Current Symptoms: Did well postsurgery; workedfor 14 months. Asymptomatic; avoids heavy physical exertion. Daily 0.3 g of aspirin; no othermedications.Physical Exam: Well-healed scar; normal heart.Clinical Studies: Bruce protocol exercise test 10 daysearlier; HR: 144 BPM; no ST-segment shifts orarrhythmias after 10 minutes of exercise. ECG:low T waves in I, L, V4, V5, and V6; no Q waves.Chest roentgenogram: normal.Diagnosis: CHD with coronary artery bypass surgery.Impairment Rating: 10% to 19% impairment of thewhole person.Class 210%-29% Impairment of the Whole PersonHistory of MI or angina pectoris documented by appropriate laboratory studies, but at time of evaluation, no symptoms whileperforming ordinary daily activities or even moderately heavyphysical exertion (functional class I)andmay require moderate dietary adjustment or medication to pre-vent angina or to remain free of signs and symptoms of CHFand able to walk on treadmill or bicycle ergometer and obtain HR of90% of predicted maximum HR without developing significant ST-segment shift, VT, or hypotension; if uncooperative or unableto exercise because of disease affecting another organ system,this requirement may be omitted; METS >7orhas recovered from coronary artery surgery or angioplasty, remains asymptomatic during ordinary daily activities, and able toexercise as outlined above; if taking a beta-adrenergic blockingagent, should be able to walk on treadmill to level estimated tocause energy expenditure of at least 7 METS as substitute for HR target38 Guides to the Evaluation of Permanent ImpairmentChapter 3Men Maximal 193 191 189 187 184 182 180 17890% Maximal 173 172 170 168 166 164 162 160Women Maximal 190 185 181 177 172 168 163 15990% Maximal 171 167 163 159 155 151 147 143Table 3-7 Maximal and 90% of Maximal AchievableHeart Rate, by Age and Sex*1Heart Rate (beats/min) by Age (y)130 135 140 145 150 155 160 165Example 3-1310% to 29% Impairment Due to Coronary Heart DiseaseSubject: 48-year-old man.History: Chest pain for 2 years interrupted his work-day. Pain accompanied by diaphoresis and dysp-nea. Slightly elevated cholesterol: 245 mg/dL.Family history: 66-year-old father with heart disease.Current Symptoms: Chest pain; palpitations.Physical Exam: BP: 140/90 mm Hg; PR: 76 BPM.Occasional ectopic beat; otherwise normal heartsounds.Clinical Studies: Exercise stress test: completed 14minutes on treadmill; maximum HR: 172; no evi-dence of ischemia. Because of the symptoms andthe man’s persistence at asking for a second opin-ion, he was referred to a cardiologist. Cardiaccatheterization: 40% stenosis in right coronaryartery; no disease in the left system; 0.60 EF.Reassured that he did not have significant CAD,he returned to work. Symptoms persisted foranother 6 months; mild palpitations began. Holtermonitor: ST segment elevation during palpitation.Second cardiologist suspected coronary arteryspasm because of the correlation between thesymptoms and mental stress. Ergonovine testing:coronary spasm in the right coronary artery.Diagnosis: Vasospastic angina pectoris; had coro-nary artery vasospasm and experienced symptomsonly with significant mental stress.Impairment Rating: 10% to 29% impairment of thewhole person.Comment: Coronary artery spasm–related symp-toms and hyperlipidemia treatment possible withmedication and psychological therapy to decreasestress. Although CAD not significantly obstruc-tive, angina pectoris limited work ability; at riskfor ischemia-related complications. Impairmentcould be adjusted by controlling the vasospasticangina with medical treatment or stress reductiontechniques. Greater impairment score if vasospas-tic angina nonresponsive, more frequent, and lessreactive to stress.Example 3-1430% to 49% Impairment Due to Coronary Heart DiseaseSubject: 58-year-old man.History: First MI 6 months ago; multivessel PTCA.Current Symptoms: Exertional angina while work-ing on industrial refrigeration equipment.Discontinued exercise 2 weeks ago because ofexertional dyspnea and angina. Symptomsdevelop after walking 1 mile in the morningbefore work. Beta-blocker and nitrate medicationsdiscontinued because he could not remember totake them.Physical Exam: Normal.Clinical Studies: ECG: ST segment depression andT-wave inversion in lateral precordial leads.Exercise thallium stress test: small area of apicalischemia at peak exercise workload of 6.8 METS.Cardiac catheterization: all previously treatedblockages widely patent; no evidence of resteno-sis. 80% blockage in distal LAD too small to betreated with a percutaneous procedure. EF: 0.40;anterior wall motion abnormalities.Diagnosis: Exertional angina pectoris secondary toCAD.Impairment Rating: 30% to 35% impairment of thewhole person.Comment: Recovered from MI; continued angina pectoris at moderately high workloads.Medications would reduce or alleviate anginalsymptoms and ischemia. Not a candidate for per-cutaneous or surgical revascularization because ofthe location and size of his one untreated coronaryartery blockage.Class 330%-49% Impairment of the Whole PersonHistory of MI documented by appropriate laboratory studies, orangina pectoris documented by changes on resting or exerciseECG or radioisotope study suggestive of ischemiaoreither fixed or dynamic focal obstruction of at least 50% of coro-nary artery, angiography, and function testingandrequires moderate dietary adjustment or drugs to prevent fre-quent angina or to remain free of symptoms and signs of CHF, but may develop angina pectoris after moderately heavy physicalexertion (functional class II); METS >5 but1.5 mm ST-segment depression in V4-V6. Coronary angiogram: 90% or greater obstruc-tion of all three native coronary arteries. Patentgrafts to the right, circumflex, and left anteriordescending coronary arteries; occluded graft tothe diagonal branch of the LAD. EF: 0.50.Diagnosis: CHD and continued angina after coro-nary artery bypass surgery. Impairment Rating: 30% to 39% impairment of thewhole person.Comment: Patent grafts to the major vessel territo-ries of the myocardium. Monitor for subsequentocclusion.Example 3-1630% to 49% Impairment Due to Coronary Heart DiseaseSubject: 55-year-old man.History: Physician; anterior wall MI 6 months ear-lier with angina pectoris, diaphoresis, and dysp-nea. ECG: new ST segment elevation in V1through V6; elevated cardiac enzymes. Treatedwith thrombolytic and the usual adjunct medicaltherapies. Completed phase II cardiac rehabilita-tion, but never regained strength and stamina.Dyspnea on exertion after 20 to 30 minutes’ briskwalk; unusually fatigued after each exercise ses-sion. Continued to practice medicine, but limitedhimself by not accepting any new patients. 6 weeks after hospital discharge, resting ECG:105 BPM;40 mm Hg(Doppler echocardiography) or if ECG showedRV hypertrophy and a suitable surgical candidate.If asymptomatic with a small ventricular septaldefect, estimate at upper end of class 1; but if bac-terial endocarditis present, then estimate higher. Ifsmall atrial septal defect and normal pressures inall cardiac chambers and great vessels, or anom-alous venous return from small lung segment, alsoestimate at upper end of class 1.Class 10%-9% Impairment of the Whole PersonEvidence by physical examination or laboratory studies of congeni-tal heart disease; has no symptoms in performance of ordinarydaily activities or even on moderately heavy physical exertionandcontinuous treatment not required, although prophylactic antibi-otics may be recommended after surgical procedures to reduce riskof bacterial endocarditis; remains free of signs of CHF and painandno signs of cardiac chamber dysfunction or dilation; evidence ofresidual valvular stenosis or regurgitation estimated to be mild; noevidence of right-to-left shunt; a small left-to-right shunt may bepresent, but Qp/Qsthenature and extent of theinjury or disease as itaffects an injuredemployee’s personal effi-ciency in the activities ofdaily living, such as self-care, communication, nor-mal living postures,ambulation, elevation,traveling, and nonspecial-ized activities of bodilymembers. (Idaho Codesection 72-424)Purpose is to provide sureand certain relief to thosewho become injured byaccident or suffer effectsof disease from exposureto hazards arising out ofand in the course ofemployment.Table 1-1 Definitions and Interpretations of Impairment and DisabilityOrganization Impairment Disability Physicians’ Role CommentsData from healthy populations, when available andwidely referenced, are incorporated into chapters ofthe Guides. In some organ or body systems, such asrespiratory, certain measurements of lung functionhave been standardized for age and gender. In otherbody systems, such as the musculoskeletal, age andgender differences are not reflected in most of thevalues. While there may be age and gender differ-ences anticipated for some musculoskeletal values,such as range of motion in the spine and extremities,this edition of the Guides mainly reflects averagerange of motion from healthy populations of mixedage and gender. The normal values presented in themusculoskeletal section are based on a review ofstudies measuring range of motion, as cited in thetext. Evaluating physicians may use their clinicaljudgment, however, and comment on any significantage or gender effect for a particular individual. Forinstance, the “normal” preinjury range of motion fora gymnast with hypermobility may exceed the listednormal values.If an individual had previous measurements of func-tion that were below or above average populationvalues, the physician may discuss that prior valueand any subsequent loss for the individual, as well ascompare it to the population normal. For example, ahighly functioning athlete with documented, above-normal lung function, who has sustained an injuryand now has decreased lung function that is nonethe-less similar to population averages, has experienceda loss in his or her lung function and has sustained animpairment. Based only on a population comparison,the athlete would be given a 0% impairment rating.However, it would be more appropriate in thisinstance for the physician to assign an impairmentrating based on the degree of change from the ath-lete’s preinjury to postinjury state.In evaluating impairment, the Guides considers bothanatomic and functional loss. Some chapters place agreater emphasis on either anatomic or functionalloss, depending upon common practice in that spe-cialty. Anatomic loss refers to damage to the organsystem or body structure, while functional loss refersto a change in function for the organ or body system.An example of an anatomic deviation is developmentof heart enlargement; functional loss includes a lossin ejection fraction or the ability of the heart to pumpadequately. Anatomic loss receives greater emphasisin the musculoskeletal system, as in measurementssuch as range of motion. Functional considerationsreceive greater emphasis in the mental and behav-ioral section.The impairment criteria outlined in the Guides pro-vide a standardized method for physicians to use todetermine medical impairment. The impairment cri-teria include diagnostic criteria, incorporatinganatomic and functional measures. The impairmentcriteria were developed from scientific evidence ascited and from consensus of chapter authors or ofmedical specialty societies.Impairment percentages or ratings developed bymedical specialists are consensus-derived estimatesthat reflect the severity of the medical condition andthe degree to which the impairment decreases anindividual’s ability to perform common activities ofdaily living (ADL), excluding work. Impairment rat-ings were designed to reflect functional limitationsand not disability. The whole person impairmentpercentages listed in the Guides estimate the impactof the impairment on the individual’s overall abilityto perform activities of daily living, excluding work,as listed in Table 1-2.4 Guides to the Evaluation of Permanent ImpairmentChapter 1Self-care, Urinating, defecating, brushing teeth,personal hygiene combing hair, bathing, dressing oneself, eatingCommunication Writing, typing, seeing, hearing, speakingPhysical activity Standing, sitting, reclining, walking,climbing stairsSensory function Hearing, seeing, tactile feeling, tasting,smellingNonspecialized Grasping, lifting, tactile hand activities discriminationTravel Riding, driving, flyingSexual function Orgasm, ejaculation, lubrication, erectionSleep Restful, nocturnal sleep patternTable 1-2 Activities of Daily Living Commonly Measuredin Activities of Daily Living (ADL) andInstrumental Activities of Daily Living (IADL) Scales 6,7Activity ExampleThe medical judgment used to determine the originalimpairment percentages could not account for thediversity or complexity of work but could accountfor daily activities common to most people. Work isnot included in the clinical judgment for impairmentpercentages for several reasons: (1) work involvesmany simple and complex activities; (2) work ishighly individualized, making generalizations inac-curate; (3) impairment percentages are unchangedfor stable conditions, but work and occupationschange; and (4) impairments interact with such otherfactors as the worker’s age, education, and priorwork experience to determine the extent of work dis-ability. For example, an individual who receives a30% whole person impairment due to pericardialheart disease is considered from a clinical standpointto have a 30% reduction in general functioning asrepresented by a decrease in the ability to performactivities of daily living. For individuals who work insedentary jobs, there may be no decline in their workability although their overall functioning isdecreased. Thus, a 30% impairment rating does notcorrespond to a 30% reduction in work capability.Similarly, a manual laborer with this 30% impair-ment rating due to pericardial disease may be com-pletely unable to do his or her regular job and, thus,may have a 100% work disability.As a result, impairment ratings are not intended foruse as direct determinants of work disability. When aphysician is asked to evaluate work-related disability,it is appropriate for a physician knowledgeable aboutthe work activities of the patient to discuss the spe-cific activities the worker can and cannot do, giventhe permanent impairment.Most impairment percentages in this fifth editionhave been retained from the fourth edition becausethere are limited scientific data to support specificchanges. It is recognized that there are limited datato support some of the previous impairment percent-ages as well. However, these ratings are currentlyaccepted and should not be changed arbitrarily. Inthis edition, some percentages have been changed forgreater scientific accuracy or to achieve consistencythroughout the book.A 0% whole person (WP) impairment rating isassigned to an individual with an impairment if theimpairment has no significant organ or body systemfunctional consequences and does not limit the per-formance of the common activities of daily livingindicated in Table 1-2. A 90% to 100% WP impair-ment indicates a very severe organ or body systemimpairment requiring the individual to be fullydependent on others for self-care, approaching death.The activities of daily living, as originally developedfor the Guides in the first and second editions,1,6 sig-nify common activities currently represented inscales of Activities of Daily Living and InstrumentalActivities of Daily Living.7 The Guides refers tocommon ADLs, as listed in Table 1-2. The ADLslisted in this table correspond to the activities thatphysicians should consider whenthe advice ofphysicians. Current Symptoms: Weakness and fatigue withheavy exercise within last year, but still performsmost daily activities without limitations.Palpitations never sustained; not associated withinadequate cerebral perfusion. No history ofcyanosis, breathlessness, or peripheral edema.Physical Exam: Comfortable; no cyanosis. Elevatedvenous pressure 15 cm without large V waves;enlarged liver width of 12 cm. Clear lungs. Noprecordium thrills, taps, or heaves. S1: loud, fol-lowed by a very loud, sharp sound in early systoleheard best along the left sternal border. S2: loud,early diastolic sound heard best at midpre-cordium. Holosystolic murmur along the left ster-nal border increased in intensity with inspiration.Clinical Studies: ECG: right bundle-branch blockpattern; very low R wave in V1. Broad, notched Pwave in leads III and F; inverted T waves in V1and V2. Occasional premature atrial beats. Chestroentgenogram: marked enlargement of cardiacsilhouette, particularly to right of the sternum;normal pulmonary vasculature. Echocardiogram:features consistent with Ebstein’s anomaly of the tricuspid valve. Tricuspid valve: markedly displaced into a small RV; severe regurgitation.Doppler: no right-to-left shunt. Cardiac catheteri-zation, angiography: mean right atrial pressure 7mm Hg; V waves 15 mm Hg. RVP and PAP: nor-mal. No evidence of a shunt.Diagnosis: Ebstein’s anomaly of the tricuspid valve.Impairment Rating: 25% impairment of the wholeperson.Class 210%-29% Impairment of the Whole PersonEvidence by physical examination or laboratory studies ofcongenital heart disease; has no symptoms in performanceof ordinary daily activities, but has symptoms with moder-ately heavy physical exertion (functional class II)orrequires moderate dietary adjustments or drugs to preventsymptoms or to remain free of signs of CHF or other conse-quences of congenital heart disease, such as syncope, chestpain, emboli, or cyanosisorsigns or laboratory findings of cardiac chamber dysfunctionor dilation, or severity of valvular stenosis or regurgitationestimated to be moderate; no evidence of right-to-leftshunt; moderate-sized left-to-right shunt may be presentwith Qp/Qsdefect.Diagnosis: Tetralogy of Fallot with surgical relief ofthe pulmonary stenosis and closure of the ventric-ular septal defect, followed by development of tri-cuspid regurgitation and heart failure.Impairment Rating: 80% to 90% impairment of thewhole person.Example 3-2650% to 100% Impairment Due to Congenital Heart DiseaseSubject: 23-year-old woman.History: Eisenmenger’s complex 10 years ago; regu-lar follow-up visits. Cardiac catheterization,angiography: ventricular septal defect; pulmonaryvascular resistance equal to systemic vascularresistance.Current Symptoms: Recent activity markedly lim-ited because of fatigue on minimal exertion.Recent peripheral edema responded to diuretics.Physical Exam: Mild cyanosis intensified with exer-tion. Neck veins: prominent A waves; no jugularvenous distention when placed at 45° angle. Noenlargement or peripheral edema. Clear lungs.Forceful, sustained, parasternal heave. S1: normal;S2: narrowly split, marked increase in secondcomponent. Short, early systolic ejection murmuralong left sternal border.Clinical Studies: ECG: RV hypertrophy, peaked Pwaves in leads II, III, and F. Chest roentgenogram:RV hypertrophy; marked prominence of proximalportion of PA; greatly diminished pulmonary vas-cular markings in peripheral lung fields.Diagnosis: Eisenmenger’s complex with ventricularseptal defect and elevated pulmonary vascularresistance.Impairment Rating: 95% to 100% impairment ofthe whole person.Class 450%-100% Impairment of the Whole PersonSigns of congenital heart disease and experiences symptoms ofCHF at less than ordinary daily activities (functional class IV),despite dietary therapy and medicationandevidence from physical examination or laboratory studies of car-diac dilation, or chamber dysfunction or dilation, or pulmonaryvascular resistance remains elevated at greater than one-half sys-temic vascular resistance; or severity of valvular stenosis or regur-gitation estimated to be moderate to severe; or left-to-right shuntwith pulmonary flow being greater than 2 times systemic flow; orleft-to-right shunt with pulmonary vascular resistance being ele-vated to greater than one-half systemic vascular resistance; orright-to-left shuntorhas recovered from heart surgery for treatment of congenitalheart disease and continues to have symptoms or signs of CHFcausing impairment as outlined above46 Guides to the Evaluation of Permanent ImpairmentChapter 3The Cardiovascular System: Heart and Aorta 47Chapter 3Asymptomaticandno evidence of congestive heartfailure (CHF) from physicalexamination or laboratory stud-iesAsymptomaticandmoderate dietary adjustment ordrug therapy necessary for indi-vidual to be free of symptomsand signs of CHForhas recovered from surgery fortreatment of hypertrophic car-diomyopathy or has recoveredfrom successful heart transplan-tation and meets above criteriaSymptoms of CHF on greaterthan ordinary daily activities(functional class II)andmoderate dietary restriction oruse of drugs necessary to mini-mize symptoms or to preventappearance of signs of CHF orevidence of it by laboratorystudyorhas recovered from surgery fortreatment of hypertrophic car-diomyopathy or has recoveredfrom successful heart transplan-tation and meets above criteriaSymptomatic during ordinarydaily activities despite appropriateuse of dietary adjustment anddrugs (functional class III or IV)orpersistent signs of CHF despiteuse of dietary adjustment anddrugsorhas recovered from surgery fortreatment of hypertrophic car-diomyopathy or has recoveredfrom successful heart transplan-tation and meets above criteriaTable 3-9 Criteria for Rating Permanent Impairment Due to CardiomyopathiesClass 1 Class 2 Class 3 Class 40%-9% Impairment of the 10%-29% Impairment of the 30%-49% Impairment of the 50%-100% Impairment of the Whole Person Whole Person Whole Person Whole Person3.5 CardiomyopathiesCardiomyopathies, caused by a primary disease thataffects the heart muscle, lead to impairment fromabnormal ventricular function. Abnormal ventricularfunction may be the result of (1) systolic dysfunc-tion, (2) diastolic dysfunction, or (3) a combinationof both. An individual with these abnormalities maybe asymptomatic or symptomatic due to pulmonaryor systemic organ congestion and decreased cardiacoutput. In people with hypertrophic cardiomyopathy,a dynamic outflow tract obstruction and secondarymitral regurgitation may cause symptoms of exer-tional dyspnea, angina, and syncope. Because somecardiomyopathies are reversible, every effort shouldbe made to identify the reversible forms and to treatthem appropriately and prevent further deterioration.When the conditions are stable, the individual maybe evaluated in terms of permanent impairment.13-18Cardiomyopathies arise from many mechanisms, butthe conditions may be divided into three major types:(1) dilated or congestive, (2) hypertrophic, and (3) restrictive. Careful history-taking and physicalexamination can reveal cardiomyopathies, but it isappropriate to confirm the diagnosis with echocar-diography and selected laboratory studies.3.5a Criteria for Rating PermanentImpairment Due to CardiomyopathiesImpairment criteria for cardiomyopathies are givenin Table 3-9.Example 3-270% to 9% Impairment Due to CardiomyopathySubject: 31-year-old man.History: Admitted to hospital following syncopeattack at detoxification center. Admitted to “aproblem with alcohol”; refused chemical depend-ency treatment.Current Symptoms: Denies exertional dyspnea,fatigue, angina, nocturnal dyspnea, and any his-tory of syncope.Physical Exam: Vital signs: normal; CV exam:normal.Clinical Studies: Echocardiogram: 0.40 LVEF; mildglobal hypokinesis of all LV wall segments.Normal atrial dimensions and function, right heartsize, function, and estimated PAP. Overnighttelemetry monitoring: no arrhythmias to explainsyncope.Diagnosis: Syncope secondary to alcohol intoxica-tion and asymptomatic LV dysfunction, presum-ably due to alcoholic cardiomyopathy.Impairment Rating: 5% to 9% impairment of thewhole person.Comment: Evaluated for reversible causes.Impairment higher if symptomatic or conditionlimits daily activities.Example 3-280% to 9% Impairment Due to CardiomyopathySubject: 26-year-old woman.History: Signs of pulmonary congestion 3 days post-partum; normal birth. Normotensive; no evidenceof valvular heart disease. ECG: within normal lim-its except for sinus tachycardia. Echocardiogram:showed diffuse global hypokinesis; 0.30 EF.Successfully treated with digitalis and diuretics.Digitalis and diuretics discontinued 6 monthsbefore evaluation. Advised to avoid subsequentpregnancies; otherwise able to do all activities ofdaily living.Current Symptoms: Asymptomatic for severalmonths; resumed full activities. Physical Exam: No CHF signs. BP: 110/70 mm Hg;PR: regular—70 BPM. Precordium quiet; no ven-tricular heaves. Heart sounds: normal.Clinical Studies: ECG: normal. Chest roentgenogram:slight cardiomegaly; no chamber enlargement.Echocardiogram: slightly enlarged; mild globalhypokinesis; 0.55 EF. Upon exercise, achieved95% of functional aerobic capacity with ECGchanges; EF fell to 0.50.Diagnosis: Postpartum cardiomyopathy.Impairment Rating: 9% impairment of the wholeperson.Comment: If symptomatic, then estimate greaterimpairment. If normal heart size and EF normal atrest and increased on exercise, then estimatefor severe exertional dyspnea and lighthead-edness. Individual’s father had hypertrophic cardiomyopathy.Current Symptoms: Active lifestyle; no furthersymptoms.Physical Exam: Appeared healthy; no evidence ofCHF. BP: 130/70 mm Hg; PR: regular—70 BPM.Brisk carotid pulses; sustained apical impulse.Soft 1/6 midsystolic murmur heard best along leftsternal border; S4gallop.Clinical Studies: ECG: prominent Q waves; highvoltage. Chest roentgenogram: heart size normal.Echocardiogram: marked thickening of ventricularseptum; some thickening of posterior ventricularwall. Mitral valve motion normal; 0.80 EF. Mildsystolic anterior motion of mitral valve. Doppler:minimal 10-mm Hg gradient across the LVOT. 48-hour Holter monitor: no evidence of VT.Diagnosis: Hypertrophic cardiomyopathy post–septalmyectomy.Impairment Rating: 20% impairment of the wholeperson.Comment: Asymptomatic after successful myec-tomy; advised avoidance of strenuous physicalexertion and importance of follow-up evaluation.If significant VT Holter, antiarrhythmic therapypossibly indicated. Impairment then estimatedaccording to combined percentages from arrhyth-mia and cardiomyopathy criteria of impairment(see Combined Values Chart, p. 604).Example 3-3010% to 29% Impairment Due to CardiomyopathySubject: 59-year-old man.History: Greenskeeper on a golf course; long-standing, excessive alcohol use; nutritional defi-ciencies. Hospitalized previously with severe pul-monary congestion probably due to LV failure dueto combination of excessive alcohol intake andpoor nutrition.Current Symptoms: Condition responded promptlyto nutritional treatment, digitalis, diuretics, andACE inhibitors. Avoided alcohol; returned to mostactivities. Regularly visited physician; continuedACE inhibitors and moderate salt restriction.Physical Exam: Appeared comfortable; no signs ofCHF. BP: 120/80 mm Hg; PR: regular—70 BPM.Precordium apical impulse larger than normal,slightly sustained, and displaced to anterior axil-lary line. No parasternal heave. S1, S2: normal. No S3.Clinical Studies: ECG: Small R waves, low T wavesin lateral chest leads. Chest roentgenogram: mod-erate cardiomegaly; no specific chamber enlarge-ment. Echocardiogram: 0.40 EF at rest and afterexercise. Achieved 75% of functional aerobiccapacity on exercise testing. No ECG changes dur-ing exercise.Diagnosis: Cardiomyopathy, probably alcoholic andnutritional.Impairment Rating: 25% impairment of the wholeperson.Class 210%-29% Impairment of the Whole PersonAsymptomaticandmoderate dietary adjustment or drug therapy necessary for individual to be free of symptoms and signs of CHForhas recovered from surgery for treatment of hypertrophic car-diomyopathy or has recovered from successful heart transplanta-tion and meets above criteriaThe Cardiovascular System: Heart and Aorta 49Chapter 3Example 3-3130% to 49% Impairment Due to CardiomyopathySubject: 38-year-old man.History: 3-month exertional dyspnea. HIV-positivefor 5 years. Treatment with ace inhibitor; stillexperienced dyspnea (functional class II).Current Symptoms: Stopped jogging after twoblocks because of dyspnea. Denied cough, fever,chills, edema, orthopnea, and paroxysmal noctur-nal dyspnea.Physical Exam: BP: 130/80 mm Hg; PR: normal—88 BPM. Normal jugular venous pressure; clearlungs. Cardiac examination: soft S1; normal S2; nogallops or murmurs. Remainder of examinationnormal.Clinical Studies: Chest roentgenogram: mild pul-monary congestion; suggested cardiomegaly.Stress testing: exercise tolerance of 3.8 minuteswith development of 1 mm ST depression.Echocardiogram: reduced systolic function; 0.30 EF; mild LV enlargement. Mild (grade 1⁄4)mitral regurgitation. Cardiac catheterization:noncritical CAD. Cardiac biopsy: no infiltrativecardiomyopathy.Diagnosis: HIV cardiomyopathy.Impairment Rating: 40% to 49% impairment dueto cardiomyopathy; combine with HIV impair-ment (see Combined Values Chart, p. 604) todetermine whole person impairment.Comment: Significantly reduced exercise capacity;poor LV function. Concurrent cardiac disordersexcluded for medical therapy. No cardiac surgerysince no significant CAD or severe valvular disease.Example 3-3230% to 49% Impairment Due to CardiomyopathySubject: 54-year-old woman.History: Treated for symptoms of CHF and inade-quate cardiac output for past 3 years. Cardiaccatheterization and cineangiography 2 years ago;no evidence of coronary artery or valvular dis-ease. Depressed ventricular function; elevatedend-diastolic pressure 28 mm Hg; 0.30 EF.Subsequently treated with ACE inhibitors.Current Symptoms: Condition stable for past year;able to do light housework and sedentary work.Breathlessness upon climbing a flight of stairs;prefers two pillows.Physical Exam: BP: 110/70 mm Hg; PR: regular—70 BPM. Venous pressure normal; clear lungs.Apical impulse markedly enlarged, sustained, dis-placed laterally to anterior axillary line. Earlydiastolic impulse palpable after systolic impulse.Diminished S1; normal S2; prominent S3.Clinical Studies: ECG: low T waves in all leads. QSpattern in V1, V2. Chest roentgenogram: markedcardiomegaly; some distention of pulmonary ves-sels in upper lobes. Echocardiogram: LV: moder-ately dilated; LVEF 0.30; enlarged LA.Diagnosis: Idiopathic cardiomyopathy.Impairment Rating: 49% impairment of the wholeperson.Comment: Reduced exercise capacity; poor LVfunction.Class 330%-49% Impairment of the Whole PersonSymptoms of CHF on greater than ordinary daily activities (func-tional class II)andmoderate dietary restriction or use of drugs necessary to minimizesymptoms or to prevent appearance of signs of CHF or evidenceof it by laboratory studyorhas recovered from surgery for treatment of hypertrophic car-diomyopathy or has recovered from successful heart transplanta-tion and meets above criteria50 Guides to the Evaluation of Permanent ImpairmentChapter 3Example 3-3350% to 100% Impairment Due to CardiomyopathySubject: 62-year-old woman.History: Increasing dyspnea and chest pressure withexertion for 2 years. Long-standing, poorly treatedhypertension; no other medical problems. Heartmurmur, hypertrophic cardiomyopathy; treatedwith large dosages of beta-blocker and calciumchannel-blocker. Current Symptoms: Still severely limited by symp-toms; unable to walk up a half flight of stairs ordo daily activities. Although dual-chamber pace-maker placed 6 months earlier, minimal change insymptoms.Physical Exam: BP: 150/90 mm Hg; HR: 50 BPM.Venous pressure: normal; carotid brisk with bifidquality. LV impulse: sustained with a tripleimpulse.Clinical Studies: Echocardiogram: severe septalhypertrophy; 0.70 EF; 70 mm Hg outflow tractobstruction. Severe mitral regurgitation secondaryto systolic anterior motion of mitral valve. Chestroentgenogram: cardiomegaly with clear fields.ECG: sinus bradycardia with paced rhythm.Diagnosis: Severe hypertrophic cardiomyopathywith outflow obstruction.Impairment Rating: 70% to 79% impairment of thewhole person.Comment: Typical symptoms of hypertrophic car-diomyopathy related to outflow tract obstructionand diastolic dysfunction. No typical findings of“backward” HF present in individuals with dilatedcardiomyopathies. If successful septal myectomy,then improved symptoms and classification.Example 3-3450% to 100% Impairment Due to CardiomyopathySubject: 47-year-old man.History: 3 months ago developed exertional dysp-nea, orthopnea, and edema.Current Symptoms: Evaluation for cardiac trans-plantation: dyspnea on exertion with one flight ofstairs or ambulating > 25 feet. Meds: ACEinhibitor, diuretics, and beta-blocker. Unable to domany activities of daily living.Physical Exam: Elevated venous pressures and ralesin both lung fields. Cardiac examination: laterallydisplaced, sustained apical impulse;2/6 apicalholosystolic murmur. No peripheral edema.Clinical Studies: ECG: normal sinus rhythm—90BPM; low amplitude QRS complex throughout allleads. QS complexes present in II, III, and aVF.Chest roentgenogram: moderate cardiomegaly;mild pulmonary venous hypertension. ReducedLV function (0.32 EF) secondary to cardiac amy-loidosis.Diagnosis: Cardiac amyloidosis with CHF.Impairment Rating: 80% to 89% impairment dueto cardiomyopathy; combine with impairment dueto organ system effects of amyloidosis (seeCombined Values Chart, p. 604) to determinewhole person impairment.Comment: Level of impairment higher if moresevere symptoms (dyspnea with minimal exertion,peripheral edema), history of syncope, or evi-dence of nonsustained ventricular tachyarrhyth-mias. Physical findings of HF despite medicaltherapy. If significant arrhythmias develop,evaluate according to arrhythmia criteria (seeCombined Values Chart, p. 604).Class 450%-100% Impairment of the Whole PersonSymptomatic during ordinary daily activities despite appropriateuse of dietary adjustment and drugs (functional class III or IV)orpersistent signs of CHF despite use of dietary adjustment anddrugsorhas recovered from surgery for treatment of hypertrophic car-diomyopathy or has recovered from successful heart transplanta-tion and meets above criteriaThe Cardiovascular System: Heart and Aorta 51Chapter 33.6 Pericardial HeartDiseaseInflammation from diseases of the pericardium isassociated with (1) systemic illnesses such as lupuserythematosus; (2) a reaction to mechanical forces,such as trauma or irradiation; (3) no obvious cause(idiopathic pericarditis); (4) infections, eg, viral, bac-terial, fungal; or (5) open heart surgery (postcar-diotomy syndrome). The pericardium may also beaffected by tumors.Recurrent pericarditis can lead to disabling episodesof fevers and pleuritic chest pain. Since chest pain isnonspecific, pericarditis evidence must be docu-mented by echocardiography to show a pericardialeffusion or by laboratory evidence of active inflam-mation, such as an increase in the erythrocyte sedi-mentation rate (ESR).Constrictive pericarditis is the most common pericar-dial disorder leading to permanent impairment; surgi-cal removal of the thickened pericardium maysignificantly reduce symptoms and improve the over-all condition of the individual. Before assessing per-manent impairment, it is mandatory to allow sufficienttime for the person to recover from a surgical proce-dure and to reach maximal medical improvement.Pain and compromised cardiac function because oftamponade may cause some impairment, but they arerare as causes of permanent impairment. Recurrentepisodes of pericarditis with tamponade or pericar-dial disease related to tumors may lead to permanentimpairment. Allow adequate time for resolution of anacute illness, generally a period of months, beforeassessing permanent impairment.Diagnosis of pericardial disease is made by history-taking; identifying a pericardial fraction rub or earlydiastolic pericardial knock; demonstrating pericar-dial effusion, thickening, or calcification on anechocardiogram; showing a thickened pericardiumwith computerized tomography (CT) or magneticresonance imaging (MRI); or findings at cardiaccatheterization.3.6a Criteria for Rating PermanentImpairment Due to Pericardial Heart DiseaseCriteria for evaluating permanent impairment relatedto pericardial heart disease are given in Table 3-10.52 Guides to the Evaluation of Permanent ImpairmentChapter 3No symptoms in performance ofordinary daily activities or mod-erately heavy physical exertion,but evidence from either physi-cal examination or laboratorystudies of pericardial heart dis-easeandcontinuous treatment notrequired, and no signs of cardiacenlargement or of congestion oflungs or other organsorin an individual who has hadsurgical removal of the peri-cardium or a surgical windowfor drainage, no adverse conse-quences from the treatment andmeets above criteriaNo symptoms in performance ofordinary daily activities, but evi-dence from either physicalexamination or laboratory stud-ies of pericardial heart diseaseanddietary adjustment or drugsrequired to keep individual freeof symptoms and signs of CHForhas recovered from pericardiec-tomy and meets above criteriaSlight to moderate discomfort inperformance of ordinary dailyactivities (functional class II)despite dietary or drug therapy,and has physician examinationor laboratory studies of pericar-dial diseaseandphysical signs present ofincreased venous pressure, orlaboratory evidence of constric-tive physiology on echocardio-graphic or hemodynamicevaluationorhas recovered from surgery toremove pericardium but contin-ues to have symptoms, signs,and laboratory evidencedescribed aboveSymptoms on performance ofordinary daily activities (func-tional class III or IV) despiteappropriate dietary restrictionsor drugs, and evidence fromphysical examination or labora-tory studies of pericardial heartdiseaseandhas recovered from surgical peri-cardiectomy and continues tohave symptoms, signs, and labo-ratory evidence described aboveTable 3-10 Criteria for Rating Permanent Impairment Due to Pericardial Heart DiseaseClass 1 Class 2 Class 3 Class 40%-9% Impairment of the 10%-29% Impairment of the 30%-49% Impairment of the 50%-100% Impairment of the Whole Person Whole Person Whole Person Whole PersonExample 3-350% to 9% Impairment Due to Pericardial Heart DiseaseSubject: 28-year-old man.History: Acute pericarditis 15 months ago.Symptoms: acute, self-limited, febrile illness,with anterior chest pain and a pericardial frictionrub. Current Symptoms: Asymptomatic; returned towork and leading a normal life.Physical Exam: Normal.Clinical Studies: Echocardiogram: small pericardialeffusion. Illness resolved with aspirin treatment.Diagnosis: Acute benign idiopathic pericarditis.Impairment Rating: 0% impairment of the wholeperson.Comment: Could develop constrictive pericarditis,but most individuals have no permanent impairment.Example 3-360% to 9% Impairment Due to Pericardial Heart DiseaseSubject: 64-year-old woman.History: Had successful pericardiocentesis for idio-pathic pericardial effusion. Moderate symptomsresolved after treatment.Current Symptoms: Asymptomatic from rigoroustraveling to South America.Physical Examination: Normal.Clinical Studies: Chest roentgenogram: normal.Echocardiogram: normal.Diagnosis: Resolved pericardial effusion followingpercutaneous pericardiocentesis with no recurrence.Impairment Rating: 0% impairment of the wholeperson.Comment: Self-limited illness; no effects on activi-ties of daily living.Example 3-3710% to 29% Impairment Due to Pericardial Heart DiseaseSubject: 32-year-old woman.History: Viral pericarditis with fever and pleuriticpain 1 year ago. Echocardiogram: moderate-sized,circumferential, pericardial effusion, an elevatedESR and white blood cell count; no evidence ofbacterial or fungal infection. Pericardial tap: nobacteria. Autoimmune workup: negative.Current Symptoms: For past year, several recur-rences of chest pain with effusions; unable tocarry out daily activities. Treated with NSAIDsfor 4-6 weeks each time. Condition stable forabout 10 months.Physical Exam: Comfortable; no signs or symptomsof CHF. Heart sounds normal; no murmurs orextra heart sounds. No audible pericardial rub.Clinical Studies: ECG: flat T-wave abnormalities.Chest roentgenogram: normal size heart; clearlung fields. Echocardiogram: small residual pericar-dial effusion.Diagnosis: Recurrent idiopathic pericarditis.Impairment Rating: 15% impairment of the wholeperson.Comment: If episodes more frequent, then considerlong-term medication (eg, salicylates, NSAIDs,steroids, or colchicine).Class 210%-29% Impairment of the Whole PersonNo symptoms in performance of ordinary daily activities, but evi-dence from either physical examination or laboratory studies ofpericardial heart diseaseanddietary adjustment or drugs required to keep the individual free of symptoms and signs of CHForhas recovered from pericardiectomy and meets above criteriaClass 10%-9% Impairment of the Whole PersonNo symptoms in performance of ordinary daily activities or moder-ately heavy physical exertion, but evidence from either physicalexamination or laboratory studies of pericardial heart diseaseandcontinuous treatment not required, and no signs of cardiacenlargement or of congestion of lungs or other organsorin an individual who has had surgical removal of the pericardiumor a surgical window for drainage, no adverse consequences fromthe treatment and meets above criteriaThe Cardiovascular System: Heart and Aorta 53Chapter 3Example 3-3810% to 29% Impairment Due to Pericardial Heart DiseaseSubject: 60-year-old man.History: Pericardiectomy for constrictive pericardi-tis 1 year ago. Current Symptoms: No symptoms even with sig-nificant exertion. Denied peripheral edema,orthopnea, exertional dyspnea, or early satiety.Physical Exam: BP: normal; no pulsus paradoxicus;normal CV examination and laboratory work.Clinical Studies: Chest roentgenogram: small areaof pericardial calcification appeared where peri-cardium incompletely stripped during surgery.Echocardiogram: mild LV enlargement; 0.50 EF;inspiratory changes in mitral inflow amplitude;early diastolic filling wave consistent with con-strictive physiology.Diagnosis: LV enlargement and constrictive peri-carditis following surgical pericardectomy.Impairment Rating: 20% to 29% impairment of thewhole person.Comment: Mild LV enlargement; persistent con-strictive physiology following surgical pericardec-tomy. Level of impairment higher if anysymptoms.Example 3-3930% to 49% Impairment Due to Pericardial Heart DiseaseSubject: 45-year-old man.History: Pericardiectomy for constrictive pericardi-tis 10 years earlier. Daily furosemide to preventlower extremity edema.Current Symptoms: Weakness and breathlessnesswith heavy physical exertion; works regularly.Physical Exam: Venous pressure mildly elevated:12 cm H2O; no edema. BP and PR: normal. Noventricular heaves or thrills. S1: normal; S2:diminished. No extra sounds or rubs.Clinical Studies: ECG: low-voltage QRS; T wavesin all leads. Chest roentgenogram: considerablecardiomegaly; some calcification at posterioraspect of heart. Clear lung fields. Echocardiogram:pericardium thickening; moderate diminution ofRV, LV contraction; 0.40 LVEF. Doppler: evidenceof residual pericardial restraint. Mitral inflow;early diastolic filling wave amplitude demon-strated 50% variation with inspiration.Diagnosis: Constrictive pericarditis with pericardiec-tomy.Impairment Rating: 30% to 39% impairment of thewhole person.Comment: After pericardiectomy, possible residualelevation of venous pressure. If more activitieslimited, then level of impairment > 30% to 39%.Example 3-4030% to 49% Impairment Due to Pericardial Heart DiseaseSubject: 48-year-old woman.History: Tuberculosis after assignment in CentralAfrica. Developed intermittent pericardial effu-sions. Two to three dyspnea episodes and lowerextremity edema annually. Pericardiocentesis for fluid removal. No chest pain. Refused surgical pericardiectomy; father died during similar procedure. Current Symptoms: Asymptomatic since priorepisode 3 months earlier.Physical Exam: Currently normal.Clinical Studies: Echocardiogram: thickened peri-cardium, constrictive physiology during asympto-matic periods; effusive constrictive physiologyduring symptomatic periods. Medications did notsuppress symptoms.Diagnosis: Recurrent pericarditis with symptomaticeffusions.Impairment Rating: 30% to 49% impairment of thewhole person.Comment: Recurrent pericardial effusions despiteaggressive treatment. Impairment higher if symp-toms more frequent or if LV dysfunction evident.Class 330%-49% Impairment of the Whole PersonSlight to moderate discomfort in performance of ordinary dailyactivities (functional class II) despite dietary or drug therapy, andhas physician examination or laboratory studies of pericardial diseaseandphysical signs present of increased venous pressure, or laboratoryevidence of constrictive physiology on echocardiographic orhemodynamic evaluationorhas recovered from surgery to remove pericardium but continuesto have symptoms, signs, and laboratory evidence describedabove54 Guides to the Evaluation of Permanent ImpairmentChapter 3Example 3-4150% to 100% Impairment Due to Pericardial HeartDiseaseSubject: 62-year-old man.History: Profound ascites, peripheral edema, weightloss, signs of pulmonary congestion attributed to apericardial effusion. Effusion drained, temporarilyrelieved severe ascites and peripheral edema.Fatigue and breathlessness continue with ordinaryactivity; unable to climb one flight of stairs with-out resting.Current Symptoms: Edema, ascites returned. Ableto walk on a level surface and do light activities ofdaily living.Physical Exam: Comfortable. Neck veins elevated20 cm H2O; 2+ peripheral edema and ascites.Evidence of marked weight loss remained. Noventricular heaves, thrills, or taps in the pre-cordium. Diminished heart sounds; no murmursor extra sounds.Clinical Studies: ECG: low voltage of the QRS andT waves. Chest roentgenogram: marked car-diomegaly; some upper lobe pulmonary vascula-ture distention. Echocardiogram: systolicventricular function: normal; 0.55 LVEF. Doppler:constrictive pericarditis.Diagnosis: Constrictive pericarditis following peri-cardial drainage.Impairment Rating: 80% to 89% impairment of thewhole person.Comment: Drainage of pericardial effusion maycause limitations from residual constrictive peri-carditis. If symptoms with minimal daily activi-ties, or if signs of overt congestion at evaluation,then impairment possibly as high as 95% to 100%(total impairment). Complete pericardiectomymay result in symptom and class improvement.Example 3-4250% to 100% Impairment Due to Pericardial HeartDiseaseSubject: 47-year-old woman.History: Pericardiectomy for constrictive pericardi-tis 2 years ago. Continued dyspnea with minimalactivities; dependent on others for self-care. Dailyfurosemide (160 mg twice a day), digitalis, andnitrates. Compression stockings caused sympto-matic improvement.Current Symptoms: Waking at night with breath-lessness.Physical Exam: BP: 115/80 mm Hg; fell to 85/45mm Hg with inspiration. Neck veins elevated; didnot fall with inspiration. Clear lung fields; distantheart sounds; audible S3. Abdomen: moderateascites and hepatomegaly. 2+ pitting edema inlower extremities and lower back region.Clinical Studies: Echocardiogram: enlarged heartwith reduced function; 0.30 EF. Constrictivephysiology. No pericardial effusion. Laboratorystudies: mild anemia; liver enzymes elevationconsistent with congestive hepatomegaly.Diagnosis: Constrictive pericarditis following surgi-cal pericardiectomy and biventricular dysfunctionwith HF.Impairment Rating: 90% to 100% impairment ofthe whole person.Comment: Class IV symptoms; terminal prognosis.Class 450%-100% Impairment of the Whole PersonSymptoms on performance of ordinary daily activities (functionalclass III or IV) despite appropriate dietary restrictions or drugs, andevidence from physical examination or laboratory studies of pericardial heart diseaseandhas recovered from surgical pericardiectomy and continues tohave symptoms, signs, and laboratory evidence described aboveThe Cardiovascular System: Heart and Aorta 55Chapter 33.7 ArrhythmiasAn arrhythmia is one or more heartbeats generated ata site other than the sinus node. An impulse gener-ated in the sinusnode but not transmitted normallythrough the conducting system is a conduction defectarrhythmia. Arrhythmias may occur in individualswith structurally and functionally normal hearts or inthose with any type of organic heart disease.Because arrhythmias tend to fluctuate remarkably infrequency, the physician must adequately documentand estimate the frequency with which an arrhythmiaoccurs. The associated symptoms can include syn-cope, weakness and fatigue, palpitations, dizziness,lightheadedness, chest heaviness, and shortness ofbreath, alone or in any combination.The degree of impairment from cardiac arrhythmiasoften has to be combined with the degree of impair-ment due to underlying heart disease and then calculated according to the Combined Values Chart(p. 604). Before estimating the degree of permanentimpairment, allow adequate time for the individual’scondition to reach maximal medical improvementafter instituting therapy.193.7a Criteria for Rating PermanentImpairment Due to ArrhythmiasCriteria for evaluating impairments related toarrhythmias are given in Table 3-11.56 Guides to the Evaluation of Permanent ImpairmentChapter 3Asymptomatic during ordinaryactivities and a cardiac arrhyth-mia is documented by ECG, orhas had an isolated syncopalepisodeandno documentation of three ormore consecutive ectopic beatsor periods of asystole > 1.5 sec-onds, and both atrial and ven-tricular rates are maintainedbetween 50 and 100 beats perminuteandno evidence of organic heart diseaseorhas recovered from surgery or acatheter procedure to correctarrhythmia and above criteriaare metAsymptomatic during ordinaryactivities and a cardiac arrhyth-mia is documented by ECG, orhas had an isolated syncopalepisodeandmoderate dietary adjustment, use of drugs, or an artificial pace-maker required to prevent symp-toms related to the arrhythmiaorarrhythmia persists and there isorganic heart diseaseorhas recovered from surgery or acatheter procedure to correctarrhythmia or implantable car-dioverter-defibrillator placementto treat arrhythmia and meetsabove criteria for impairmentSymptoms despite use of dietarytherapy or drugs or of an artifi-cial pacemaker, and a cardiacarrhythmia is documented withECGandis able to lead an active life andsymptoms due to arrhythmia arelimited to infrequent palpitationsand/or episodes of lightheaded-ness, presyncope, or temporaryinadequate cardiac outputorhas recovered from surgery, acatheter procedure, orimplantable cardioverter-defibril-lator placement to treat arrhyth-mia and meets above criteria forimpairmentSymptoms due to documentedcardiac arrhythmia that are con-stant and interfere with ordinarydaily activities (functional class IIIor IV)orfrequent symptoms of inade-quate cardiac output docu-mented by ECG to be due tofrequent episodes of cardiacarrhythmiaorcontinues to have episodes ofsyncope that are either due to,or have a high probability ofbeing related to, arrhythmia; tofit into this category of impair-ment, symptoms must be pres-ent despite use of dietarytherapy, drugs, or artificial pace-makersorhas recovered from surgery, a catheter procedure, orimplantable cardioverter-defibrillator placement to treatarrhythmia and continues tohave symptoms causing impair-ment outlined aboveTable 3-11 Criteria for Rating Permanent Impairment Due to ArrhythmiasClass 1 Class 2 Class 3 Class 40%-9% Impairment of the 10%-29% Impairment of the 30%-49% Impairment of the 50%-100% Impairment of the Whole Person Whole Person Whole Person Whole PersonExample 3-430% to 9% Impairment Due to ArrhythmiasSubject: 56-year-old man.History: Frequent premature beats during annualphysical examination.Current Symptoms: None. Able to perform allactivities of daily living.Physical Exam: Remainder of exam normal.Clinical Studies: ECG: frequent premature complexes.Diagnosis: Atrial premature complexes.Impairment Rating: 0% impairment of the wholeperson.Example 3-440% to 9% Impairment Due to ArrhythmiasSubject: 21-year-old woman.History: Syncopal spell while studying for finalexam. Gastrointestinal illness for 3 days beforeepisode. ER evaluation. HR: 110 BPM; BP withorthostatic drop: 110/65 mm Hg supine to 85/40mm Hg standing, with presyncope. Didn’t followup for 3 months; no subsequent episodes.Physical Exam: Normal now.Clinical Studies: None.Diagnosis: Orthostatic hypotension with vasovagalsyncope.Impairment Rating: 0% impairment of the wholeperson.Comment: Isolated episode of dehydration-relatedsyncope. No further evaluation necessary.Example 3-4510% to 29% Impairment Due to ArrhythmiasSubject: 62-year-old man.History: 1-year history of atrial fibrillation withirregular ventricular response 75 BPM.Current Symptoms: Asymptomatic.Physical Exam: PR: 75 BPM.Clinical Studies: ECG, chest roentgenogram, andechocardiogram: normal.Diagnosis: Atrial fibrillation with controlled ventric-ular response.Impairment Rating: 15% impairment of the wholeperson.Comment: If medications needed to maintain ven-tricular response, then impairment estimateslightly higher.Example 3-4610% to 29% Impairment Due to ArrhythmiasSubject: 52-year-old man.History: Recurring syncope 8 months ago; treatedwith insertion of a permanent pacemaker for com-plete heart block.Current Symptoms: Asymptomatic.Physical Exam: Appeared well. BP: 120/80 mm Hg;PR: 72 BPM. Normal heart sounds; no murmurs.Clinical Studies: ECG: complete capture of theheart by artificial pacemaker at 72 BPM.Pacemaker sensed and properly inhibited rare pre-mature ventricular beat.Class 210%-29% Impairment of the Whole PersonAsymptomatic during ordinary activities and a cardiac arrhythmiais documented by ECG, or has had an isolated syncopal episodeandmoderate dietary adjustment, use of drugs, or an artificial pace-maker required to prevent symptoms related to the arrhythmiaorarrhythmia persists and there is organic heart diseaseorhas recovered from surgery or a catheter procedure to correctarrhythmia or implantable cardioverter-defibrillator placement totreat arrhythmia and meets above criteria for impairmentClass 10%-9% Impairment of the Whole PersonAsymptomatic during ordinary activities and a cardiac arrhythmiais documented by ECG, or has had an isolated syncopal episodeandno documentation of three or more consecutive ectopic beats orperiods of asystole > 1.5 seconds, and both atrial and ventricularrates are maintained between 50 and 100 beats per minuteandno evidence of organic heart diseaseorhas recovered from surgery or a catheter procedure to correctarrhythmia and above criteria are metThe Cardiovascular System: Heart and Aorta 57Chapter 3Diagnosis: Adams-Stokes attacks in individual withcomplete heart block; managed with properlyfunctioning artificial pacemaker.Impairment Rating: 20% impairment of the wholeperson.Example 3-4730% to 49% Impairment Due to ArrhythmiasSubject: 44-year-old man.History: Multiple, recurrent, 5- to 15-minuteepisodes of rapid heart rate accompanied by light-headedness. Vagal-type maneuvers occasionallyterminated episodes; spontaneous termination. Nofrank syncope. Occasional episode with verapamilLA 240 mg a day. Symptom free with verapamilLA 360 mg a day. Regimen continued for 13months when impairment evaluated.Current Symptoms: Episodes of rapid heart rate.Episodes cause weakness and prohibit any physi-cal activity. Physical Exam: PR: regular—86 BPM.Clinical Studies: ECG: Holter monitoring: atrialtachycardia: 155 BPM during episode. Typicalpatterns of reentry atrioventricular (AV) nodaltachycardia.Diagnosis: AV nodal reentry tachycardia with atrialtachycardia, adequately controlled by calcium-channel blocker.Impairment Rating: 30% impairment of the wholeperson.Comment: If palpitations continued with medica-tions, orif rare episode associated with inade-quate cerebral perfusion, then estimatedimpairment possibly as high as 49%.Example 3-4830% to 49% Impairment Due to ArrhythmiasSubject: 58-year-old man.History: Asymptomatic LV dysfunction; out-of-hospital cardiac arrest 3 months ago. Returned forevaluation of implanted pacemaker-cardioverter-defibrillator. No syncope; five instances of pro-found palpitations followed by internal firing ofthe cardioverter-defibrillator system 45 secondsafter symptom onset.Current Symptoms: Internal shocks were “mildlydisconcerting” at best. No HF or angina symptoms.Physical Exam: PR: 80 BPM, normal pacing.Clinical Studies: Pacemaker-cardioverter-defibrilla-tor working well.Diagnosis: Sustained VT.Impairment Rating: 40% to 49% impairment of thewhole person.Comment: Infrequent discharges of internal defibril-lator system in response to sustained VT. Leadssomewhat active life; higher impairment if (a)shocks occurring weekly or more frequently, (b)LV dysfunction symptoms, or (c) episodes includesyncope.Class 330%-49% Impairment of the Whole PersonSymptoms despite use of dietary therapy or drugs or of an artificial pacemaker, and a cardiac arrhythmia is documented with ECGandis able to lead an active life and symptoms due to arrhythmia arelimited to infrequent palpitations and/or episodes of lightheaded-ness, presyncope, or temporary inadequate cardiac outputorhas recovered from surgery, a catheter procedure, or implantablecardioverter-defibrillator placement to treat arrhythmia and meetsabove criteria for impairment58 Guides to the Evaluation of Permanent ImpairmentChapter 3Example 3-4950% to 100% Impairment Due to ArrhythmiasSubject: 38-year-old woman.History: Rapid heart action episodes for over 10years with retrosternal pressure, fainting sensa-tion, and general weakness. Several spells ofunconsciousness, during which husband usedCPR. Tachyarrhythmia ended spontaneouslywithin 30 minutes; no external electrical conver-sion necessary. Many antiarrhythmic medicationsfor past 5 months (ie, quinidine sulfate, 300 mgevery 6 h; procainamide, 750 mg every 4 h; andpropranolol, 160 mg twice daily) controlledarrhythmia fairly well. Previous verapamil usefailed to prevent arrhythmia. Current Symptoms: Episodes continue monthly,none associated with loss of consciousness.Occasional swelling of small joints in the handsrespond to low corticosteroid doses.Physical Exam: Cardiovascular: no evidence ofvalvular or myocardial disease.Clinical Studies: Serologic abnormalities character-istic of systemic lupus erythematosis (SLE). ECG:normal pattern and rhythm; ECG during palpita-tions: rapid regular rhythm 200-250 BPM.Electrophysiologic studies: no abnormal conduc-tion problems. VT easily induced; pattern similarto one during spontaneous episode.Diagnosis: Recurrent VT.Impairment Rating: 70% to 90% impairment of thewhole person.Comment: Impairment depends on frequency andsymptomatic nature of episodes.Example 3-5050% to 100% Impairment Due to ArrhythmiasSubject: 42-year-old man.History: Medications, pacemaker for syncope forpast 8 years. Syncope continued daily withoutwarning despite all efforts. Work limited; unableto conduct business meetings because of embar-rassment about syncope unpredictability. Couldnot legally drive an automobile or use any powerequipment that might endanger his safety if spelloccurred.Physical Exam: Normal.Clinical Studies: Echocardiogram, exercise stresstest: heart within normal limits.Diagnosis: Recurrent syncope despite maximal therapy.Impairment Rating: 75% to 90% impairment of thewhole person.Comment: Daily syncope with maximal therapy. Class 450%-100% Impairment of the Whole PersonSymptoms due to documented cardiac arrhythmia that are con-stant and interfere with ordinary daily activities (functional class IIIor IV)orfrequent symptoms of inadequate cardiac output documented byECG to be due to frequent episodes of cardiac arrhythmiaorcontinues to have episodes of syncope that are either due to, orhave a high probability of being related to, arrhythmia; to fit intothis category of impairment, symptoms must be present despiteuse of dietary therapy, drugs, or artificial pacemakersorhas recovered from surgery, a catheter procedure, or implantablecardioverter-defibrillator placement to treat arrhythmia and con-tinues to have symptoms causing impairment outlined aboveThe Cardiovascular System: Heart and Aorta 59Chapter 360 Guides to the Evaluation of Permanent ImpairmentChapter 3Table 3-12 Cardiac Impairment Evaluation SummaryDisorderHistory, Including SelectedRelevant Symptoms Examination Record Assessment of Cardiac FunctionGeneral Cardiovascular symptoms (eg,fatigue, palpitations, dyspnea,chest pain) and general symp-toms; impact of symptoms onfunction and ability to do dailyactivitiesPrognosis if change anticipatedReview medical historyComprehensive physical examina-tion; detailed cardiovascular sys-tem assessmentData derived from relevant studies(eg, ECG, echocardiography, stresstests, cardiac catheterization)Valvular Heart Disease Discuss symptoms and any result-ing limitation of physical activity(eg, angina) Address cardiac output, pulmonaryand systemic congestionNote rate, rhythm, heart sounds,and other organ functionDoppler echocardiography or cardiac catheterizationCoronary Heart Disease (CHD) Angina pectoris; reduced ventric-ular function; limitation of physi-cal activity due to fatigue;palpitations; dyspnea; anginalpainDetailed historyNote rate, rhythm, heart sounds,and other organ functionCoronary angiography; chest x-ray; ECG; EF; studies may beobtained at rest and during andafter exerciseCongenital Heart Disease Dyspnea; fatigue; palpitations;symptoms of end-organ dysfunctionNote rate, rhythm, heart sounds,and other organ functionECG; chest roentgenogram;radioisotope studies; echocardio-graphy; hemodynamic measure-ments; angiographyCardiomyopathies Exertional dyspnea; angina; syn-cope; pulmonary or systemicorgan congestionNote rate, rhythm, heart sounds,and other organ functionEchocardiography; ECG; chestroentgenogram; abnormal ven-tricular function; dynamic out-flow tract obstructionPericardial Heart Disease Chest painNote active inflammation,increase in ESRNote rate, rhythm, heart sounds(pericardial rub, early diastolicpericardial knock), and otherorgan functionECHO-pericardial effusion, thickening, or calcification; thick-ened pericardium on CT scan orMRI; cardiac catheterizationArrhythmias Syncope; weakness and fatigue;palpitations; dizziness; chestheaviness; shortness of breathNote rate, rhythm, heart sounds;document arrhythmia and esti-mate its frequencyECG: frequent premature complexes, tachycardiaEchocardiogram: atrial enlargement3.8 CardiovascularImpairmentEvaluationSummarySee Table 3-12 for an evaluation summary for theassessment of cardiovascular impairment.The Cardiovascular System: Heart and Aorta 61Chapter 3End-Organ Damage Diagnosis(es) Degree of ImpairmentInclude assessment of sequelae,including end-organ damage andimpairmentRecord all pertinent diagnosis(es);note if they are at maximal medicalimprovement; if not, discuss underwhat conditions and when stabilityis expectedCriteria outlined in this chapterAssess relevant organs (eg, lungs,kidneys) for congestion or dysfunctionAortic or mitral valve stenosis;mitral valve prolapse; aortic ormitral valve regurgitation; aorticand/or mitral valve disease; ven-tricular dysfunctionSee Table 3-5Assess relevant organs (eg, brain,lungs, kidneys, eyes, peripheralvascular system)MI; angina pectoris; coronaryartery vasospasm; ventricular failureSee Table 3-6Assess relevant organs (eg, brain,lungs, kidneys, peripheral vascu-lar system)Valve stenosis, septaldefects;valve anomalies; tetralogy ofFallot; Ebstein’s anomaly; vesseltransposition; Eisenmenger’scomplexSee Table 3-8Assess relevant organs (eg, brain,lungs, kidneys, peripheral vascu-lar system)Dilated or congested; hyper-trophic; restrictiveSee Table 3-9Assess relevant organs (eg, brain,lungs, kidneys, peripheral vascu-lar system)Constrictive or idiopathic peri-carditis; tamponade; tumor; peri-cardial effusion; pericardialdamageSee Table 3-10Assess relevant organs (eg, brain,lungs, kidneys, peripheral vascu-lar system)Syncope; VT; atrial fibrillation;complete heart block; prematurecomplexesSee Table 3-11References1. Criteria Committee of the New York Heart Association.Diseases of the Heart and Blood Vessels: Nomenclatureand Criteria for Disease. 6th ed. Boston, Mass: LittleBrown & Co; 1964.2. Cheitlin MD, Alpert JS, Armstrong WF, et al.ACC/AHA guidelines for the clinical application ofechocardiography. A report of the American College ofCardiology/American Heart Association Task Force onPractice Guidelines (Committee on Clinical Applicationof Echocardiography). Developed in collaboration withthe American Society of Echocardiography. Circulation.1997;95:1686-1744.Summarizes the utility of echocardiography in patientswith heart disease.3. Fox SM III, Naughton JP, Haskell WL. Physical activityand the prevention of coronary heart disease. Ann ClinRes. 1971;3:404-432.4. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHAguidelines for exercise testing. A report of the AmericanCollege of Cardiology/American Heart Association TaskForce on Practice Guidelines (Committee on ExerciseTesting). J Am Coll Cardiol. 1997;30:260+.Summarizes the most recent data on the prognostic anddiagnostic utility of exercise testing for patients withheart disease.5. Nishimura RA, Tajik AJ. Evaluation of diastolic fillingof left ventricle in health and disease: Doppler echocar-diography is the clinician’s Rosetta Stone. J Am CollCardiol. 1997;30:8-18. A simplified approach to understanding the process ofdiastolic filling of the left ventricle and interpreting theDoppler flow velocity curves as they relate to this proce-dure. Specific therapy for diastolic dysfunction based onDoppler flow velocity curves is discussed.6. Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHAguidelines for coronary angiography: executive sum-mary and recommendations. A report of the AmericanCollege of Cardiology/American Heart Association TaskForce on Practice Guidelines (Committee on CoronaryAngiography) developed in collaboration with theSociety for Cardiac Angiography and Interventions.Circulation. 1999;99:2345-2357.Summarizes the latest data on the diagnostic utility ofinvasive catheterization in patients with heart disease.7. ACC/AHA guidelines for the management of patientswith valvular heart disease. A report of the AmericanCollege of Cardiology/American Heart Association TaskForce on Practice Guidelines (Committee onManagement of Patients with Valvular Heart Disease). J Am Coll Cardiol. 1998;32:1486-1588.Summarizes the latest treatment and prognostic informa-tion for patients with valvular heart disease.8. Jaffe WM, Roche AG, Coverdale HA, McAlister HF,Ormiston JA, Greene ER. Clinical evaluation versusDoppler echocardiography in quantitative assessment ofvalvular heart disease. Circulation. 1988;78:267-275. Tests the hypotheses that Doppler echocardiography hasa higher accuracy than clinical evaluation in the detec-tion of significant aortic and mitral valvular heart dis-ease and that Doppler echocardiography is highlyaccurate as compared with cardiac catheterization forthe assessment of valvular disease severity.9. Lee KL, Woodlief LH, Topol EJ, et al. Predictors of 30-day mortality in the era of reperfusion for acute MI:results from an international trial of 41,021 patients.Circulation. 1995;91:1659-1668. Analyzes predictors of short-term mortality in acute MIand establishes the relative importance of a variety ofprognostic variables.10. Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHAguidelines for the management of patients with acuteMI. A report of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines (Committee on Management of Acute MI). J Am Coll Cardiol. 1996;28:1328-1428. Summarizes the latest treatment recommendations andprognostic information for patients with acute MI.11. Congenital heart disease after childhood: an expandingpatient population [22nd Bethesda Conference,Maryland, October 18-19, 1990]. J Am Coll Cardiol.1991;18:312-342. Summarizes a consensus opinion on adult congenitalheart disease.12 Nishimura RA, Miller FA Jr, Callahan MJ, Benassi RC,Seward JB, Tajik AJ. Doppler echocardiography: theory,instrumentation, technique, and application. Mayo ClinProc. 1985;60:321-343. Doppler echocardiography is a valuable adjunct to acomplete cardiovascular examination. Evaluation ofother aspects of Doppler echocardiography, such ascolor-flow mapping and assessment of diastolic events,are also included.13. Rihal CS, Nishimura RA, Hatle LK, et al. Systolic anddiastolic dysfunction in patients with clinical diagnosisof dilated cardiomyopathy: relation to symptoms andprognosis. Circulation. 1994;90:2772-2779.In patients with the clinical diagnosis of dilated car-diomyopathy, markers of diastolic dysfunction corre-lated strongly with congestive symptoms, whereasvariables of systolic function were the strongest predic-tors of survival. Consideration of both ejection fractionand deceleration time allowed identification of sub-groups with divergent long-term prognoses.62 Guides to the Evaluation of Permanent ImpairmentChapter 314. Feldman AM. Can we alter survival in patients with con-gestive heart failure? JAMA. 1992;267:1956-1961. Assesses the efficacy of pharmacologic therapy inimproving survival in patients with congestive heart fail-ure (CHF) in the context of recent investigational studieshaving mortality as an endpoint.15. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK.The progression from hypertension to congestive heartfailure. JAMA. 1996;275:1557-1562.Reviews the relative and population-attributable risks ofhypertension for the development of CHF, assesses thetime course of progression from hypertension to CHF,and identifies the risk factors that contribute to the devel-opment of overt heart failure in hypertensive subjects.16. Garg R, Yusuf S. Overview of randomized trials ofangiotensin-converting enzyme inhibitors on mortalityand morbidity in patients with heart failure [publishederratum appears in JAMA. 1995;274:462. JAMA.1995;273:1450-1456. Evaluates the effect of angiotensin-converting enzyme(ACE) inhibitors on mortality and morbidity in patientswith symptomatic CHF. Total mortality and hospitaliza-tion for CHF are significantly reduced by ACE inhibitorswith consistent effects in a broad range of patients.17. Hatle LK, Appleton CP, Popp RL. Differentiation ofconstrictive pericarditis and restrictive cardiomyopathyby Doppler echocardiography. Circulation.1989;79:357-370. A landmark publication that suggests that patients withconstrictive pericarditis and restrictive cardiomyopathycan be differentiated by comparing respiratory changesin transvalvular flow velocities. In also adds thatalthough baseline hemodynamics in the two groups weresimilar, characteristic changes were seen with respira-tion that suggest that differentiation of these diseasestates may also be possible from hemodynamic data.18. Edwards BS. Recent advances in cardiac transplantation.Curr Opin Cardiol. 1990;5:295-299. This review summarizes the issue of cardiac transplantation.19. Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHAguidelines for implantation of cardiac pacemakers andantiarrhythmia devices: executive summary—a report ofthe American College of Cardiology/American HeartAssociationTask Force on Practice Guidelines(Committee on Pacemaker Implantation). Circulation.1998;97:1325-1335. Reviews the current indications for pacemaker therapyin patients with heart disease.The Cardiovascular System: Heart and Aorta 63Chapter 3Chapter 4654.1 Hypertensive Cardiovascular Disease4.2 Diseases of the Aorta4.3 Vascular Diseases Affecting the Extremities4.4 Diseases of the Pulmonary Arteries4.5 Cardiovascular Impairment Evaluation SummaryIntroductionThis chapter provides criteria for evaluating perma-nent impairments of the systemic and pulmonaryarteries as they affect an individual’s ability to function and perform activities of daily living. Theinformation regarding medical evaluation, analysisof findings, and impairment criteria in Chapter 3,The Cardiovascular System: Heart and Aorta, remainapplicable for this chapter. See Table 3-1 for thefunctional classification of cardiac disease.This chapter also integrates new findings in the rapidly changing specialty of cardiovascular disease.The following areas are new or revised from thefourth edition: (a) the addition of recent guidelinesof the sixth report of the Joint National Committeeon Prevention, Detection, Evaluation and Treatmentof High Blood Pressure (JNC-6)1; (b) an expandedsection on pulmonary hypertension that outlinesguides for impairment assessment; and (c) the latestdata for prognosis of individuals with pulmonaryhypertension.The Cardiovascular System:Systemic and PulmonaryArteriesChapter 4Chapter 4Asymptomatic; stage 1 or 2hypertension without medica-tionsornormal blood pressure on anti-hypertensive medicationandno evidence of end-organ damageAsymptomatic; stage 1 or 2hypertension despite multiplemedicationsor antihypertensive medicationwith any of the following: (1)proteinuria, urinary sedimentabnormalities, no renal functionimpairment as measured by theblood urea nitrogen (BUN) andserum creatinine; (2) definitehypertensive changes on fundus-copic examination in arterioles,eg, “copper” or “silver wiring,”or arteriovenous crossingchanges with or without hemor-rhages and exudates; eitherabnormality suggests end-organdamageAsymptomatic; stage 3 hyper-tension despite multiple medica-tionsor antihypertensive medicationwith any of the following: (1)proteinuria, urinary sedimentabnormalities, renal functionimpairment as measured by theBUN and serum creatinine, and adecreased creatinine clearanceof 20% to 50% normal; (2) LVhypertrophy by ECG or echocar-diography but no symptoms ofHF; either abnormality suggestsmore extensive end-organ damageAntihypertensive medicationwith stages 1–3 and any of thefollowing abnormalities: (1)proteinuria, urinary sedimentabnormalities, renal functionimpairment as measured by theBUN and serum creatinine, anda creatinine clearance 89 mm Hg on two or more separate readings.1 (SeeTable 4-1 for the JNC-6 three-stage hypertensionclassification.) Hypertension, the leading cause ofambulatory office visits in the United States, can pro-duce heart disease, stroke, and renal failure. The eco-nomic impact of heart disease and stroke exceeds$29 billion annually in the United States. The preva-lence of hypertension and its complications make it amajor public health concern, particularly in theSoutheast and among African Americans.2,31 Adapted from the sixth report of the Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413-2446.Hypertensive heart disease includes hypertension,hypertension-associated systolic and diastolic heart failure (HF), hypertension-associated angina,and hypertension-induced left ventricular (LV)hypertrophy. Hypertensive heart disease can be verydebilitating and demands aggressive treatment.Preventive treatment strategies may reduce the riskof developing secondary cardiac changes, the symp-toms associated with hypertension, and other organdysfunction.4-74.1a Criteria for Rating PermanentImpairment Due to HypertensiveCardiovascular DiseaseTable 4-2 addresses the impairment classification forhypertensive cardiovascular disease. Cardiovascularcomplications of hypertension should be establishedbefore assigning a diagnosis of hypertensive cardio-vascular disease. Because patients with hypertensivecardiovascular disease do not become symptomaticuntil the very late stages, the impairment classifica-tion requires information on the end-organ damagethat may occur even in the absence of symptoms.66 Guides to the Evaluation of Permanent ImpairmentChapter 4Blood High-Pressure Optimal Normal Normal Stage 1 Stage 2 Stage 3Systolicsleep apnea and thepersistence of hypertension despite multiple med-ications. Also check echo as exertional dyspneamay reflect LVH, which would increase impair-ment.Class 2 10%-29% Impairment of the Whole PersonAsymptomatic; stage 1 or 2 hypertension despite multiplemedicationsorantihypertensive medication with any of the following: (1) proteinuria, urinary sediment abnormalities, no renal functionimpairment as measured by the blood urea nitrogen (BUN) andserum creatinine; (2) definite hypertensive changes on fundus-copic examination in arterioles, eg, “copper” or “silver wiring,” or arteriovenous crossing changes with or without hemorrhagesand exudates; either abnormality suggests end-organ damageClass 1 0%-9% Impairment of the Whole PersonAsymptomatic; stage 1 or 2 hypertension without medicationsornormal blood pressure on antihypertensive medicationandno evidence of end-organ damageExample 4-410% to 29% Impairment Due to HypertensiveCardiovascular DiseaseSubject: 40-year-old woman.History: Elevated BP during pregnancy at 32; nor-mal BP 3 weeks, 12 months postpartum. Recentbleeding between menstrual periods. Several BPreadings between 150/100 and 160/105 mm Hg.Elevated leg BP. Low-salt diet and exercise pro-gram did not effectively lower BP. Medicationneeded.Current Symptoms: Occasional headaches.Physical Exam: Otherwise normal.Clinical Studies: ECG: normal. Chestroentgenogram: normal. Serum electrolyte, BUN,and creatinine levels: normal. Urinalysis: 2+,twice-confirmed proteinuria; sediment: one tothree red blood cells per high-power field; 24-hrurine collection: 1400 mg protein.Diagnosis: Essential hypertension with proteinuria.Impairment Rating: 15% impairment of the wholeperson.Comment: Monitor for further renal impairment orother end-organ damage.Example 4-530% to 49% Impairment Due to HypertensiveCardiovascular DiseaseSubject: 48-year-old man.History: Severe hypertension; intermittent therapeu-tic drugs. Current triple therapy: beta-blocker,vasodilator, and diuretic.Current Symptoms: None. Remains mildly active.Physical Exam: BP: 170/95 mm Hg in both arms;PR: 64 BPM. No signs of congestive heart failure(CHF). Fundus: increased light reflexes from arte-rioles and arteriovenous crossing depressions; nohemorrhages or exudates. Disk flat. Enlarged, sus-tained LV impulse in normal position. Normal S1;S2increased in intensity; S4present.Clinical Studies: ECG: LV hypertrophy; tall R andinverted T waves in lateral chest leads. Chestroentgenogram: mild cardiomegaly; pulmonaryvasculature normal. Serum electrolyte levels andurinalysis: normal.Diagnosis: Essential hypertension and hypertensiveheart disease with documented LV hypertrophy.Impairment Rating: 30% to 39% impairment of thewhole person.Example 4-630% to 49% Impairment Due to HypertensiveCardiovascular DiseaseSubject: 55-year-old manHistory: Hypertension; beta-blocker and ACE-inhibitor. Well-controlled BP remained in normalrange.Current Symptoms: None. Remains mildly active.Physical Exam: Normal except for S4; sustained apical impulse.Clinical Studies: ECG: LV hypertrophy.Echocardiogram: consistent; concentric, increasedwall thickness. Normal systolic function; II/IVdiastolic dysfunction.Diagnosis: Hypertensive heart disease with LVhypertrophy and early diastolic dysfunction.Impairment Rating: 30% to 39% impairment of thewhole person.Comment: Evidence of end-organ damage butasymptomatic; medication adequately controlshypertension and treats end-organ dysfunction.Higher impairment if (a) more symptoms, (b)additional medications required to control hyper-tension, or (c) greater evidence of additional end-organ damage.Class 3 30%-49% Impairment of the Whole PersonAsymptomatic; stage 3 hypertension despite multiple medicationsorantihypertensive medication with any of the following: (1) proteinuria, urinary sediment abnormalities, renal function impairment as measured by the BUN, and serum creatinine, and a decreased creatinine clearance of 20 to 50% normal; (2) LVhypertrophy by ECG or echocardiography but no symptoms of HF; either abnormality suggests more extensive end-organdamage68 Guides to the Evaluation of Permanent ImpairmentChapter 4Example 4-750% to 100% Impairment Due to HypertensiveCardiovascular DiseaseSubject: 48-year-old man.History: In hospital 8 months ago for 2 weeks ofheadaches, blurred vision, and breathlessness. BP:260/160 mm Hg in arms and legs. Drowsy; nolocalizing neurologic signs. Fundi: arterial spasm,hemorrhages, and bilateral papilledema.Current Symptoms: Asymptomatic.Physical Exam: Papilledema cleared with treatment,remained asymptomatic. Normal heart, lungs,abdomen.Clinical Studies: Chest roentgenogram: normal.ECG: Low T waves in lateral chest leads. BUN:14.3 mmol/L (40 mg/dL); serum creatinine:203 mmol/L (2.3 mg/dL). Urinalysis: abnormal:3+ proteinuria, numerous red blood cells, occa-sional white blood cells. Diastolic BP remained>120 mm Hg despite three antihypertensives.Diagnosis: Essential hypertension with a history ofhypertensive encephalopathy.Impairment Rating: 55% impairment of the wholeperson.Comment: Lower impairment if diastolic pressure,renal function return to normal but not if any ofother findings persist.Example 4-850% to 100% Impairment Due to HypertensiveCardiovascular DiseaseSubject: 62-year-old woman.History: 10 years’ BP treatment. Elevated BPdespite medication, salt restriction, and weightcontrol. CHF 2 years ago; improved with digitalisand diuretics.Current Symptoms: 6 months’ marked tirednessand breathlessness with ordinary activity; ankleedema. Difficulty in performing most activities ofdaily living.Physical Exam: BP: 180/100 mm Hg in arms andlegs. Ankle and lower leg edema. Fundus:increased arteriole light reflexes, arteriovenouscrossing compressions, no hemorrhages or exu-dates; flat disks. Apical impulse: enlarged, sus-tained, displaced to anterior axillary line. NormalS1; increased S2; S3and S4present. Rales at bothlung bases.Clinical Studies: ECG: deep S wave in V2; normal Rwaves in V5and V6. Low T waves in I, L,and V4through V6. Chest roentgenogram: car-diomegaly; pulmonary vasculature prominent in upper lung fields. Serum electrolyte, BUN,creatinine levels, and urinalysis: normal.Echocardiogram: increased wall thickness; dilatedLV cavity with global hypokinesis; 0.30 EF.Diagnosis: Essential hypertension with CHF.Impairment Rating: 80% impairment of the wholeperson.Comment: Lower impairment after hypertensiontreatment if improvement in HF symptoms andEF. Note: Impairment class corresponds to car-diomyopathy impairment in Chapter 3. Here, theclass 4 impairment for hypertensive cardiovascu-lar disease (CVD) is not combined with car-diomyopathy since hypertensive CVD class 4includes cardiomyopathy.Class 4 50%-100% Impairment of the Whole PersonAntihypertensive medication with stages 1–3 and any of the following abnormalities: (1) proteinuria, urinary sediment abnor-malities, renal function impairment as measured by the BUN and serum creatinine, and a creatinine clearanceestablishing a per-manent impairment rating. A physician can oftenassess a person’s ability to perform ADLs based onknowledge of the patient’s medical condition andclinical judgment. When the physician is estimatinga permanent impairment rating, Table 1-2 can help todetermine how significantly the impairment impactsthese activities. Using the impairment criteria withina class and knowing the activities the individual canperform, the physician can estimate where the indi-vidual stands within that class.There are many scales that measure ability to performADLs with greater degrees of accuracy. Many ofthese scales are concerned with more severe levels ofdisability, relevant to institutionalized patients and theelderly.7 During the 1970s, the ADL concept wasextended to consider problems experienced by thoseliving in the community, a field that has come to betermed Instrumental Activities of Daily Living(IADL).7 There is a continued effort to validate thesescales; some of the more commonly utilized, vali-dated IADL and ADL scales are listed in Table 1-3.7Scales vary in their appropriateness for a given indi-vidual, based upon the level of impairment, body sys-tems affected, and degree of accuracy required. Somescales are most appropriate for an active, workingpopulation; others are more suited to a chronically ill,disabled population. Since there is no agreed-uponscale for a working population and physicians whouse the Guides may evaluate different populations ofindividuals (ie, healthy or chronically ill), a physicianmay choose the most appropriate of any of the vali-dated scales for a more in-depth assessment of ADL,to obtain further information to supplement clinicaljudgment, or to gain assistance in determining wherean individual stands within an impairment range.Philosophy, Purpose, and Appropriate Use of the Guides 5Chapter 16 Guides to the Evaluation of Permanent ImpairmentChapter 1The OECD Long-TermDisabilityQuestionnaire 8Summary of the impact ofill health on essentialactivities of daily living.General population • Eyesight• Hearing• Speaking• Carry an object of 5 kgfor 10 meters• Run 100 meters• Walk 400 meters with-out resting• Move between rooms• Get in and out of bed• Dress and undress• Cut toenails• Bend and pick up a shoe from floor• Cut food• Bite and chew hard foodAn early attempt todevelop an internationalset of disability items;European contentThe Health AssessmentQuestionnaire 9Measures difficulty in performing activities ofdaily livingUsed to assess adultarthritics in a wide rangeof research settings toevaluate care• Dressing and grooming• Arising• Eating• Walking• Hygiene• Reach• Grip• Outdoor activityWidely used instrument;pays close attention torigorous measuresThe FunctionalIndependence Measure 10Assesses physical and cog-nitive disability, monitorspatient progress, andassesses outcomes ofrehabilitationGeneral population • Self-care• Sphincter control• Mobility• Locomotion• Communication• Social cognitionBased on the BarthelindexScale Design/Description Target Population Measures CommentTable 1-3 Scales for Measurement of Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL)IADLADLThe Barthel Index(Formerly the MarylandDisability Index) 11Measures functional inde-pendence in personal careand mobility; completedby health professionalsUsed in patients withchronic conditions, beforeand after treatmentTen-item version evaluates:• Feeding• Moving from wheel-chair to bed and return• Personal toilet• Getting on and off toilet• Bathing self• Mobility• Ascending anddescending stairs• Dressing• Controlling bowels• Controlling bladderMeasures what a patientdoes; widely appliedScale Description Target Population Measures CommentPhilosophy, Purpose, and Appropriate Use of the Guides 7Chapter 1The Index ofIndependence inActivities of DailyLiving 12Describes primary biologi-cal and psychosocial func-tion; limited informationon ambulationOriginally developed forelderly and chronically illpatients with strokes andfractured hipsAssesses independence insix activities:• Bathing• Dressing• Toileting• Transferring from bedto chair• Continence• FeedingWidely used with childrenand adults, with the mentally retarded and the physically disabled, in the community andinstitutionsThe Functional StatusRating System 13Based on a method devel-oped to provide nationalstatistics on hospital uti-lization and treatmentoutcomesRehabilitation patients • Functional Status inSelf-Care (eating/feed-ing, personal hygiene,toileting, bathing,bowel/bladder/skinmanagement, bedactivities, dressing)• Functional Status inMobility (transfers,wheelchair skills, ambu-lation, stairs, commu-nity mobility)• Functional Status inCommunication (read-ing, talking, motor com-munication, writtenlanguage expression)• Functional Status inPsychosocialAdjustment(emotional adjustment,social support, adjust-ment to limitations)• Functional Status inCognitive Function(attention span, judg-ment, reasoning, memory)The OARSMultidimensionalFunctional AssessmentQuestionnaire 14A combined 7 ADL and 7IADL scale that coversfunctional and servicesassessmentGeneral population, espe-cially elderly• Individual functioning(basic demographics,social, economicresources)• Mental health• Physical health• ADL• Services assessment(transportation,social/recreational)Flexible instrument, reli-able, and valid ADL andIADL sectionsThe Medical OutcomesStudy PhysicalFunctioning Measure 15An extended ADL scalethat is sensitive to varia-tions at relatively high lev-els of physical functionGeneral population • Vigorous activities (running, lifting heavyobjects, strenuoussports)• Moderate activities(moving a table, push-ing a vacuum cleaner,bowling, playing golf)• Lifting or carrying groceries• Climbing several flightsof stairs• Climbing one flight ofstairs• Bending, kneeling, orstooping• Walking more than onemile• Walking several blocks• Walking one block• Bathing or dressing selfRecognizes differences inpeople’s values regardingfunctional ability byincluding a question onsatisfaction with physicalperformance1.2b DisabilityThe term disability has historically referred to abroad category of individuals with diverse limitationsin the ability to meet social or occupational demands.However, it is more accurate to refer to the specificactivity or role the “disabled” individual is unable toperform. Several organizations are moving awayfrom the term disability and instead are referring tospecific activity limitations to encourage an emphasison the specific activities the individual can performand to identify how the environment can be altered to enable the individual to perform the activitiesassociated with various social or occupational roles.(Table 1-1).4According to a 1997 Institute of Medicine Report,“disability is a relational outcome, reflecting theindividual’s capacity to perform a specific task oractivity, contingent on the environmental conditionsin which they are to be performed.”16 Disability iscontext-specific, not inherent in the individual, but afunction of the interaction of the individual and theenvironment.The World Health Organization (WHO) is revising its1980 International Classification of Impairments,Disabilities and Handicaps and has released a draftdocument, The International Classification ofImpairments, Activities and Participation (ICIDH-2).17The term disability has been replaced by a neutralterm, activity, and limits in ability are described asactivity limitations. The change in terminology arosefor several reasons: to choose terminology without anassociated stigma, to avoid labeling, and to emphasizethe person’s residual ability. RepresentativesComment: Aortic ectasia unlikely to progress to aor-tic aneurysm; no effect on function. Evaluate forimpairment from hypertension.Example 4-100% to 9% Impairment Due to Disease of the AortaSubject: 55-year-old man.History: Excellent health except for past tobacco use.Current Symptoms: Asymptomatic. Physical Exam: Normal.Clinical Studies: Abdominal ultrasound: 3.9-cmabdominal aortic aneurysm. Class 1 0%-9% Impairment of the Whole PersonAsymptomatic during ordinary activities; has evidence of mild aortic abnormality that is unlikely to progress70 Guides to the Evaluation of Permanent ImpairmentChapter 4Asymptomatic during ordinaryactivities; has evidence of mildaortic abnormality that isunlikely to progressAsymptomatic during ordinaryactivities; has a known progres-sive aortic abnormalityorrecovered from aortic surgery,asymptomatic, and is notexpected to be at risk for futureaortic disease as a consequenceof surgeryMild to moderate symptomsfrom aortic abnormality despitemedicationor recovered from aortic surgery,continues mild to moderatesymptoms, or at risk for recur-rence of aortic abnormalityModerate to severe symptomsdue to aortic abnormality thatpersist despite medication andthat interfere with activities ofdaily living (functional class 3 or 4)or recovered from aortic surgerybut moderate to severe symp-toms persist despite medicationTable 4-3 Criteria for Rating Permanent Impairment Due to the Diseases of the AortaClass 1 Class 2 Class 3 Class 4 0%-9% Impairment of the 10%-29% Impairment of the 30%-49% Impairment of the 50%-100% Impairment of the Whole Person Whole Person Whole Person Whole Person4.2 Diseases of theAortaDiseases of the aorta, less prevalent than heart dis-ease, can be more acutely life threatening. Diseasesof the aorta include atherosclerotic dilatation, dilata-tion and/or stenosis from a concurrent connective tis-sue disease or vasculitis, and atheroemboliccomplications from diffuse aortic atherosclerosis.Aortic atherosclerotic dilatation can progress to asignificant degree and cause dyspnea, wheezing,cough, recurrent pneumonia, and hemoptysis. Aorticdilatation can be associated with significant aorticregurgitation and can also enlarge to the point of rup-ture and death.The physician must obtain a careful and detailed his-tory to estimate aortic involvement. Physical exami-nation and chest roentgenogram may suggest aorticenlargement, but often a more advanced imagingassessment is necessary. MRI, CT scan, and trans-esophageal imaging identify aortic aneurysms, aorticvasculitic involvement, and atheromatous embolisources. Laboratory studies help establish the pres-ence of atheroemboli.8-134.2a Criteria for Rating PermanentImpairment Due to Diseases of the AortaSee Table 4-3 for the classification of whole personimpairment due to diseases of the aorta.The Cardiovascular System: Systemic and Pulmonary Arteries 71Chapter 4Diagnosis: Asymptomatic abdominal aorticaneurysm.Impairment Rating: 0% to 5% impairment of thewhole person.Comment: Small abdominal aortic aneurysm may ormay not progress. Periodic ultrasound or CT scan.Higher impairment if symptomatic.Example 4-1110% to 29% Impairment Due to Disease of the AortaSubject: 60-year-old man.History: Uncomplicated surgical repair of abdominal aortic aneurysm 5 years ago.Current Symptoms: None.Physical Exam: Normal.Clinical Studies: Abdominal ultrasound: well-seatedgraft; aneurysm repair site normal.Diagnosis: Abdominal aortic aneurysm with surgicalrepair; no evidence of recurrence.Impairment Rating: 10% to 15% of the whole person.Comment: Higher impairment if graft failure evidence, adjacent vasculature enlargement, orperipheral embolization from the graft.Example 4-1210% to 29% Impairment Due to Disease of the AortaSubject: 50-year-old man.History: Mixed connective tissue disorder.Current Symptoms: None at rest. Participating incommunity senior sports league causes symptoms.Physical Exam: BP: 130/50 mm Hg; PR: 88 BPM;1/6 diastolic murmur.Clinical Studies: Transesophageal echocardiogram:proximal ascending aortic enlargement at 50 mm;mild aortic regurgitation.Diagnosis: Proximal ascending aortic aneurysm,asymptomatic.Impairment Rating: 10% to 20% impairment of thewhole person.Comment: Aortic aneurysm at increased risk of progression. Asymptomatic but annual follow-upsfor aneurysm progression.Example 4-1330% to 49% Impairment Due to Disease of the AortaSubject: 48-year-old woman.History: Twice experienced peripheral atheroemboliccomplications from diffuse aortic atherosclerosis.“Blue toe” resolved with treatment; mild renalinsufficiency after subcutaneous heparin injectionsfor deep vein thrombosis (DVT) prophylaxis fol-lowing uncomplicated knee arthroscopic procedure.Current Symptoms: Fatigue and pain on walkinglong distances.Physical Exam: Embolic lesions on foot.Clinical Studies: Transesophageal echocardiogram:“shaggy atheromatous” changes in distal descend-ing thoracic aorta; one mobile atheromatousplaque 0.5 mm by 1.5 mm. Enlarged ascendingaorta 54 mm in sinotubular junction. Stoppedsmoking; statin cholesterol-lowering agent forhyperlipidemia. Combination beta-blocker andalpha-blocker for aneurysm.Diagnosis: Proximal ascending aortic aneurysm withdiffuse atheromatous involvement of the descend-ing aorta with two episodes of peripheral throm-boembolism.Impairment Rating: 30% to 40% impairment of thewhole person.Comment: Aortic aneurysm at increased risk of pro-gression. Increased risk for further atheromatousemboli.Class 3 30%-49% Impairment of the Whole PersonMild to moderate symptoms from aortic abnormality despite medicationorrecovered from aortic surgery, continues mild to moderate symptoms, or at risk for recurrence of aortic abnormalityClass 210%-29% Impairment of the Whole PersonAsymptomatic during ordinary activities; has a known progressive aortic abnormalityor recovered from aortic surgery, asymptomatic, and is not expected to be at risk for future aortic disease as a consequence of surgeryExample 4-1430% to 49% Impairment Due to Disease of the AortaSubject: 54-year-old man.History: Ascending aortic aneurysm. Mildlyenlarged proximal ascending aorta 48 mm; traumatic dissection repair primarily involveddescending thoracic aorta. Mild preoperative aor-tic regurgitation; no aortic valve replacement.Current Symptoms: Exertional dyspnea with exer-cise and after walking 1.5 blocks. Denies angina,orthopnea, and paroxysmal nocturnal dyspnea.Physical Exam: BP: 140/45 mm Hg; PR: 92 BPM.Normal neck veins; 3/6 diastolic decrescendo murmur at upper sternal border—right > left. LVapical impulse laterally displaced, mildly sustainedto palpation. Remainder of examination normal.Clinical Studies: Chest roentgenogram: mild aorticectasia and LV enlargement. Echocardiogram:class 3 aortic regurgitation; increased diastolicdimensions 58 cm. 0.62 LVEF. Transesophagealechocardiogram: enlarged ascending aorta 54mm; secondary aortic regurgitation. Exercisestress test: 5.2 minutes on Bruce protocol; HR144. Stopped because of dyspnea.Diagnosis: Progressive symptomatic aortic regurgi-tation secondary to an ascending aortic aneurysm.Impairment Rating: 30% to 49% impairment of thewhole person.Comment: Enlarging aortic aneurysm, aortic regurgitation secondary to aneurysm. Symptoms,significant limitation from aneurysm. Higherimpairment if more symptoms or greater severityof valvular dysfunction. Overlap often seenamong aortic, valvular, and cardiomyopathic heart diseases.Example 4-1550% to 100% Impairment Due to Disease of the AortaSubject: 62-year-old man.History: Surgical treatment of dissecting proximalaortic aneurysm 2 years ago; valved conduit.Postoperative complaint: exertional dyspnea;moderately severe aortic regurgitation. Symptomspersist despite beta-blocker,an ACE-inhibitor, andloop diuretic.Current Symptoms: Dyspnea after 1 block of exer-tion; discontinued exercise. Requires nap everyafternoon. No hypertension.Physical Exam: BP: 150/85 mm Hg; PR: 96 BPM;4/6 diastolic murmur at upper right sternal border.Clinical Studies: Continued dissection of aorta dis-tal to graft insertion. Diagnosis: Moderately severe aortic regurgitationwith exertional dyspnea following repair of proxi-mal aortic dissection.Impairment Rating: 60% to 70% impairment of thewhole person.Comment: Leakage of valved conduit and residualdistal dissection. Symptoms are of moderatelysevere intensity (class 3).Example 4-1650% to 100% Impairment Due to Disease of the AortaSubject: 52-year-old man.History: Diffuse aortic atherosclerosis; multipleatheroembolisms for 2 years. Lipid-lowering and potent antiplatelet medications. Nonsmokerfor 8 years.Current Symptoms: Moderate to severe exertionaldyspnea (pletely responds tolifestyle changes and/ormedical therapyIntermittent claudicationon severe upper extremityusageorpersistent edema of amoderate degree, con-trolled by elastic supportsorvascular damage evi-denced by a sign such asa healed, painless stumpof an amputated digitshowing evidence of per-sistent vascular disease, ora healed ulcerorRaynaud’s phenomenawith obstructive physiol-ogy (as documented byfinger/brachial indices ofand no more than100 yards at average paceormarked edema that isonly partially controlled byelastic supportsandvascular damage evi-denced by a sign such as healed amputation oftwo or more digits of one extremity, with evi-dence of persisting vascular disease or super-ficial ulcerationIntermittent claudicationon walking less than 25yards, or intermittent painat restormarked edema that can-not be controlled by elas-tic supportsorvascular damage as evi-denced by signs such as anamputation at or above anankle, or amputation oftwo or more digits of twoextremities with evidenceof persistent vascular dis-ease; or persistent wide-spread or deep ulcerationinvolving one extremitySevere and constant painat restorvascular damage evidencedby signs such as amputa-tion at or above the anklesof two extremities, oramputation of all digits oftwo or more extremitieswith evidence of persistent,widespread, or deep ulcer-ation involving two ormore extremitiesTable 4-5 Criteria for Rating Permanent Impairment of the Lower Extremity Due to Peripheral Vascular DiseaseClass 1 0%-9% Impairment ofthe Lower ExtremityClass 2 10%-39% Impairment ofthe Lower ExtremityClass 3 40%-69% Impairment ofthe Lower ExtremityClass 4 70%-89% Impairment ofthe Lower ExtremityClass 5 90%-100% Impairmentthe Lower ExtremityDiagnosis: Mild incompetence of the left lowerextremity venous system.Impairment Rating: 0% to 9% impairment of thelower extremity.Comment: Mild incompetence of deep venous sys-tem following vein harvesting for CABG surgery.Symptoms controlled by compression stocking.Has no limitations. Higher impairment if (a) moresymptoms, (b) venous compression stocking notcontrolling symptoms on intermittent basis, or (c)signs of venous stasis dermatitis or other signs ofchronic venous incompetence.Example 4-2210% to 39% Impairment of the Lower ExtremitySubject: 36-year-old man.History: Progressive swelling of both lower extremi-ties for 8 years; edema did not recede overnight.Four to eight episodes a year of acute malaisewith chills and fever that required treatment of thedermatophytosis and monthly injections of long-acting penicillin. Current Symptoms: Leg edema receded incom-pletely with elevation for 3 days; incompletelycontrolled with heavy-duty, fitted leotard.Physical Exam: Firm edema of both legs, feet, andtoes. Bilateral interdigital fissuring (typical of dermatophytosis).Clinical Studies: None.Diagnosis: Lymphedema of both legs secondary torecurring lymphangitis.Impairment Rating: 20% impairment of the lowerextremity.Comment: Moderate edema incompletely controlledby elastic support.Example 4-2310% to 39% Impairment of the Lower ExtremitySubject: 48-year-old woman.History: Diabetic. Amputation of gangrenous fourthtoe 1 year ago. Completed physical rehabilitation;ambulates normally. Returned to teaching.Current Symptoms: Denies further trouble withlower extremity ulcers.Physical Exam: Well-healed amputation site; noadditional abnormalities. Gait essentially normal.Clinical Studies: Glucose level: slighty elevated.Diagnosis: Amputation of left fourth toe for gan-grene, now resolved.Impairment Rating: 20% to 30% impairment of thelower extremity.Comment: Complete recovery from amputation.Higher impairment if additional digits amputatedor if ambulation limited from surgery.Example 4-2440% to 69% Impairment of the Lower ExtremitySubject: 54-year-old man.History: PVD complication: ulcerated left great toe.Conservative treatment failed; toe gangrenous.Toe amputated; returned to work but could notperform duties on foot. Ulcerated then gangrenousright fifth toe 6 months later; toe amputated.Individual recovered; asymptomatic. Gait returnedto preoperative level for short distances.Current Symptoms: Difficulty standing or walkingfor long periods.Physical Exam: Well-healed amputation sites; noulcerations.Clinical Studies: None.Class 340%-69% Impairment of the Lower Extremityintermittent claudication on walking as few as 25 yards and nomore than 100 yards at average paceormarked edema that is only partially controlled by elastic supportsandvascular damage evidenced by a sign such as healed amputationof two or more digits of one extremity, with evidence of persisting vascular disease or superficial ulcerationClass 210%-39% Impairment of the Lower ExtremityIntermittent claudication on severe usage of the lower extremityorpersistent edema of a moderate degree, controlled by elastic supportsorvascular damage evidenced by a sign such as a healed, painlessstump of an amputated digit showing evidence of persistent vas-cular disease, or a healed ulcerThe Cardiovascular System: Systemic and Pulmonary Arteries 77Chapter 4Diagnosis: Amputation of two digits secondary toPVD.Impairment Rating: 60% to 69% impairment of thelower extremity.Comment: Encourage excellent foot hygiene.Example 4-2570% to 89% Impairment of the Lower ExtremitySubject: 24-year-old man.History: 3 years’ recurrent thrombophlebitis inlower extremities. Venous stasis ulceration ofright ankle 1 year ago; bed rest, skin grafting toeffect healing. Long-term oral anticoagulant ther-apy to prevent further thrombosis.Current Symptoms: Difficulty with prolongedstanding and ambulation.Physical Exam: Marked standing bilateral leg andankle edema despite full-length fitted elasticstockings.Clinical Studies: Noninvasive venous plethysmogra-phy: recurrent thrombophlebitis; deep venousinsufficiency.Diagnosis: Recurrent thrombophlebitis with bilateralchronic postphlebitic deep venous insufficiency.Impairment Rating: 80% impairment of the lowerextremity.Comment: Marked, postphlebitic deep venous insuf-ficiency caused venous stasis ulceration; depend-ent leg edema poorly controlled by elastic support.Example 4-2670% to 89% Impairment of the Lower ExtremitySubject: 62-year-old man.History: Diabetic.Current Symptoms: Painful extremity ulcers; ten-derness in foot. Claudication when walking shortdistances.Physical Exam: Painful ulcers on third, fourth, andfifth toes of left foot.Clinical Studies: Peripheral angiography: diffusedistal arterial disease. Transcutaneous oximetry:limited amputation unlikely to effect healing.Diagnosis: Severe claudication with painful ulcers.Impairment Rating: 80% to 89% impairment of thelower extremity.Comment: May need BKA to resolve ulcers. Needsexcellent control of diabetes.Example 4-2790% to 100% Impairment of the Lower ExtremitySubject: 56-year-old man.History: Myocardial infarction; category III anginapectoris. Type 1 diabetic. Symptomatic arte-riosclerosis obliterans in lower extremities for 9years. Walking capacitypain at restormarked edema that cannot be controlled by elastic supportsorvascular damage as evidenced by signs such as an amputation at or above an ankle, or amputation of two or more digits of twoextremities with evidence of persistent vascular disease; or persistent widespread or deep ulceration involving one extremity78 Guides to the Evaluation of Permanent ImpairmentChapter 4The Cardiovascular System: Systemic and Pulmonary Arteries 79Chapter 4Example 4-280% to 9% Impairment Due to Pulmonary HypertensionSubject: 43-year-old man.History: Moderate obesity (body mass index 29).No diet pill or illicit drug use.Current Symptoms: No symptoms.Physical Exam: Systolic ejection murmur.Clinical Studies: Chest roentgenogram: normal.ECG: normal. Echocardiogram: normal ventricu-lar function. Mild pulmonary hypertension; esti-mated PAP 45 mm Hg. Heart valves: normal.Diagnosis: Mild pulmonary hypertension.Impairment Rating: 0% to 5% impairment of thewhole person.Comment: Counsel individual to exercise regularlyand lose weight. Higher impairment if right HFsymptoms.Class 10%-9% Impairment of the Whole PersonNo symptoms or signs of right HF and mild pulmonary hyperten-sion (PAP 40-50 mm Hg) or a Doppler echocardiography–derivedpeak tricuspid velocity of 3.0-3.5 m/secClass 1 Class 2 Class 3 Class 40%-9% Impairment of the 10%-29% Impairment of the 30%-49% Impairment of the 50%-100% Impairment of the Whole Person Whole Person Whole Person Whole PersonNo symptoms or signs of rightHF and mild pulmonary hypertension (PAP 40-50 mmHg) or a Doppler echocardiography–derived peak tricuspid velocity of 3.0-3.5 m/secNo symptoms or signs of rightHF and moderate PA hyperten-sion (PAP 51-75 mm Hg)Moderate pulmonary hyperten-sion (PAP > 75 mm Hg)andsigns and symptoms of right HForsymptoms of mild limitation(class 2) with any degree of pulmonary hypertensionSevere pulmonary hypertension(PAP > 75 mm Hg)or symptoms of severe limitation(class 3 or 4) with any degree ofpulmonary hypertensionTable 4-6 Criteria for Rating Permanent Impairment Due to Pulmonary Hypertension4.4 Diseases of thePulmonary ArteriesPrimary pulmonary hypertension is a consequence ofobliterative and plexiform changes of unknown etiol-ogy in the pulmonary arteriolar bed. Many othercauses of pulmonary hypertension include pul-monary parenchymal disease, left-sided HF, CHF,and PVD (either from pulmonary emboli or systemicdisease). Pulmonary venous and capillary systemdisorders can also produce pulmonary hypertension.All of these disorders are classified disorders of thepulmonary circulation for impairment assessment.The physician should take a careful history of func-tional impairment and symptoms for individuals withpulmonary hypertension. Classic findings include aright ventricular (RV) lift and an increased intensity ofthe S2pulmonic component. Pulmonary hypertensionis often diagnosed by chest roentgenogram changes,RV hypertrophy, or ECG strain. The definitive assessment of pulmonary hypertension is made byPAP assessment with an echocardiogram or right heartcatheterization.17-204.4a Criteria for Rating PermanentImpairment Due to PulmonaryHypertensionThe degree of pulmonary hypertension can be classi-fied by the measurement of PAP or PA resistance.Impairment classification should be based on morethan the observed PAP; also consider the presence orabsence of signs and symptoms of right HF. Dyspneais the most limiting symptom of pulmonary hyper-tension. Cyanosis may occur from right to left shunt-ing, especially in individuals with pulmonaryhypertension associated with CHF.Table 4-6 lists the impairment criteria for disordersof the pulmonary circulation. (The Guides followsthe new World Health Organization [WHO] criteriafor pulmonary hypertension classification.21)Example 4-290% to 9% Impairment Due to Pulmonary HypertensionSubject: 48-year-old woman.History: Smoker for 35 years. Current Symptoms: Dyspnea with slight exertion.No angina or peripheral edema.Physical Exam: Prolonged expiration otherwise normal.Clinical Studies: Echocardiogram: normal LV sizeand function, valvular function, right heart sizeand function. Mild PA hypertension; estimatedPAP: 45 mm Hg; systemic pressure: 120 mm Hg.Pulmonary function testing: moderate chronicobstuctive pulmonary disease (COPD); FEV155%. Counseled to stop smoking.Diagnosis: Mild pulmonary hypertension secondaryto COPD.Impairment Rating: 5% impairment of the wholepersonComment: Combine impairment from PA hyperten-sion with respiratory impairment to determinewhole person impairment.Example 4-3010% to 29% Impairment Due to Pulmonary HypertensionSubject: 58-year-old woman.History: Fully recovered from pulmonary embolism5 years ago.Current Symptoms: None. Exercises regularlyPhysical Exam: Normal; soft, 1/6 holosystolic heartmurmur, intensifies with inspiration.Clinical Studies: Echocardiogram: PAP: 55 mm Hg.Mildly enlarged RV; moderate pulmonary valveregurgitation.Diagnosis: Moderate pulmonary hypertension secondary to possible pulmonary embolism.Impairment Rating: 10% to 15% of the whole person.Comment: Higher impairment if any signs of rightHF. Identify potential underlying cause, particu-larly chronic pulmonary thromboembolic disease.Example 4-3110% to 29% Impairment Due to Pulmonary HypertensionSubject: 38-year-old woman.History: Heart murmur. Exercises regularly; lost24.7 kg (55 lbs).Current Symptoms: Denies right HF symptoms.Physical Exam: Normal; jugular pressure normal.Clinical Studies: Echocardiogram: mild tricuspidand pulmonary regurgitation. Mild RV enlarge-ment. Normal systolic function; estimated PAP:60 mm Hg. Systemic pressure: 110 mm Hg.Diagnosis: Moderate pulmonary artery hypertensionwith mild RV enlargement. No signs of HF.Impairment Rating: 15% to 20% impairment of thewhole person.Comment: Moderate pulmonary hypertension. Noevidence of right HF. Evaluate regularly; treatpossible causes of pulmonary hypertension to pre-vent progression. If persistent, consider vasodila-tor therapy.Example 4-3230% to 49% Impairment Due to Pulmonary HypertensionSubject: 38-year-old woman.History: Abnormal ECG. 2 years’ moderate dyspneawhile walking up two flights of stairs.Current Symptoms: External dyspnea.Physical Exam: Right ventricular heave; increased P2.Clinical Studies: Echocardiogram: estimated PAP:70 mm Hg. Normal LV, RV function; no significantvalvular disease. Systemic pressure 120 mm Hg.Class 330%-49% Impairment of the Whole PersonModerate pulmonary hypertension (PAP > 75 mm Hg)andsigns and symptoms of right HForsymptoms of mild limitation (class 2) with any degree of pulmonary hypertensionClass 2 10%-29% Impairment of the Whole PersonNo symptoms or signs of right HF and moderate PA hypertension(PAP 51-75 mm Hg)80 Guides to the Evaluation of Permanent ImpairmentChapter 4Diagnosis: Primary pulmonary hypertension withsymptoms of mild limitation (class 2).Impairment Rating: 30% to 40% impairment of thewhole person.Comment: Evaluation included cardiac catheteriza-tion and pulmonary angiography. Diagnosis madeafter other causes excluded. Initiate appropriatetreatment.Example 4-3330% to 49% Impairment Due to Pulmonary HypertensionSubject: 58-year-old man.History: Pulmonary embolism after arthroscopicknee surgery 5 years ago. Current Symptoms: Exertional dyspnea duringdoubles tennis; moderate (2+) pitting edema atend of workday.Physical Exam: Parasternal heave left and rightlower sternal border; tricuspid regurgitation.Clinical Studies: Echocardiogram: pulmonary hyper-tension. PAP: 55 mm Hg; systemic BP: 140 mmHg. Moderate RV enlargement; moderately severegrade 3 out of 4 tricuspid regurgitation. Started onnitrates, digitalis, and diuretics. After 3 months,dyspnea present; less peripheral edema.Diagnosis: Moderate pulmonary hypertension andRV failure possibly secondary to pulmonaryembolism.Impairment Rating: 40% to 49% impairment of thewhole person.Comment: Moderate pulmonary hypertension andright HF that improved slightly on medical ther-apy. Higher impairment if symptoms progress.Directed evaluation and treatment are warranted.Example 4-3450% to 100% Impairment Due to Pulmonary HypertensionSubject: 42-year-old woman.History: Primary pulmonary hypertension. PAP: 80mm Hg; systemic pressure: 120 mm Hg. Mildshortness of breath when pulling luggage at air-port. Denies edema, other symptoms; lips turnblue with exertion. Current Symptoms: Perform some daily activitieswithout dyspnea; symptomatic with moderatelysevere exertion.Phyical Exam: Increased right ventricular heave;increased P2.Clinical Studies: Echocardiagram: increased pul-monary pressure estimated at 70 mm Hg.Diagnosis: Primary pulmonary hypertension withmild symptoms.Impairment Rating: 50% to 70% impairment of thewhole person.Comment: Higher impairment if greater difficultyperforming activities of daily living.Example 4-3550% to 100% Impairment Due to Pulmonary HypertensionSubject: 37-year-old man.History: Scleroderma; CREST syndrome.Treatment: diuretics, nitrates, and digitalis.Current Symtoms: Exertional dyspnea with mild tomoderate exertion. Daily morning peripheraledema. Very tired by midmorning.Physical Exam: Changes of scleroderma; systolicheart murmur along lower left sternal border.Clinical Studies: Echocardiogram: large RV withseverely depressed function. Estimated PAP:58 mm Hg. Normal LV, left-sided heart valvefunction. Exercise stress test: significant func-tional impairment; 3.5 minutes on Bruce protocolbefore stopping with severe dyspnea. Peak HR:115 BPM.Diagnosis: Pulmonary hypertension with associatedscleroderma and symptoms of moderate to severefunctional limitation.Impairment Rating: 70% to 90% impairment dueto cardiovascular disease; combine with impair-ment due to muskuloskeletal disorders to deter-mine whole person impairment.Comment: Moderate pulmonary hypertension; significant functional limitation and comorbid disease.Class 450%-100% Impairment of the Whole PersonSevere pulmonary hypertension (PAP > 75 mm Hg)orsymptoms of severe limitation (class 3 or 4) with any degree of pulmonary hypertensionThe Cardiovascular System: Systemic and Pulmonary Arteries 81Chapter 482 Guides to the Evaluation of Permanent ImpairmentChapter 44.5 CardiovascularImpairmentEvaluation SummarySee Table 4.7 for an evaluation summary for theassessment of systemic and pulmonary artery cardiovascular impairment.General Determine degree of functionalimpairment with regard to activities of daily livingJugular venous pressure; com-ment on carotid and peripheralvascular pulses; heart and lungexam; abdominal exam; fundo-scopic exam; blood pressuretaken in supine, sitting, andstanding positionsData derived from relevant stud-ies (eg, ECG, echocardiogram,stress tests, cardiac catheteriza-tion)Hypertensive CardiovascularDiseaseDetermine symptoms that document cardiac, renal, andcerebrovascular limitationComprehensive; note end-organconditionsECG, echocardiogram, stress test-ing, catheterization; serum BUNand creatinine, urinalysis and urinary protein excretion, creati-nine clearance or GFR assess-ment; renal ultrasound; head CTor MRI scan; angiographyAortic Disease Determine impairment of dailyactivities and of cardiac andperipheral vascular functionComprehensive examination Transthoracic and trans-esophageal echocardiography; CT and/or MRI imaging; aorticangiographyPeripheral Vascular Disease Full history, including degree oflimitation of activities of daily livingComprehensive examination Stress testing; ankle-brachial pres-sure indices and transcutaneousoximetry; peripheral angiography;venous imaging with dye or ultra-sound/DopplerLymphatic assessment with con-trast or tagged markersPulmonary Circulation Disease Detailed history with regard tofunctional impairment and priormedical issues, medication usage,and occupational exposureComprehensive examination Echocardiography; pulmonaryangiography; CT or MRI imagingTable 4-7 Cardiac Impairment Evaluation SummaryDisorderHistory, Including MajorRelevant Symptoms Examination RecordAssessment of Cardiac FunctionThe Cardiovascular System: Systemic and Pulmonary Arteries 83Chapter 4Include assessment of sequelae,including end-organ damage andimpairmentRecord all pertinent diagnosis(es);note if they are at maximal med-ical improvement; if not, discussunder what conditions and whenstability is expectedCriteria outlined in this chapterEnd-Organ Damage Diagnosis(es) Degree of ImpairmentHeart; eyes; kidney; brain; moni-tor for proteinuria, elevated crea-tinine, reduced creatinineclearance, and abnormal urinarysediment; funduscopic changesincluding silver-wiring and arte-rio-venous crossing changesHypertension; left ventricularhypertrophy; hypertensive hypertrophic cardiomyopathy;hypertension-related systolicheart failure; hypertension-relateddiastolic heart failure; hyperten-sive nephrosclerosis; hypertensiveencephalopathy; stroke; TIASee Table 4-2Heart; aorta Aortic aneurysm—thoracic orabdominal; aortic dissection; aortic coarctation; aortic athero-sclerosisSee also aortic valvular regurgitationSee Table 4-3Upper and lower extremities Raynaud’s phenomenon; arterialand venous ulceration; claudica-tion; arterial aneurysms excludingthe aorta; ischemic digital ampu-tation, gangrene, and throm-boangiitis obliteransVenous disorders, includingedema, induration, stasis der-matitis, cellulitis, ulceration, andthrombosis Lymphatic disorders, includinglymphedema, lymphangitis, andcellulitisSee Tables 4-4 and 4-5Assess cardiac and pulmonarydamagePrimary and secondary pulmonaryhypertension; pulmonaryembolism; pulmonary veno-occlusive disease; pulmonary vein stenosisSee Table 4-6References1. The sixth report of the Joint National Committee on pre-vention, detection, evaluation, and treatment of highblood pressure [published erratum appears in ArchIntern Med. 1998; 158: 573]. Arch Intern Med.1997;157:2413-2446. Guidelines for management and treatment of hyperten-sion provided for racial and ethnic minorities, children,women, and elders as well as patients with LVH, CAD,HF, renal insufficiency, and diabetes. Hypertension maycoexist with various other conditions and may beinduced by various pressure agents. Clinicians should beaware of these management challenges and take social,cultural, and preexisting conditions into account.2. Burt VL, Cutler JA, Higgins M, et al. Trends in theprevalence, awareness, treatment, and control of hyper-tension in the adult US population. Data from the healthexamination surveys, 1960 to 1991 [published erratumappears in Hypertension. 1996;27:1192]. Hypertension.1995;26:60-69. Describes secular trends in the distribution of bloodpressure and prevalence of hypertension in US adultsand changes in rates of awareness, treatment, and con-trol of hypertension.3. Hall WD, Ferrario CM, Moore MA, et al. Hypertension-related morbidity and mortality in the southeasternUnited States. Am J Med Sci. 1997;313:195-206. Highlights the differential regional impact of hyperten-sion within the United States and summarizes the datathat document the problem, the consequences, and pos-sible causative factors.4. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK.The progression from hypertension to congestive heartfailure. JAMA. 1996;275:1557-1562. Studies the relative and population-attributable risks ofhypertension for the development of congestive heartfailure (CHF) to assess factors that contribute to thedevelopment of overt heart failure in hypertensive sub-jects. Hypertension is the mostcommon risk factor forCHF and contributes to a large proportion of heart fail-ure cases in this population-based sample. Preventivestrategies directed toward earlier and more aggressiveblood pressure control are likely to offer the greatestpromise for reducing the incidence of CHF and its asso-ciated mortality.5. Glynn RJ, Brock DB, Harris T, et al. Use of antihyper-tensive drugs and trends in blood pressure in the elderly.Arch Intern Med. 1995;155:1855-1860. Examines the benefits of treatment for hypertension inthe elderly. In the United States, the ongoing therapeuticefforts to lower elevated blood pressure in elderly popu-lations may be contributing to the continuing decline incardiovascular and stroke mortality.6. Levy D, Salomon M, D’Agostino RB, Belanger AJ,Kannel WB. Prognostic implications of baseline electro-cardiographic features and their serial changes in sub-jects with left ventricular hypertrophy. Circulation.1994;90:1786-1793. Summarizes the prognostic importance of ECG changesassociated with hypertension-related ventricular hyper-trophy. Persons with ECG evidence of left ventricularhypertrophy are at increased risk for the development ofcardiovascular disease.7. Frohlich ED. Pathophysiology of systemic arterialhypertension. In: Schlant RC, Alexander RW, O’RourkeRA, Roberts R, Sonnenblick EH, eds. Hurst’s TheHeart. 8th ed. New York, NY: McGraw-Hill; 1993:1391-1401. Nicely outlines the pathophysiological implications ofhypertension.8. Isselbacher EM, Eagle KA, DeSanctis RW. Diseases ofthe aorta. In: Heart Disease by Braunwald. 5th ed.Philadelphia, Pa: WB Saunders; 1997:1546. This chapter provides an excellent summary of contem-porary management of diseases of the aorta.9. Heinemann M, Laas J, Karck M, Borst HG. Thoracicaortic aneurysms after acute type A aortic dissection:necessity for follow-up. Ann Thorac Surg. 1990;49:580-584. Discusses the long-term prognosis of thoracic aorticaneurysms and underscores the importance of close follow-up of patients having operations for acute type Aaortic dissection. Early recognition of progressive down-stream aortic pathology permits effective prevention ofaortic rupture and timely reoperation.10. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ Jr,Mintz GS. Recognition and embolic potential ofintraaortic atherosclerotic debris. J Am Coll Cardiol.1991;17:73-78. Highlights the potential for embolic complications inpatients with thoracic aortic atherosclerosis. In a patientwith an embolic event, the thoracic aorta should be con-sidered as a potential source. Transesophageal echocar-diography can reliably detect intra-aortic atheroscleroticdebris, and when it is identified, an invasive aortic pro-cedure should be avoided if possible.84 Guides to the Evaluation of Permanent ImpairmentChapter 411. Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracicaortic aneurysms: a population-based study. Surgery.1982;92:1103-1108. A population-based perspective on the prevalence ofthoracic aortic aneurysms. Actuarial 5-year survival forall 72 patients in study was 13%; for patients with aorticdissection, 7%; and for patients without dissection,19.2%.12. Bengtsson H, Bergqvist D, Sternby NH. Increasingprevalence of abdominal aortic aneurysms: necroscopystudy. Eur J Surg. 1992;158:19-23. Analyzes the prevalence of abdominal aortic aneurysmsin the city of Malmo. Prevalence increased during thelast three decades and is age- and sex-dependent.13. Bickerstaff LK, Hollier LH, Van Peenen HJ, Melton LJ III, Pairolero PC, Cherry KJ. Abdominal aorticaneurysms: the changing natural history. J Vasc Surg.1984;1:6-12. Provides a contemporary perspective on abdominal aor-tic aneurysms. Evaluation of data (records, includingautopsy reports, of all patients with abdominal aorticaneurysms in a Midwest city with a stable populationover a 30-year period) by decade reveals an absoluteincrease in the incidence of abdominal aortic aneurysms.14. Widlus DM, Osterman FA Jr. Evaluation and percuta-neous management of atherosclerotic peripheral vasculardisease. JAMA. 1989;261:3148-3154. Review article. This review provides a contemporaryassessment of atherosclerotic peripheral vascular diseaseincluding current treatment strategies and outcome data.15. Coffman JD. Intermittent claudication—be conservative.N Engl J Med. 1991;325:577-578. This editorial summarizes contemporary issues surrounding percutaneous transluminal angioplasty andperipheral vascular revascularization.16. Schabauer AMA, Rooke TW. Cutaneous laser Dopplerflowmetry: applications and findings. Mayo Clinic Proc.1994;69:564-574.17. McGoon MD, et al. Pulmonary hypertension. In:Giuliani ER, Gersh, BL, McGoon MD, Hayes DL,Schaff HV, eds. Mayo Clinic Practice of Cardiology. 3rd ed. St Louis, Mo: Mosby; 1996. Provides an excellent framework for understanding thepathophysiology of pulmonary hypertension.18. Rubin LJ. Primary pulmonary hypertension. Chest.1993;104:236-250. Summarizes the consensus opinion of the AmericanCollege of Chest Physicians.19. D’Alonzo GE, Barst RJ, Ayres SM, et al. Survival inpatients with primary pulmonary hypertension: resultsfrom a national prospective registry. Ann Intern Med.1991;115:343-349. Characterizes mortality in persons diagnosed with pri-mary pulmonary hypertension and investigates factorsassociated with survival. Mortality most closely associ-ated with right ventricular hemodynamic function andcharacterized by means of an equation that uses threevariables: mean pulmonary artery pressure, mean rightatrial pressure, and cardiac index. The equation,validated prospectively, can be used as an adjunct inplanning treatment strategies and allocating medicalresponse.20. Burrows B, Kettel LJ, Niden AH, Rabinowitz M,Diener CF. Patterns of cardiovascular dysfunction inchronic obstructive lung disease. N Engl J Med.1972;286:912-918. Provides insight into the interaction between chronicobstructive airway disease and cardiovascular disease.21. Fishman AP, McGoon MD, Chazova IE, Fedullo PF,Kneussl M, Peacock AJ, et al. Diagnosis and assessmentof pulmonary hypertension. In: Rich S, ed. PrimaryPulmonary Hypertension: Executive Summary from theWorld Symposium: Primary Pulmonary Hypertension1998. This is the most recent update on primary pulmonaryhypertension and provides the latest WHO definitionsfor pulmonary hypertension severity. It is accessible onthe Internet: http://www.who.int/ncd/cvd/pph.html.The Cardiovascular System: Systemic and Pulmonary Arteries 85Chapter 4Chapter 5875.1 Principles of Assessment5.2 Symptoms Associated With RespiratoryDisease5.3 Tobacco Use and Environmental ExposureAssociated With Respiratory Disease5.4 Examinations, Clinical Studies, and OtherTests for Evaluating Respiratory Disease5.5 Asthma5.6 Obstructive Sleep Apnea5.7 Hypersensitivity Pneumonitis5.8 Pneumoconiosis5.9 Lung Cancer5.10 Permanent Impairment Due to Respiratory Disorders5.11 Respiratory Impairment EvaluationSummaryIntroductionThis chapter provides criteria for evaluating perma-nent impairment of the respiratory system as it affects overall lung function and the ability to per-form the activities of daily living. The respiratory sys-tem includes the tracheobronchial tree, pulmonaryparenchyma, and ribcage.The following sections have been revised for the fifthedition: (1) criteria for asthma impairment wereupdated to incorporate guidelines recently publishedby the American Thoracic Society (ATS)1; (2) respi-ratory impairment criteria now incorporate the lowerlimits of normal2 for forced vital capacity (FVC),forced expiratory volume in the first second (FEV1),and diffusing capacity for carbon monoxide (DCO);and (3) the section on sleep apnea has been updatedto reflect current assessment and practice.The Respiratory SystemChapter 5Chapter 55.1 PrinciplesofAssessmentBefore using the information in this chapter, theGuides user should become familiar with Chapters 1and 2 and the Glossary. Chapters 1 and 2 discuss theGuides’ purpose, applications, and methods for per-forming and reporting impairment evaluations. TheGlossary provides definitions of common terms usedby many specialties in impairment evaluations.The purpose of respiratory impairment assessment isto determine if a permanent respiratory impairmentexists, quantify its severity, assess its impact on theability to perform activities of daily living, and, ifpossible, identify the cause of the abnormality andrecommend measures to prevent further impairmentand ensure optimum function.An impairment, as stated in Chapter 1, is “a loss, lossof use, or derangement of any body part, organ sys-tem, or organ function” (Table 1-1). Not all impair-ments result in a functional loss or affect the abilityto perform activities of daily living. Respiratoryimpairments that produce a decrement of lung func-tion and affect the ability to perform activities ofdaily living are assigned an impairment rating. Forexample, an anatomic change such as a circum-scribed pleural plaque would be an impairment basedon an abnormality in anatomic structure. However, ifthere were no abnormality in lung function and nodecrease in the ability to perform activities of dailyliving, the individual would be assigned a 0%impairment rating.Changes in organ function are the primary criteriafor determining the impairment class. To establishthe specific impairment percentage, consider boththe severity and prognosis of the condition and howthe impairment affects the individual’s ability to per-form the activities of daily living listed in Table 1-2.Table 5-13 is provided at the end of the chapter toensure all pertinent information is included in therespiratory assessment.Begin the evaluation with an inquiry into specificsymptoms and their severity, duration, and manner ofonset. Since environmental exposure frequently leadsto symptomatic complaints, it is important to deter-mine if the individual’s personal habits or surround-ings, such as cigarette smoking and workplaceexposures, explain or contribute to the symptoms. Athorough history enables the examiner to direct thephysical examination to areas of concern and thenidentify the most useful diagnostic and evaluativestudies. For instance, structural and movement disor-ders of the chest wall or diaphragm found on physicalexamination would prompt different investigationsthan an observation of wheezing. Radiographic tech-niques such as chest roentgenograms or computedtomography (CT) scans help elucidate anatomicabnormalities that are sometimes diagnostic of spe-cific disease processes. To assess impairment, weighboth subjective and objective information derivedfrom thorough history-taking, physical examination,imaging and laboratory studies, and pulmonary func-tion tests. These complementary evaluation tech-niques enable the examiner to obtain an accurate andthorough view of the impairment’s nature, as well asthe individual’s limitations and ability to performactivities of daily living.5.1a Interpretation of Symptoms and SignsSymptomatic assessment of individuals with respira-tory disease is diagnostically useful, but it provideslimited quantitative information and should not serveas the sole criterion upon which to make decisionsabout impairment. Rather, the examiner shouldobtain objective data about the extent of the limita-tion and integrate those findings with the subjectivedata to estimate the degree of permanent impairment.5.1b Description of Clinical StudiesClinical studies used to assess pulmonary impair-ment include radiographs; other imaging studies,including CT scans and MR images; pulmonaryfunction tests; and exercise testing. Pulmonaryfunction tests are the most useful in assessing functional changes.Chapter 588 Guides to the Evaluation of Permanent Impairment5.2 SymptomsAssociated WithRespiratory DiseaseThe major symptoms of pulmonary disease includedyspnea; cough, sputum production, and hemoptysis;wheezing; and chest pain or tightness. The examinerneeds to document these symptoms and their courseover time, and correlate the symptoms with objectivestudies to assess their importance and implications.The significance of respiratory symptoms is betterunderstood when integrated with findings from moreobjective measures such as the physical examination,radiography, lung function, and laboratory studies.5.2a DyspneaDyspnea is the most common symptom noted on ini-tial examination of individuals with any type of pul-monary impairment. Despite its importance, dyspneais nonspecific; it is often caused by cardiac, hemato-logic, metabolic, or neurologic disease, or by anxietyor physical deconditioning.Dyspnea can be evaluated and quantitated using sev-eral systems. The most widely used classificationsystem, developed with the ATS, (Table 5-1), is basedon the American Thoracic Society/Division of LungDiseases Respiratory Symptom questionnaire.3 TheATS classification is best used in conjunction withmore objective respiratory function measurements. If a disparity is found between subjective complaintsof dyspnea and findings on respiratory testing,consider a nonrespiratory dyspnea component.45.2b Cough, Sputum Production, andHemoptysisCoughing can be an important indicator of respira-tory tract disease, although it is difficult to quantifyand not easily measured. Document its presence orabsence, whether it is productive or nonproductive ofsputum, its relationship to work or other activities, itsduration, its association with hemoptysis, andwhether further investigation is warranted.An acute, self-limited cough is most commonly dueto infection or irritation. A subacute or recurrent,nonproductive cough may be a manifestation ofasthma and should be investigated with pulmonaryfunction testing. A chronic, productive cough mayindicate bronchitis. According to ATS criteria, theterm chronic bronchitis may be used to describe asputum-producing cough that occurs on most daysfor at least 3 consecutive months a year for at least 2consecutive years.4Hemoptysis frequently accompanies bronchitis andpneumonia, usually as blood-streaked sputum.Serious conditions that often manifest with hemopty-sis include bronchogenic carcinoma, pulmonaryemboli, bronchiectasis, tuberculosis, aspergilloma,and arteriovenous malformations. At a minimum,hemoptysis requires radiologic evaluation that mayuncover respiratory or other impairment-producingtypes of diseases.5.2c WheezingSubjects with partial airway obstruction often reporthigh-pitched, musical sounds, or wheezing. Thesesounds can be generated at any point along the respi-ratory tract from the glottis to the bronchioles.Inspiratory wheezing, or stridor, suggests laryngealdisease; expiratory wheezing indicates bron-chospasm or localized bronchial narrowing.Information about seasonal wheezing is also diag-nostically significant. Wheezing and/or cough occur-ring primarily in the workplace or having a definitetemporal relationship to work suggests occupationalasthma; wheezing that follows several minutes ofexercise suggests exercise-induced asthma; andwheezing that usually accompanies respiratory tractinfections is classified as asthmatic bronchitis. Whilethese different varieties of asthma are commonlydescribed as separate entities, there is substantialoverlap among the syndromes. This is due to theunderlying commonalities of airway hyperrespon-siveness in all types of asthma.The Respiratory System 89Chapter 5Table 5-1 Impairment Classification of Dyspnea*Severity Definition and QuestionMild Do you have to walk more slowly on the level thanpeople of your age because of breathlessness?Moderate Do you have to stop for breath when walking atyour own pace on the level?Severe Do you ever have to stop for breath after walkingabout 100 yards or for a few minutes on the level?Very severe Are you too breathless to leave the house, orbreathless on dressing or undressing?* The person’s lowest level of physical activity and exertion that produces breathlessnessdenotes the severity of dyspnea.3Chapter 55.2d Thoracic Cage AbnormalitiesOsseous spine abnormalities may produce respira-tory impairment due to mechanical factors involvingthe size of the chest cavity and restriction of ribmotion. Kyphoscoliosis, the most common of theseabnormalities, is characterized by curvature of thevertebral column from side to side in the frontalplane (scoliosis) and from the dorsal to the ventralaspect of the sagittal plane (kyphosis). The Cobbmethod is the most common measurement tool forcurvature severity. With this method, posteroanteriorand lateral spinal radiographs measure the curvatureangles. Only severe curvature angles—that is, Cobbangles that are greater than 100°—are likely to leadto respiratory failure. Even when there are severespinal deformities, respiratory decompensation usu-ally does not occur until middle age or later.With severe spinal abnormalities, respiratory com-promise is produced by the combined effects ofrestricted lung volume, decreased cross-sectionalarea of the vascular bed, and age-related decrease inchest wall compliance. Progressive stiffness of thechest wall with advancing age increases the work ofbreathing and leads to hypoventilation, which pro-duces hypoxia and hypercapnia. Hypoxia is a power-ful pulmonary vasoconstrictor and further decreasesthe vascular cross-sectional area, eventually leadingto cor pulmonale. Judge the severity of respiratoryimpairment on the criteria described in the sectionson forced respiratory maneuvers (5.4d), diffusingcapacity for carbon monoxide (5.4e), and the criteriafor rating impairment due to respiratory disease(5.4g) in this chapter.5.3 Tobacco Use andEnvironmentalExposure AssociatedWith RespiratoryDisease5.3a Tobacco UseExposure to tobacco smoke is a common cause ofrespiratory impairment. Although susceptibility to theadverse effects of cigarette smoke varies, there is adiscernible dose-response relationship. The examinershould ask the individual’s current age; the age atwhich he or she started smoking; the average numberof packs smoked per day if the smoking has contin-ued; and, if the person quit smoking at any time, theage and date he or she quit smoking.Multiply the number of years of smoking by thenumber of packs smoked per day to produce thestandard measure of pack-years of cigarette smoking.Use this information to assess the impact of personalhabits on respiratory impairment. Cigarette smokingis the most frequent causative factor in the develop-ment of chronic bronchitis, emphysema, and lungcancer, and it can exacerbate asthma. Chronic expo-sure to environmental tobacco smoke may also be afactor in the origin of lung cancer, and it can alsoexacerbate asthma. Smoking cessation should benoted since it often benefits respiratory status.Although the anatomic abnormalities of emphysemaare irreversible, both bronchospasm and productivecough can be favorably affected by the discontinua-tion of cigarette use. In addition, risk of bron-chogenic carcinoma decreases progressively in thefirst 10 to 15 years after quitting smoking. After thattime, the risk stabilizes at a point slightly higher thanthat of someone who has never smoked.55.3b Environmental ExposureEnvironmental exposures in the workplace often arecited as causative or contributory factors in thedevelopment of respiratory impairment. It is impor-tant to obtain a complete occupational history fromthe individual to evaluate the possible effect of theseexposures. A chief component of the history containsa chronological description of work activities begin-ning with the first year of employment and includesnames of employers, the specific types of work per-formed, the materials used by the person, and thepotentially toxic materials present in the workplace.Employers are required to maintain a list (madeavailable to the employee and the treating physicianin the form of Material Safety Data Sheets) of poten-tially toxic materials used in the workplace, theirchemical descriptions, and their physical and healthhazards. This information can be quite helpful to theexaminer to direct the diagnostic and evaluativeprocess. To assess its significance, ask the individualto estimate the frequency and intensity of exposureto each substance, as well as information about theuse of respiratory protective devices.90 Guides to the Evaluation of Permanent ImpairmentRespiratory injuries in the workplace can occur inseveral different patterns, depending on the nature ofthe inhaled material and the circumstances of expo-sure. Acute lung injury may be the result of inhala-tion of a highly irritative gas, fume, mist, or vaporthat results in noncardiogenic pulmonary edema oracute respiratory distress syndrome. If the individualsurvives the acute lung injury, the healing processmay produce diffuse pulmonary fibrosis or oblitera-tive bronchiolitis, which may lead to functionalimpairment. Depending on the nature, duration, andintensity of exposure, inhalation of irritative sub-stances can cause subsequent persistent problemssuch as chronic bronchitis and airway hyperreactiv-ity. Allergic pulmonary reactions can result frominhalation of organic material or certain types ofreactive chemical molecules, causing asthma orhypersensitivity pneumonitis. Inhalation of fibro-genic dust can cause pneumoconiosis over a pro-longed period. Workplace exposures can alsoexacerbate underlying conditions such as asthma,chronic bronchitis, or emphysema.In addition to information on workplace exposure,inquire about home and environmental exposure(including hobbies or leisure time activities) toorganic and inorganic agents such as allergens,bioaerosols, paints, glues, or pesticides. In the home,exposure to pets and use of cool-mist vaporizers,humidifiers, and indoor hot tubs also may be associ-ated with respiratory disease.5.4 Examinations,Clinical Studies, and Other Tests for EvaluatingRespiratory Disease5.4a Physical ExaminationAlthough a thorough physical examination is manda-tory to reach valid conclusions about an individual’simpairment, certain portions of the examination areparticularly pertinent in evaluating the respiratorysystem. Observe and record respiratory rate, use ofaccessory muscles, and body habitus. Noisy breathsounds are a physical finding that may indicate airflow obstruction. A breathing pattern character-ized by pursed lip breathing during expiration sug-gests chronic obstructive pulmonary disease(COPD). Inspect the thoracic cage for vertebral orrib cage deformity and movement of the ribs withinspiration and expiration. A barrel-shaped chestmay indicate hyperinflation. Percuss the chest toascertain hyperresonance or consolidation and assessdiaphragmatic motion.Chest auscultation detects decreased breath sounds,crackles, wheezes, or rhonchi. Describe the intensity,quality, and location of these, as well as whether theyare heard during inspiration, expiration, or both.Inspiratory crackles, heard in two thirds of peoplewith chronic interstitial lung disease, may be associ-ated with restrictive respiratory impairment. Wheezesand rhonchi are indicative of bronchial abnormalitiesand are often accompanied by obstructive airway dis-ease. Auscultate during both quiet breathing andforced expiration before excluding wheezing.Diffuse, bilateral, expiratory wheezing indicates gen-eralized bronchospasm, while unilateral or localizedwheezing may be caused by partial bronchial obstruc-tion due to an endobronchial tumor or mucus plug-ging. Early inspiratory crackles or opening snaps maybe heard in diseases of airflowobstruction and partic-ularly in bronchiolitis obliterans.Cyanosis, indicated by a bluish tint of the lips andnail beds, is a striking but unreliable indicator ofsevere pulmonary impairment. Poor lighting in theexamination room, anemia, and skin pigmentationcan interfere with assessment of severity. Suspicionof cyanosis calls for pulse oximetry or arterial bloodgas analysis.Digital clubbing is characterized by loss of the angleat the junction of the cuticle and the nail, softeningof the nail bed, increased curvature of the nails, andwidening of the distal portions of the fingers andtoes. Chest diseases associated with clubbing includepulmonary fibrosis, bronchiectasis, bronchogeniccarcinoma, pleural tumors, lung abscess, empyema,and cyanotic congenital heart disease.The Respiratory System 91Chapter 5Chapter 55.4b Chest RoentgenogramsThe initial radiographic examination should includeposteroanterior and lateral views of the chest taken infull inspiration. Chest radiographic findings oftencorrelate poorly with physiologic findings in diseaseswith airflow limitation, such as asthma and emphy-sema. Chronic radiographic abnormalities of thechest may be classified as parenchymal, bronchovas-cular, cardiovascular, pleural, or osseous. Mediastinalor tracheal changes may be observed. Terms used todescribe parenchymal changes can be classified ashyperinflation, fibrosis, cavitary, or cystic.Hyperinflation is characteristic of airway obstruc-tion. Radiographic findings of hyperinflation areseen in airway obstruction, while volume restrictionis associated with fibrosis, loss of chest wall compli-ance, or severe neuromuscular weakness. Severechronic obstructive pulmonary disease is manifestedradiographically by diaphragm flattening, attenuationof pulmonary vasculature within the parenchyma,increased anteroposterior diameter of the chest, andincreased retrosternal air space. An individual withan acute asthmatic attack can have radiographic evi-dence of hyperinflation without parenchymal vascu-lar attenuation; when the asthmatic attack dissipates,the radiographic appearance reverts to normal.Diffuse fibrotic changes in the pulmonaryparenchyma may appear linear (streaky) and/ornodular (rounded). Specific diagnostic information isobtained by noting both the type and the predomi-nant location of fibrotic changes and whether theyare focal or diffuse. For example, silicosis is mani-fested by nodular opacities that predominate in theupper portions of the chest, while asbestosis is mani-fested by linear opacities that typically are mostmarked in lower portions of the lungs. Pleuralchanges such as pleural plaques may also be presentin individuals with asbestosis or may be the solemanifestation of past asbestos exposure.The International Labor Organization (ILO) adopteda standardized method of classifying radiographicabnormalities associated with fibrotic changescaused by pneumoconiosis.6 The National Institutefor Occupational Safety and Health (NIOSH) regu-larly administers a course and examination to certifyknowledge and proficiency in the use of this method.Information on courses and programs can beobtained from the NIOSH Division of RespiratoryDisease Studies, Morgantown, WVa, or by calling800 35-NIOSH.Evidence of cardiovascular abnormalities associatedwith chronic pulmonary disease is suggested whenchest films show evidence of pulmonary hyperten-sion and/or cor pulmonale. Pulmonary hypertensionis indicated by enlargement of pulmonary arteries inthe hila and rapid tapering of the peripheral vessels.Cor pulmonale presents as an enlargement of theright ventricle and the radiographic indicators of pul-monary hypertension. The presence of pulmonaryhypertension and/or cor pulmonale and the severityof those processes may need to be confirmed byadditional clinical and laboratory tests.5.4c Computed TomographyComputed tomography (CT) and high-resolutioncomputed tomography (HRCT) are radiographictechniques than can augment the standard chest radi-ograph and are more sensitive in evaluating certainpulmonary diseases such as asbestosis. ConventionalCT is obtained using 10-mm-thick slices throughvarious lung fields. This technique is good for evalu-ating nodules with high radiographic attenuation.The HRCT, which consists of 1- to 2-mm thick slicesevery 10 mm, is useful for evaluating changes withlow radiographic attenuation such as early interstitiallung disease. The standard CT and/or HRCT canprovide greater accuracy as part of a thoroughassessment of the pulmonary parenchyma. It shouldbe noted that, in general, the HRCT delivers signifi-cantly less whole body effective dose radiation thanthe standard CT.With regard to airway disease, HRCT can detectearly changes in the lung consistent with focalemphysema; regional air trapping associated withsmall airway disease, such as obliterative bronchioli-tis; and large airway abnormalities, such asbronchiectasis. For example, air trapping of the typeseen with obliterative bronchiolitis is best demon-strated by comparing full inspiratory and full expira-tory scans. Prone and supine position scans also arehelpful in distinguishing hydrostatic changes relatedto blood volume that are transient and can occur inthe dependent position of the lungs from fixedparenchymal abnormalities.7,892 Guides to the Evaluation of Permanent Impairment5.4d Forced Expiratory Maneuvers (Simple Spirometry)Pulmonary function tests, performed on standardizedequipment with validated administration techniques,provide the framework for evaluation of respiratorysystem impairment. Spirometric testing equipment,calibration, and administration techniques must con-form to the guidelines of the 1994 ATS Statement onStandardization of Spirometry.9–15If tolerated by the individual, remove pulmonarymedications up to 24 hours before spirometry ormethacholine challenge testing to assess pulmonaryfunction without the effects of medication.Forced expiratory maneuver measurements are madefrom at least three acceptable spirometric tracingsthat demonstrate uniformity pertaining to both theexpiratory flow pattern and concordance of at leasttwo of the test results within 5% of each other.Measurements include the following: forced vitalcapacity (FVC), forced expiratory volume in the firstsecond (FEV1), and the ratio of these measurements(FEV1/FVC). Use the tracings with the highest FVCand FEV1 to calculate the FEV1/FVC ratio, even ifthese measurements occur on different expiratoryefforts.12-14,16Repeat spirometry after bronchodilator administra-tion if FEV1/FVC is below 0.70 or if there is wheez-ing on physical examination. Use the spirogramindicating the best effort, before or after administra-tion of a bronchodilator, to determine FVC and FEV1for impairment assessment. Postbronchodilator FEV1and FVC are important in understanding potentialmedication responsiveness and prognosis.12,14,17,18The Respiratory System 93Chapter 5Figure 5-1 Lung Capacities and Volumes in the Normal State and in Three Abnormal Conditions*IC = inspiratory capacity; VC = vital capacity; TLC = total lung capacity; RV = residual volume; ERV = expiratory reserve volume.*Residual volume, and therefore total lung capacity, cannot be measured by spirometry alone.ForcedExpirationForcedExpirationAsthmaEmphysemaNormalFibrosisnormalTLCnormalTLCICVCTLCERVRVnormal TLCChapter 5To use pulmonary function measures, obtain meas-urements of the FVC, FEV, and DCO and comparethese to the predicted normal values as presented inTables 5-2a through 5-7a. For the average or meanpredicted normal value, find the individual’s age inthe left-hand column and height along the top row;the predicted value lies at the intersection of theappropriate row and column. In addition, identify thelower limit of normal for the measure of interest byusingworld-wide are reviewing this international classificationscale of impairments, function, and activities.The Guides continues to define disability as analteration of an individual’s capacity to meet per-sonal, social, or occupational demands or statu-tory or regulatory requirements because of animpairment.2 An individual can have a disability inperforming a specific work activity but not have adisability in any other social role.2 Physicians havethe education and training to evaluate a person’shealth status and determine the presence or absenceof an impairment. If the physician has the expertiseand is well acquainted with the individual’s activitiesand needs, the physician may also express an opinionabout the presence or absence of a specific disability.For example, an occupational medicine physicianwho understands the job requirements in a particularworkplace can provide insights on how the impair-ment could contribute to a workplace disability.The impairment evaluation, however, is only oneaspect of disability determination. A disability deter-mination also includes information about the individ-ual’s skills, education, job history, adaptability, age,and environment requirements and modifications.3Assessing these factors can provide a more realisticpicture of the effects of the impairment on the abilityto perform complex work and social activities. Ifadaptations can be made to the environment, theindividual may not be disabled from performing thatactivity.8 Guides to the Evaluation of Permanent ImpairmentChapter 1Figure 1-1 The Relationship Among the Concepts of Normal Health, Impairment, Functional Limitation, and Activity Disability (Performance Limitation)Normal Health Impairment(loss, loss of use, derangement of body part, organ system, or organ function)Functional Limitation(limit in the ability to perform basic activities of daily living)DisabilityNo DisabilityNormal Health(eg, healthy back)Impairment(eg, disk herniation L5/S1,decreased rangeof motion)Functional Limitation(eg, unable to lift 45 kg [100 lb])Disability(no accomodation available; unable to work as a stock clerk)No Disability(mechanical lift available; able to operate lift; can work as a stock clerk)As discussed in this chapter and illustrated in Figure1-1, medical impairments are not related to disabilityin a linear fashion. An individual with a medicalimpairment can have no disability for some occupa-tions, yet be very disabled for others. For example,severe degenerative disk disease may impair thefunctioning of the spine of both a licensed practicalnurse and a bank president in a similar fashion whenperforming their activities of daily living. However,in terms of occupation, the bank president is lesslikely to be disabled by this impairment than thelicensed practical nurse. An individual who developsrheumatoid arthritis may be disabled from work as atailor but may be able to work as a child care aide. Apilot who develops a visual impairment, correctablewith glasses, may be able to perform all of his dailyactivities but is no longer able to fly a commercialplane. An individual with repeated hernias andrepairs may no longer be able to lift more than 20 kg (40 lb) but could work in a factory wheremechanical lifts are available.The Guides is not intended to be used for direct estimates of work disability. Impairment percentagesderived according to the Guides criteria do not measure work disability. Therefore, it is inappropri-ate to use the Guides’ criteria or ratings to makedirect estimates of work disability.1.2c HandicapHandicap is a term historically used in both a legaland a policy context to describe disability or peopleliving with disabilities. Though the term continues tobe used, generally it is being replaced with the pre-ferred term disability.1.3 The Organ Systemand Whole BodyApproach toImpairmentThe Guides impairment ratings reflect the severityand limitations of the organ/body system impairmentand resulting functional limitations. Mostorgan/body systems chapters in the Guides provideimpairment ratings that represent the extent of wholeperson impairment. In addition to listing whole per-son impairments, the musculoskeletal chapters pro-vide regional impairment ratings (eg, upper extremity,lower extremity); regional ratings are then convertedinto whole person impairment ratings. Within somemusculoskeletal regions, a consensus group devel-oped weights to reflect the relative importance of certain regions. For example, different fingers or dif-ferent areas of the spine are given different weights,representing their unique and relative importance tothe region’s overall functioning. These weights,which have gained acceptance in clinical practice,have been retained to enable regulatory authorities toconvert from a regional body to whole person impair-ment when needed.1.4 Philosophy and Useof the CombinedValues ChartThe Combined Values Chart (p. 604) was designedto enable the physician to account for the effects ofmultiple impairments with a summary value. A stan-dard formula was used to ensure that regardless ofthe number of impairments, the summary valuewould not exceed 100% of the whole person.According to the formula listed in the combined val-ues chart, multiple impairments are combined so thatthe whole person impairment value is equal to or lessthan the sum of all the individual impairment values.Philosophy, Purpose, and Appropriate Use of the Guides 9Chapter 1A scientific formula has not been established to indi-cate the best way to combine multiple impairments.Given the diversity of impairments and great vari-ability inherent in combining multiple impairments,it is difficult to establish a formula that accounts forall situations. A combination of some impairmentscould decrease overall functioning more than sug-gested by just adding the impairment ratings for theseparate impairments (eg, blindness and inability touse both hands). When other multiple impairmentsare combined, a less than additive approach may bemore appropriate. States also use different tech-niques when combining impairments. Many work-ers’ compensation statutes contain provisions thatcombine impairments to produce a summary ratingthat is more than additive. Other options are to com-bine (add, subtract, or multiply) multiple impair-ments based upon the extent to which they affect anindividual’s ability to perform activities of daily liv-ing. The current edition has retained the same com-bined values chart, since it has become the standardof practice in many jurisdictions. Other approaches,when published in scientific peer-reviewed literature,will be evaluated for future editions.In general, impairment ratings within the sameregion are combined before combining the regionalimpairment rating with that from another region. Forexample, when there are multiple impairmentsinvolving abnormal motion, neurologic loss, andamputation of an extremity part, these impairmentsfirst should be combined for a regional extremityimpairment. The regional extremity impairment thenis combined with an impairment from anotherregion, such as from the respiratory system. Spinalimpairments in multiple regions are combined.Exceptions, as detailed in the musculoskeletal chap-ter, include impairments of the joints of the thumb,which are added, as are the ankle and subtalar jointsin the lower extremity: both situations include com-plex motions.1.5 IncorporatingScience with ClinicalJudgmentThe Guides uses objective and scientifically baseddata when available and references these sources.When objective data have not been identified, esti-mates of the degree of impairment are used, based onclinical experience and consensus. Subjective con-cerns, including fatigue, difficulty in concentrating,and pain, when not accompanied by demonstrableclinical signs orTables 5-2b through 5-7b. The lower limit ofnormal has been calculated based upon the standardconvention of the lower limit of normal lying at thefifth percentile, below the upper 95% of the refer-ence population, according to recommendationsfrom the ATS.13,14 The lower limits of normal are usedto distinguish between class 1 and class 2 respiratoryimpairment in Table 5-12.North American whites have larger spirometric valuesfor a given age, height, and gender than NorthAmerican blacks, with a similar tendency noted forHispanics, Native Americans, and Asians. Populationvalues of normal lung function have been identifiedfor blacks. The ATS Task Force for Interpretation ofPulmonary Function recommends an adjustment on apopulation basis for predicted lung function in blacks.Multiply values for predicted normal FVC (Tables 5-2a and 5-3a) by 0.88; for predicted normal FEV1(Tables 5-4a and 5-5a) by 0.88; and for normal sin-gle-breath DCO (Tables 5-6a and 5-7a) by 0.93. Incases where the correction value may not apply, theexaminer may choose not to use this correction andinstead may provide an explanation why it is inappro-priate. Reliable population data are not yet availablefor other ethnic groups, such as Hispanics, NativeAmericans, and Asians. For these ethnic groups, thevalues for North American whites may be used.16,19–21The FEV1/FVC ratio helps diagnose obstructive air-way disease. However, according to the most recentATS statement on pulmonary function testing inter-pretation, the absolute volume or the percentage ofpredicted value of FEV1 is the primary parameter forassessing severity of obstruction, although theFEV1/FVC may be helpful.13 Rather, judge severityon the absolute value or the percentage of predictedvalue of FEV1.5.4e Diffusing Capacity for CarbonMonoxide (DCO)Use single-breath DCO to evaluate all levels of impairment. The single-breath DCO testing method is described in a 1995 ATS statement.14,22 The DCOmeasurement provides information about gas transferefficiency across the lungs.23 Several physiologic factors affect the gas transfer process, including alveolar-capillary membrane thickness, available gasexchange surface area, gas solubility, pulmonary capillary blood volume, hematocrit, test gas concen-tration gradient across the alveolar-capillary membrane, and hemoglobin-binding site availability.Mechanical factors that affect DCO results include testgas inhalation speed, inspiration depth, period ofbreath holding, and expiration speed. While mechani-cal factors generally are controlled by DCO testautomation, extrapulmonary factors are important toascertain proper interpretation. For example, cigarettesmoking can elevate the blood’s carbon monoxidelevels, causing as much as 10% to 12% hemoglobinsaturation and decreasing DCO. Instruct the individualnot to smoke for at least 8 hours before the test.See Tables 5-6a and 5-7a for reference values for population-based predicted normal diffusing capacity. Use these tables in a manner similar to thespirometry tables. A laboratory that tests DCO underconditions or with procedures different than that rec-ommended by the ATS should either develop andverify its own prediction equations or use anaccepted and verified equation.See Table 5-12 for classification of respiratoryimpairment based on the testing results of FVC,FEV1, FEV1/FVC, and DCO. Also consider the possi-ble contribution of extrapulmonary factors to respira-tory system impairment. For example, morbidobesity may decrease FVC, and anemia maydecrease DCO. Evaluate other organ system impair-ments according to the criteria given in other Guideschapters and combine those impairment ratings withthe respiratory system impairment rating (see theCombined Values Chart, p. 604).94 Guides to the Evaluation of Permanent ImpairmentThe Respiratory System 95Chapter 5Table 5-2b Predicted Lower Limit of Normal Forced Vital Capacity (FVC) for Men*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 2.605 2.725 2.845 2.965 3.085 3.205 3.325 3.445 3.565 3.685 3.805 3.925 4.045 4.165 4.285 4.405 4.525 4.645 4.765 4.885 5.005 5.125 5.245 5.365 5.48520 2.565 2.685 2.805 2.925 3.045 3.165 3.285 3.405 3.525 3.645 3.765 3.885 4.005 4.125 4.245 4.365 4.485 4.605 4.725 4.845 4.965 5.085 5.205 5.325 5.44522 2.525 2.645 2.765 2.885 3.005 3.125 3.245 3.365 3.485 3.605 3.725 3.845 3.965 4.085 4.205 4.325 4.445 4.565 4.685 4.805 4.925 5.045 5.165 5.285 5.40524 2.485 2.605 2.725 2.835 2.965 3.085 3.205 3.325 3.445 3.565 3.685 3.805 3.925 4.045 4.165 4.285 4.405 4.525 4.645 4.765 4.885 5.005 5.125 5.245 5.36526 2.435 2.555 2.675 2.795 2.915 3.035 3.155 3.275 3.395 3.515 3.635 3.755 3.875 3.995 4.115 4.235 4.355 4.475 4.595 4.715 4.835 4.955 5.075 5.195 5.31528 2.395 2.515 2.635 2.755 2.875 2.995 3.115 3.235 3.355 3.475 3.595 3.715 3.835 3.955 4.075 4.195 4.315 4.435 4.555 4.675 4.795 4.915 5.035 5.155 5.27530 2.355 2.475 2.595 2.715 2.835 2.955 3.075 3.195 3.315 3.435 3.555 3.675 3.795 3.915 4.035 4.155 4.275 4.395 4.515 4.635 4.755 4.875 4.995 5.115 5.23532 2.315 2.435 2.555 2.675 2.795 2.915 3.035 3.155 3.275 3.395 3.515 3.635 3.755 3.875 3.995 4.115 4.235 4.355 4.475 4.595 4.715 4.835 4.955 5.075 5.19534 2.265 2.385 2.505 2.625 2.745 2.865 2.985 3.105 3.225 3.345 3.465 3.585 3.705 3.825 3.945 4.065 4.185 4.305 4.425 4.545 4.665 4.785 4.905 5.025 5.14536 2.225 2.345 2.465 2.585 2.705 2.825 2.945 3.065 3.185 3.305 3.425 3.545 3.665 3.785 3.905 4.025 4.145 4.265 4.385 4.505 4.625 4.745 4.865 4.985 5.10538 2.185 2.305 2.425 2.545 2.665 2.785 2.905 3.025 3.145 3.265 3.385 3.505 3.625 3.745 3.865 3.985 4.105 4.225 4.345 4.465 4.585 4.705 4.825 4.945 5.06540 2.135 2.255 2.375 2.495 2.615 2.735 2.855 2.975 3.095 3.215 3.335 3.455 3.575 3.695 3.815 3.935 4.055 4.175 4.295 4.415 4.535 4.655 4.775 4.895 5.01542 2.095 2.215 2.335 2.455 2.575 2.695 2.815 2.935 3.055 3.175 3.295 3.415 3.535 3.655 3.775 3.895 4.015 4.135 4.255 4.375 4.495 4.615 4.735 4.855 4.97544 2.055 2.175 2.295 2.415 2.535 2.655 2.775 2.895 3.015 3.135 3.255 3.375 3.495 3.615 3.735 3.855 3.975 4.095 4.215 4.335 4.455 4.575 4.695 4.815 4.93546 2.015 2.135 2.255 2.375 2.495 2.615 2.735 2.855 2.975 3.095 3.215 3.335 3.455 3.575 3.695 3.815 3.935 4.055 4.175 4.295 4.415 4.535 4.655 4.775 4.89548 1.965 2.085 2.205 2.325 2.445 2.565 2.685 2.805 2.925 3.045 3.165 3.285 3.405 3.525 3.645 3.765 3.885 4.005 4.125 4.245 4.365 4.485 4.605 4.725 4.84550 1.925 2.045 2.165 2.285 2.405 2.525 2.645 2.765 2.885 3.005 3.125 3.245 3.365 3.485 3.605 3.725 3.845 3.965 4.085 4.205 4.325 4.445 4.565 4.685 4.80552 1.885 2.005 2.125 2.245 2.365 2.485 2.605 2.725 2.845 2.965 3.085 3.205 3.325 3.445 3.565 3.685 3.805 3.925 4.045 4.165 4.285 4.405 4.525 4.645 4.76554 1.835 1.955 2.075 2.195 2.315 2.435 2.555 2.675 2.795 2.915 3.035 3.155 3.275 3.395 3.515 3.635 3.755 3.875 3.995 4.115 4.235 4.355 4.475 4.595 4.71556 1.795 1.915 2.035 2.155 2.275 2.395 2.515 2.635 2.755 2.875 2.995 3.115 3.235 3.355 3.475 3.595 3.715 3.835 3.955 4.075 4.195 4.315 4.435 4.555 4.67558 1.755 1.875 1.995 2.115 2.235 2.355 2.475 2.595 2.715 2.835 2.955 3.075 3.195 3.315 3.435 3.555 3.675 3.795 3.915 4.035 4.155 4.275 4.395 4.515 4.63560 1.715 1.835 1.955 2.075 2.195 2.315 2.435 2.555 2.675 2.795 2.915 3.035 3.155 3.275 3.395 3.515 3.635 3.755 3.875 3.995 4.115 4.235 4.355 4.475 4.59562 1.665 1.785 1.905 2.025 2.145 2.265 2.385 2.505 2.625 2.745 2.865 2.985 3.105 2.225 3.345 3.465 3.585 3.705 3.825 3.945 4.065 4.185 4.305 4.425 4.54564 1.625 1.745 1.865 1.985 2.105 2.225 2.345 2.465 2.585 2.705 2.825 2.945 3.065 3.185 3.305 3.425 3.545 3.665 3.785 3.905 4.025 4.145 4.265 4.385 4.50566 1.585 1.705 1.825 1.945 2.065 2.185 2.305 2.425 2.545 2.665 2.785 2.905 3.025 3.145 3.265 3.385 3.505 3.625 3.745 3.865 3.985 4.105 4.225 4.345 4.46568 1.535 1.655 1.775 1.895 2.015 2.135 2.255 2.375 2.495 2.615 2.735 2.855 2.9753.095 3.215 3.335 3.455 3.575 3.695 3.815 3.935 4.055 4.175 4.295 4.41570 1.495 1.615 1.735 1.855 1.975 2.095 2.215 2.335 2.455 2.575 2.695 2.815 2.935 3.055 3.175 3.295 3.415 3.535 3.655 3.775 3.895 4.015 4.135 4.255 4.37572 1.455 1.575 1.695 1.815 1.935 2.055 2.175 2.295 2.415 2.535 2.655 2.775 2.895 3.015 3.135 3.255 3.375 3.495 3.615 3.735 3.855 3.975 4.095 4.215 4.33574 1.415 1.535 1.655 1.775 1.895 2.015 2.135 2.255 2.375 2.495 2.615 2.735 2.855 2.975 3.095 3.215 3.335 3.455 3.575 3.695 3.815 3.935 4.055 4.175 3.180*FVC values are given in liters. The values listed here reflect the FVC as listed in Table 5–2a minus 1.115 L (95% confidence interval). Adapted from Crapo et al.2Table 5-2a Predicted Normal Forced Vital Capacity (FVC) in Liters for Men (BTPS)*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 3.72 3.84 3.96 4.08 4.20 4.32 4.44 4.56 4.68 4.80 4.92 5.04 5.16 5.28 5.40 5.52 5.64 5.76 5.88 6.00 6.12 6.24 6.36 6.48 6.6020 3.68 3.80 3.92 4.04 4.16 4.28 4.40 4.52 4.64 4.76 4.88 5.00 5.12 5.24 5.36 5.48 5.60 5.72 5.84 5.96 6.08 6.20 6.32 6.44 6.5622 3.64 3.76 3.88 4.00 4.12 4.24 4.36 4.48 4.60 4.72 4.84 4.96 5.08 5.20 5.32 5.44 5.56 5.68 5.80 5.92 6.04 6.16 6.28 6.40 6.5224 3.60 3.72 3.84 3.95 4.08 4.20 4.32 4.44 4.56 4.68 4.80 4.92 5.04 5.16 5.28 5.40 5.52 5.64 5.76 5.88 6.00 6.12 6.24 6.36 6.4826 3.55 3.67 3.79 3.91 4.03 4.15 4.27 4.39 4.51 4.63 4.75 4.87 4.99 5.11 5.23 5.35 5.47 5.59 5.71 5.83 5.95 6.07 6.19 6.31 6.4328 3.51 3.63 3.75 3.87 3.99 4.11 4.23 4.35 4.47 4.59 4.71 4.83 4.95 5.07 5.19 5.31 5.43 5.55 5.67 5.79 5.91 6.03 6.15 6.27 6.3930 3.47 3.59 3.71 3.83 3.95 4.07 4.19 4.31 4.43 4.55 4.67 4.79 4.91 5.03 5.15 5.27 5.39 5.51 5.63 5.75 5.87 5.99 6.11 6.23 6.3532 3.43 3.55 3.67 3.79 3.91 4.03 4.15 4.27 4.39 4.51 4.63 4.75 4.87 4.99 5.11 5.23 5.35 5.47 5.59 5.71 5.83 5.95 6.07 6.19 6.3134 3.38 3.50 3.62 3.74 3.86 3.98 4.10 4.22 4.34 4.46 4.58 4.70 4.82 4.94 5.06 5.18 5.30 5.42 5.54 5.66 5.78 5.90 6.02 6.14 6.2636 3.34 3.46 3.58 3.70 3.82 3.94 4.06 4.18 4.30 4.42 4.54 4.66 4.78 4.90 5.02 5.14 5.26 5.38 5.50 5.62 5.74 5.86 5.98 6.10 6.2238 3.30 3.42 3.54 3.66 3.78 3.90 4.02 4.14 4.26 4.38 4.50 4.62 4.74 4.86 4.98 5.10 5.22 5.34 5.46 5.58 5.70 5.82 5.94 6.06 6.1840 3.25 3.37 3.49 3.61 3.73 3.85 3.97 4.09 4.21 4.33 4.45 4.57 4.69 4.81 4.93 5.05 5.17 5.29 5.41 5.53 5.65 5.77 5.89 6.01 6.1342 3.21 3.33 3.45 3.57 3.69 3.81 3.93 4.05 4.17 4.29 4.41 4.53 4.65 4.77 4.89 5.01 5.13 5.25 5.37 5.49 5.61 5.73 5.85 5.97 6.0944 3.17 3.29 3.41 3.53 3.65 3.77 3.89 4.01 4.13 4.25 4.37 4.49 4.61 4.73 4.85 4.97 5.09 5.21 5.33 5.45 5.57 5.69 5.81 5.93 6.0546 3.13 3.25 3.37 3.49 3.61 3.73 3.85 3.97 4.09 4.21 4.33 4.45 4.57 4.69 4.81 4.93 5.05 5.17 5.29 5.41 5.53 5.65 5.77 5.89 6.0148 3.08 3.20 3.32 3.44 3.56 3.68 3.80 3.92 4.04 4.16 4.28 4.40 4.52 4.64 4.76 4.88 5.00 5.12 5.24 5.36 5.48 5.60 5.72 5.84 5.9650 3.04 3.16 3.28 3.40 3.52 3.64 3.76 3.88 4.00 4.12 4.24 4.36 4.48 4.60 4.72 4.84 4.96 5.08 5.20 5.32 5.44 5.56 5.68 5.80 5.9252 3.00 3.12 3.24 3.36 3.48 3.60 3.72 3.84 3.96 4.08 4.20 4.32 4.44 4.56 4.68 4.80 4.92 5.04 5.16 5.28 5.40 5.52 5.64 5.76 5.8854 2.95 3.07 3.19 3.31 3.43 3.55 3.67 3.79 3.91 4.03 4.15 4.27 4.39 4.51 4.63 4.75 4.87 4.99 5.11 5.23 5.35 5.47 5.59 5.71 5.8356 2.91 3.03 3.15 3.27 3.39 3.51 3.63 3.75 3.87 3.99 4.11 4.23 4.35 4.47 4.59 4.71 4.83 4.95 5.07 5.19 5.31 5.43 5.55 5.67 5.7958 2.87 2.99 3.11 3.23 3.35 3.47 3.59 3.71 3.83 3.95 4.07 4.19 4.31 4.43 4.55 4.67 4.79 4.91 5.03 5.15 5.27 5.39 5.51 5.63 5.7560 2.83 2.95 3.07 3.19 3.31 3.43 3.55 3.67 3.79 3.91 4.03 4.15 4.27 4.39 4.51 4.63 4.75 4.87 4.99 5.11 5.23 5.35 5.47 5.59 5.7162 2.78 2.90 3.02 3.14 3.26 3.38 3.50 3.62 3.74 3.86 3.98 4.10 4.22 3.34 4.46 4.58 4.70 4.82 4.94 5.06 5.18 5.30 5.42 5.54 5.6664 2.74 2.86 2.98 3.10 3.22 3.34 3.46 3.58 3.70 3.82 3.94 4.06 4.18 4.30 4.42 4.54 4.66 4.78 4.90 5.02 5.14 5.26 5.38 5.50 5.6266 2.70 2.82 2.94 3.06 3.18 3.30 3.42 3.54 3.66 3.78 3.90 4.02 4.14 4.26 4.38 4.50 4.62 4.74 4.86 4.98 5.10 5.22 5.34 5.46 5.5868 2.65 2.77 2.89 3.01 3.13 3.25 3.37 3.49 3.61 3.73 3.85 3.97 4.09 4.21 4.33 4.45 4.57 4.69 4.81 4.93 5.05 5.17 5.29 5.41 5.5370 2.61 2.73 2.85 2.97 3.09 3.21 3.33 3.45 3.57 3.69 3.81 3.93 4.05 4.17 4.29 4.41 4.53 4.65 4.77 4.89 5.01 5.13 5.25 5.37 5.4972 2.57 2.69 2.81 2.93 3.05 3.17 3.29 3.41 3.53 3.65 3.77 3.89 4.01 4.13 4.25 4.37 4.49 4.61 4.73 4.85 4.97 5.09 5.21 5.33 5.4574 2.53 2.65 2.77 2.89 3.01 3.13 3.25 3.37 3.49 3.61 3.73 3.85 3.97 4.09 4.21 4.33 4.45 4.57 4.69 4.81 4.93 5.05 5.17 5.29 5.41*FVC in liters = 0.0600 H – 0.0214 A – 4.650. R2 = 0.54; SEE = 0.644; 95% confidence level = 1.115. Definitions of abbreviations: R2 = coefficient of determination; SEE = standard error ofestimate; H = height in cm; A = age in years. BTPS = body temperature, ambient pressure, and saturated with water vapor at these conditions. Adapted from Crapo et al.2 Chapter 596 Guides to the Evaluation of Permanent ImpairmentTable 5-3b Predicted Lower Limit of Normal Forced Vital Capacity (FVC) for Women*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 2.514 2.614 2.714 2.804 2.904 3.004 3.104 3.204 3.304 3.394 3.494 3.594 3.694 3.794 3.884 3.984 4.084 4.184 4.284 4.384 4.474 4.574 4.674 4.774 4.87420 2.474 2.564 2.664 2.764 2.864 2.964 3.064 3.154 3.254 3.354 3.454 3.554 3.644 3.744 3.844 3.944 4.044 4.144 4.234 4.334 4.434 4.534 4.634 4.734 4.82422 2.424 2.524 2.624 2.724 2.824 2.914 3.014 3.114 3.214 3.314 3.414 3.504 3.604 3.704 3.804 3.904 3.994 4.094 4.194 4.294 4.394 4.494 4.584 4.684 4.78424 2.384 2.484 2.584 2.674 2.774 2.874 2.974 3.074 3.174 3.264 3.364 3.464 3.564 3.664 3.754 3.854 3.954 4.054 4.154 4.254 4.344 4.444 4.544 4.644 4.74426 2.344 2.444 2.534 2.634 2.734 2.834 2.934 3.024 3.124 3.224 3.324 3.424 3.524 3.614 3.714 3.814 3.914 4.014 4.104 4.204 4.304 4.404 4.504 4.604 4.69428 2.294 2.394 2.494 2.594 2.694 2.784 2.884 2.984 3.084 3.184 3.284 3.374 3.474 3.574 3.674 3.774 3.864 3.964 4.064 4.164 4.264 4.364 4.454 4.554 4.65430 2.254 2.354 2.454 2.554 2.644 2.744 2.844 2.944 3.044 3.134 3.234 3.334 3.434 3.534 3.634 3.724 3.824 3.924 4.024 4.124 4.214 4.314 4.414 4.514 4.61432 2.214 2.314 2.404 2.504 2.604 2.704 2.804 2.894 2.994 3.094 3.194 3.294 3.394 3.484 3.584 3.684 3.784 3.884 3.974 4.074 4.174 4.274 4.374 4.474 4.56434 2.164 2.264 2.364 2.464 2.564 2.664 2.754 2.854 2.954 3.054 3.154 3.244 3.344 3.444 3.544 3.644 3.744 3.834 3.934 4.034 4.134 4.234 4.324 4.424 4.52436 2.124 2.224 2.324 2.424 2.514 2.614 2.714 2.814 2.914 3.004 3.104 3.204 3.304 3.404 3.504 3.594 3.694 3.794 3.894 3.994 4.084 4.184 4.284 4.384 4.48438 2.084 2.184 2.274 2.374 2.474 2.574 2.674 2.774 2.864 2.964 3.064 3.164 3.264 3.354 3.454 3.554 3.654 3.754 3.854 3.944 4.044 4.144 4.244 4.344 4.43440 2.034 2.134 2.234 2.334 2.434 2.534 2.624 2.724 2.824 2.924 3.024 3.114 3.214 3.314 3.414 3.514 3.614 3.704 3.804 3.904 4.004 4.104 4.194 4.294 4.39442 1.994 2.094 2.194 2.294 2.384 2.484 2.584 2.684 2.784 2.884 2.974 3.074 3.174 3.274 3.374 3.464 3.564 3.664 3.764 3.864 3.964 4.054 4.154 4.254 4.35444 1.954 2.054 2.144 2.244 2.344 2.444 2.544 2.644 2.734 2.834 2.934 3.034 3.134 3.224 3.324 3.424 3.524 3.624 3.724 3.814 3.914 4.014 4.114 4.214 4.30446 1.904 2.004 2.104 2.204 2.304 2.404 2.494 2.594 2.694 2.794 2.894 2.994 3.084 3.184 3.284 3.384 3.484 3.574 3.674 3.774 3.874 3.974 4.074 4.164 4.26448 1.864 1.964 2.064 2.164 2.254 2.354 2.454 2.554 2.654 2.754 2.844 2.944 3.044 3.144 3.244 3.334 3.434 3.534 3.634 3.734 3.834 3.924 4.024 4.124 4.22450 1.824 1.924 2.014 2.114 2.214 2.314 2.414 2.514 2.604 2.704 2.804 2.904 3.004 3.104 3.194 3.294 3.394 3.494 3.594 3.684 3.784 3.884 3.984 4.084 4.18452 1.784 1.874 1.974 2.074 2.174 2.274 2.364 2.464 2.564 2.664 2.764 2.864 2.954 3.054 3.154 3.254 3.354 3.444 3.544 3.644 3.744 3.844 3.944 4.034 4.13454 1.734 1.834 1.934 2.034 2.124 2.224 2.3242.424 2.524 2.624 2.714 2.814 2.914 3.014 3.114 3.214 3.304 3.404 3.504 3.604 3.704 3.794 3.894 3.994 4.09456 1.694 1.794 1.894 1.984 2.084 2.184 2.284 2.384 2.474 2.574 2.674 2.774 2.874 2.974 3.064 3.164 3.264 3.364 3.464 3.554 3.654 3.754 3.854 3.954 4.05458 1.654 1.744 1.844 1.944 2.044 2.144 2.234 2.334 2.434 2.534 2.634 2.734 2.824 2.924 3.024 3.124 3.224 3.324 3.414 3.514 3.614 3.714 3.814 3.904 4.00460 1.604 1.704 1.804 1.904 2.004 2.094 2.194 2.294 2.394 2.494 2.584 2.684 2.784 2.884 2.984 2.084 3.174 3.274 3.374 3.474 3.574 3.664 3.764 3.864 3.96462 1.564 1.664 1.764 1.854 1.954 2.054 2.154 2.254 2.344 2.444 2.544 2.644 2.744 2.844 2.934 3.034 3.134 3.234 3.334 3.434 3.524 3.624 3.724 3.824 3.92464 1.524 1.614 1.714 1.814 1.914 2.014 2.114 2.204 2.304 2.404 2.504 2.604 2.694 2.794 2.894 2.994 3.094 3.194 3.284 3.384 3.484 3.584 3.684 3.774 3.87466 1.474 1.574 1.674 1.774 1.874 1.964 2.064 2.164 2.264 2.364 2.464 2.554 2.654 2.754 2.854 2.954 3.044 3.144 3.244 3.344 3.444 3.544 3.634 3.734 3.83468 1.434 1.534 1.634 1.724 1.824 1.924 2.024 2.124 2.224 2.314 2.414 2.514 2.614 2.714 2.804 2.904 3.004 3.104 3.204 3.304 3.394 3.494 3.594 3.694 3.79470 1.394 1.484 1.584 1.684 1.784 1.884 1.984 2.074 2.174 2.274 2.374 2.474 2.564 2.664 2.764 2.864 2.964 3.064 3.154 3.254 3.354 3.454 3.554 3.654 3.74472 1.344 1.444 1.544 1.644 1.744 1.834 1.934 2.034 2.134 2.234 2.334 2.424 2.524 2.624 2.724 2.824 2.914 3.014 3.114 3.214 3.314 3.414 3.504 3.604 3.70474 1.304 1.404 1.504 1.594 1.694 1.794 1.894 1.994 2.094 2.184 2.284 2.384 2.484 2.584 2.684 2.774 2.874 2.974 3.074 3.174 3.264 3.364 3.464 3.564 3.664*FVC values are given in liters. The values listed here reflect the FVC as listed in Table 5–3a minus 0.676 L (95% confidence interval). Adapted from Crapo et al.2Table 5-3a Predicted Normal Forced Vital Capacity (FVC) in Liters for Women (BTPS)*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 3.19 3.29 3.39 3.48 3.58 3.68 3.78 3.88 3.98 4.07 4.17 4.27 4.37 4.47 4.56 4.66 4.76 4.86 4.96 5.06 5.15 5.25 5.35 5.45 5.5520 3.15 3.24 3.34 3.44 3.54 3.64 3.74 3.83 3.93 4.03 4.13 4.23 4.32 4.42 4.52 4.62 4.72 4.82 4.91 5.01 5.11 5.21 5.31 5.41 5.5022 3.10 3.20 3.30 3.40 3.50 3.59 3.69 3.79 3.89 3.99 4.09 4.18 4.28 4.38 4.48 4.58 4.67 4.77 4.87 4.97 5.07 5.17 5.26 5.36 5.4624 3.06 3.16 3.26 3.35 3.45 3.55 3.65 3.75 3.85 3.94 4.04 4.14 4.24 4.34 4.43 4.53 4.63 4.73 4.83 4.93 5.02 5.12 5.22 5.32 5.4226 3.02 3.12 3.21 3.31 3.41 3.51 3.61 3.70 3.80 3.90 4.00 4.10 4.20 4.29 4.39 4.49 4.59 4.69 4.78 4.88 4.98 5.08 5.18 5.28 5.3728 2.97 3.07 3.17 3.27 3.37 3.46 3.56 3.66 3.76 3.86 3.96 4.05 4.15 4.25 4.35 4.45 4.54 4.64 4.74 4.84 4.94 5.04 5.13 5.23 5.3330 2.93 3.03 3.13 3.23 3.32 3.42 3.52 3.62 3.72 3.81 3.91 4.01 4.11 4.21 4.31 4.40 4.50 4.60 4.70 4.80 4.89 4.99 5.09 5.19 5.2932 2.89 2.99 3.08 3.18 3.28 3.38 3.48 3.57 3.67 3.77 3.87 3.97 4.07 4.16 4.26 4.36 4.46 4.56 4.65 4.75 4.85 4.95 5.05 5.15 5.2434 2.84 2.94 3.04 3.14 3.24 3.34 3.43 3.53 3.63 3.73 3.83 3.92 4.02 4.12 4.22 4.32 4.42 4.51 4.61 4.71 4.81 4.91 5.00 5.10 5.2036 2.80 2.90 3.00 3.10 3.19 3.29 3.39 3.49 3.59 3.68 3.78 3.88 3.98 4.08 4.18 4.27 4.37 4.47 4.57 4.67 4.76 4.86 4.96 5.06 5.1638 2.76 2.86 2.95 3.05 3.15 3.25 3.35 3.45 3.54 3.64 3.74 3.84 3.94 4.03 4.13 4.23 4.33 4.43 4.53 4.62 4.72 4.82 4.92 5.02 5.1140 2.71 2.81 2.91 3.01 3.11 3.21 3.30 3.40 3.50 3.60 3.70 3.79 3.89 3.99 4.09 4.19 4.29 4.38 4.48 4.58 4.68 4.78 4.87 4.97 5.0742 2.67 2.77 2.87 2.97 3.06 3.16 3.26 3.36 3.46 3.56 3.65 3.75 3.85 3.95 4.05 4.14 4.24 4.34 4.44 4.54 4.64 4.73 4.83 4.93 5.0344 2.63 2.73 2.82 2.92 3.02 3.12 3.22 3.32 3.41 3.51 3.61 3.71 3.81 3.90 4.00 4.10 4.20 4.30 4.40 4.49 4.59 4.69 4.79 4.89 4.9846 2.58 2.68 2.78 2.88 2.98 3.08 3.17 3.27 3.37 3.47 3.57 3.67 3.76 3.86 3.96 4.06 4.16 4.25 4.35 4.45 4.55 4.65 4.75 4.84 4.9448 2.54 2.64 2.74 2.84 2.93 3.03 3.13 3.23 3.33 3.43 3.52 3.62 3.72 3.82 3.92 4.01 4.11 4.21 4.31 4.41 4.51 4.60 4.70 4.80 4.9050 2.50 2.60 2.69 2.79 2.89 2.99 3.09 3.19 3.28 3.38 3.48 3.58 3.68 3.78 3.87 3.97 4.07 4.17 4.27 4.36 4.46 4.56 4.66 4.76 4.8652 2.46 2.55 2.65 2.75 2.85 2.95 3.04 3.14 3.24 3.34 3.44 3.54 3.63 3.73 3.83 3.93 4.03 4.12 4.22 4.32 4.42 4.52 4.62 4.71 4.8154 2.41 2.51 2.61 2.71 2.80 2.90 3.00 3.10 3.20 3.30 3.39 3.49 3.59 3.69 3.79 3.89 3.98 4.08 4.18 4.28 4.38 4.47 4.57 4.67 4.7756 2.37 2.47 2.57 2.66 2.76 2.86 2.96 3.06 3.15 3.25 3.35 3.45 3.55 3.65 3.74 3.84 3.94 4.04 4.14 4.23 4.33 4.43 4.53 4.63 4.7358 2.33 2.42 2.52 2.62 2.72 2.82 2.91 3.01 3.11 3.21 3.31 3.41 3.50 3.60 3.70 3.80 3.90 4.00 4.09 4.19 4.29 4.39 4.49 4.58 4.6860 2.28 2.38 2.48 2.58 2.68 2.77 2.87 2.97 3.07 3.17 3.26 3.36 3.46 3.56 3.66 2.76 3.85 3.95 4.05 4.15 4.25 4.34 4.44 4.54 4.6462 2.24 2.34 2.44 2.53 2.63 2.73 2.83 2.93 3.02 3.12 3.22 3.32 3.42 3.52 3.61 3.71 3.81 3.91 4.01 4.11 4.20 4.30 4.40 4.50 4.6064 2.20 2.29 2.39 2.49 2.59 2.69 2.79 2.88 2.98 3.08 3.18 3.28 3.37 3.47 3.57 3.67 3.77 3.87 3.96 4.06 4.16 4.26 4.36 4.45 4.5566 2.15 2.25 2.35 2.45 2.55 2.64 2.74 2.84 2.94 3.04 3.14 3.23 3.33 3.43 3.53 3.63 3.72 3.82 3.92 4.02 4.12 4.22 4.31 4.41 4.5168 2.11 2.21 2.31 2.40 2.50 2.60 2.70 2.80 2.90 2.99 3.09 3.19 3.29 3.39 3.48 3.58 3.68 3.78 3.88 3.98 4.07 4.17 4.27 4.37 4.4770 2.07 2.16 2.26 2.36 2.46 2.56 2.66 2.75 2.85 2.95 3.05 3.15 3.24 3.34 3.44 3.54 3.64 3.74 3.83 3.93 4.03 4.13 4.23 4.33 4.4272 2.02 2.12 2.22 2.32 2.42 2.51 2.61 2.71 2.81 2.91 3.01 3.10 3.20 3.30 3.40 3.50 3.59 3.69 3.79 3.89 3.99 4.09 4.18 4.28 4.3874 1.98 2.08 2.18 2.27 2.37 2.47 2.57 2.67 2.77 2.86 2.96 3.06 3.16 3.26 3.36 3.45 3.55 3.65 3.75 3.85 3.94 4.04 4.14 4.24 4.34*FVC in liters = 0.0491 H – 0.0216 A – 3.590. R2 = 0.74; SEE = 0.393; 95% confidence interval = 0.676. Definitions of abbreviations: R2 = coefficient of determination; SEE = standard error ofestimate; H = height in cm; A = age in years. BTPS = body temperature, ambient pressure, and saturated with water vapor at these conditions. Adapted from Crapo et al.2The Respiratory System 97Chapter 5Table 5-4b Predicted Lower Limit of Normal Forced Expiratory Volume in the First Second (FEV1) for Men*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 2.578 2.658 2.738 2.818 2.908 2.988 3.068 3.148 3.238 3.318 3.398 3.488 3.568 3.648 3.728 3.818 3.898 3.978 4.068 4.148 4.228 4.308 4.398 4.478 4.55820 2.528 2.608 2.688 2.768 2.858 2.938 3.018 3.108 3.188 3.268 3.348 3.438 3.518 3.598 3.688 3.768 3.848 3.928 4.018 4.098 4.178 4.268 4.348 4.428 4.50822 2.478 2.558 2.638 2.728 2.808 2.888 2.968 3.058 3.138 3.218 3.308 3.388 3.468 3.548 3.638 3.718 3.798 3.888 3.968 4.048 4.128 4.208 4.298 4.378 4.45824 2.428 2.508 2.588 2.678 2.758 2.838 2.928 3.008 3.088 3.168 3.258 3.338 3.418 3.508 3.588 3.668 3.748 3.838 3.918 3.998 4.078 4.168 4.248 4.328 4.41826 2.378 2.458 2.548 2.628 2.708 2.788 2.878 2.958 3.038 3.128 3.208 3.288 3.368 3.458 3.538 3.618 3.698 3.788 3.868 3.948 4.038 4.058 4.198 4.278 4.36828 2.328 2.408 2.498 2.578 2.658 2.748 2.828 2.908 2.988 3.078 3.158 3.238 3.318 3.408 3.488 3.568 3.658 3.738 3.818 3.898 3.988 4.068 4.148 4.238 4.31830 2.278 2.368 2.448 2.528 2.608 2.698 2.778 2.858 2.938 3.028 3.108 3.188 3.278 3.358 3.438 3.518 3.608 3.688 3.768 3.858 3.938 4.018 4.098 4.188 4.26832 2.228 2.318 2.398 2.478 2.558 2.648 2.728 2.808 2.898 2.978 3.058 3.138 3.228 3.308 3.388 3.478 3.558 3.638 3.718 3.808 3.888 3.968 4.058 4.138 4.21834 2.178 2.268 2.348 2.428 2.518 2.598 2.678 2.758 2.848 2.928 3.008 3.098 3.178 3.258 3.338 3.428 3.508 3.588 3.678 3.758 3.838 3.918 4.008 4.088 4.16836 2.138 2.218 2.298 2.378 2.468 2.548 2.628 2.718 2.798 2.878 2.958 3.048 3.128 3.208 3.298 3.378 3.458 3.538 3.628 3.708 3.788 3.868 3.958 4.038 4.11838 2.088 2.168 2.248 2.338 2.418 2.498 2.578 2.668 2.748 2.828 2.918 2.998 3.078 3.158 3.248 3.328 3.408 3.488 3.578 3.658 3.738 3.828 3.908 3.988 4.06840 2.0382.118 2.198 2.288 2.368 2.448 2.538 2.618 2.698 2.778 2.868 2.948 3.028 3.108 3.198 3.278 3.358 3.448 3.528 3.608 3.688 3.778 3.858 3.938 4.02842 1.988 2.068 2.158 2.238 2.318 2.398 2.488 2.568 2.648 2.728 2.818 2.898 2.978 3.068 3.148 3.228 3.308 3.398 3.478 3.558 3.648 3.728 3.808 3.888 3.97844 1.938 2.018 2.108 2.188 2.268 2.348 2.438 2.518 2.598 2.688 2.768 2.848 2.928 3.018 3.098 3.178 3.268 3.348 3.428 3.508 3.598 3.678 3.758 3.848 3.92846 1.888 1.968 2.058 2.138 2.218 2.308 2.388 2.468 2.548 2.638 2.718 2.798 2.888 2.968 3.048 3.128 3.218 3.298 3.378 3.468 3.548 3.628 3.708 3.798 3.87848 1.838 1.928 2.008 2.088 2.168 2.258 2.338 2.418 2.508 2.588 2.668 2.748 2.838 2.918 2.998 3.088 3.168 3.248 3.328 3.408 3.498 3.578 3.658 3.748 3.82850 1.788 1.878 1.958 2.038 2.128 2.208 2.288 2.368 2.458 2.538 2.618 2.708 2.788 2.868 2.948 3.038 3.118 3.198 3.278 3.368 3.448 3.528 3.618 3.698 3.77852 1.748 1.828 1.908 1.988 2.078 2.158 2.238 2.328 2.408 2.488 2.568 2.658 2.738 2.818 2.898 2.988 3.068 3.148 3.238 3.318 3.398 3.478 3.568 3.648 3.72854 1.698 1.778 1.858 1.948 2.028 2.108 2.188 2.278 2.358 2.438 2.518 2.608 2.688 2.768 2.858 2.938 3.018 3.098 3.188 3.268 3.348 3.438 3.518 3.598 3.67856 1.648 1.728 1.808 1.898 1.978 2.058 2.138 2.228 2.308 2.388 2.478 2.558 2.638 2.718 2.808 2.888 2.968 3.058 3.138 3.218 3.298 3.388 3.468 3.548 3.63858 1.598 1.678 1.758 1.848 1.928 2.008 2.098 2.178 2.258 2.338 2.428 2.508 2.588 2.678 2.758 2.838 2.918 3.008 3.088 3.168 3.258 3.338 3.418 3.498 3.58860 1.548 1.628 1.708 1.798 1.878 1.958 2.048 2.128 2.208 2.298 2.378 2.458 2.538 2.628 2.708 2.788 2.878 2.958 3.038 3.118 3.208 3.288 3.368 3.448 3.53862 1.498 1.578 1.668 1.748 1.828 1.918 1.998 2.078 2.158 2.248 2.328 2.408 2.498 2.578 2.658 2.738 2.828 2.908 2.988 3.068 3.158 3.238 3.318 3.408 3.48864 1.448 1.538 1.618 1.698 1.778 1.868 1.948 2.028 2.118 2.198 2.278 2.358 2.448 2.528 2.608 2.688 2.778 2.858 2.938 3.028 3.108 3.188 3.268 3.358 3.43866 1.398 1.488 1.568 1.648 1.738 1.818 1.898 1.978 2.068 2.148 2.228 2.308 2.398 2.478 2.558 2.648 2.728 2.808 2.888 2.978 3.058 3.138 3.228 3.308 3.38868 1.358 1.438 1.518 1.598 1.688 1.768 1.848 1.928 2.018 2.098 2.178 2.268 2.348 2.428 2.508 2.598 2.678 2.758 2.848 2.928 3.008 3.088 3.178 3.258 3.33870 1.308 1.388 1.468 1.548 1.638 1.718 1.798 1.888 1.968 2.048 2.128 2.218 2.298 2.378 2.468 2.548 2.628 2.708 2.798 2.878 2.958 3.048 3.128 3.208 3.28872 1.258 1.338 1.418 1.508 1.588 1.668 1.748 1.838 1.918 1.998 2.088 2.168 2.248 2.328 2.418 2.498 2.578 2.668 2.748 2.828 2.908 2.998 3.078 3.158 3.23874 1.208 1.288 1.368 1.458 1.538 1.618 1.708 1.788 1.868 1.948 2.038 2.118 2.198 2.288 2.368 2.448 2.528 2.618 2.698 2.778 2.858 2.948 3.028 3.108 3.198*FEV1 values are given in liters. The values listed here reflect the FEV1 as listed in Table 5–4a minus 0.842 L (95% confidence interval). Adapted from Crapo et al.2Table 5-4a Predicted Normal Forced Expiratory Volume in the First Second (FEV1) in Liters for Men*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 3.42 3.50 3.58 3.66 3.75 3.83 3.91 3.99 4.08 4.16 4.24 4.33 4.41 4.49 4.57 4.66 4.74 4.82 4.91 4.99 5..07 5.15 5.24 5.32 5.4020 3.37 3.45 3.53 3.61 3.70 3.78 3.86 3.95 4.03 4.11 4.19 4.28 4.36 4.44 4.53 4.61 4.69 4.77 4.86 4.94 5.02 5.11 5.19 5.27 5.3522 3.32 3.40 3.48 3.57 3.65 3.73 3.81 3.90 3.98 4.06 4.15 4.23 4.31 4.39 4.48 4.56 4.64 4.73 4.81 4.89 4.97 5.05 5.14 5.22 5.3024 3.27 3.35 3.43 3.52 3.60 3.68 3.77 3.85 3.93 4.01 4.10 4.18 4.26 4.35 4.43 4.51 4.59 4.68 4.76 4.84 4.92 5.01 5.09 5.17 5.2626 3.22 3.30 3.39 3.47 3.55 3.63 3.72 3.80 3.88 3.97 4.05 4.13 4.21 4.30 4.38 4.46 4.54 4.63 4.71 4.79 4.88 4.90 5.04 5.12 5.2128 3.17 3.25 3.34 3.42 3.50 3.59 3.67 3.75 3.83 3.92 4.00 4.08 4.16 4.25 4.33 4.41 4.50 4.58 4.66 4.74 4.83 4.91 4.99 5.08 5.1630 3.12 3.21 3.29 3.37 3.45 3.54 3.62 3.70 3.78 3.87 3.95 4.03 4.12 4.20 4.28 4.36 4.45 4.53 4.61 4.70 4.78 4.86 4.94 5.03 5.1132 3.07 3.16 3.24 3.32 3.40 3.49 3.57 3.65 3.74 3.82 3.90 3.98 4.07 4.15 4.23 4.32 4.40 4.48 4.56 4.65 4.73 4.81 4.90 4.98 5.0634 3.02 3.11 3.19 3.27 3.36 3.44 3.52 3.60 3.69 3.77 3.85 3.94 4.02 4.10 4.18 4.27 4.35 4.43 4.52 4.60 4.68 4.76 4.85 4.93 5.0136 2.98 3.06 3.14 3.22 3.31 3.39 3.47 3.56 3.64 3.72 3.80 3.89 3.97 4.05 4.14 4.22 4.30 4.38 4.47 4.55 4.63 4.71 4.80 4.88 4.9638 2.93 3.01 3.09 3.18 3.26 3.34 3.42 3.51 3.59 3.67 3.76 3.84 3.92 4.00 4.09 4.17 4.25 4.33 4.42 4.50 4.58 4.67 4.75 4.83 4.9140 2.88 2.96 3.04 3.13 3.21 3.29 3.38 3.46 3.54 3.62 3.71 3.79 3.87 3.95 4.04 4.12 4.20 4.29 4.37 4.45 4.53 4.62 4.70 4.78 4.8742 2.83 2.91 3.00 3.08 3.16 3.24 3.33 3.41 3.49 3.57 3.66 3.74 3.82 3.91 3.99 4.07 4.15 4.24 4.32 4.40 4.49 4.57 4.65 4.73 4.8244 2.78 2.86 2.95 3.03 3.11 3.19 3.28 3.36 3.44 3.53 3.61 3.69 3.77 3.86 3.94 4.02 4.11 4.19 4.27 4.35 4.44 4.52 4.60 4.69 4.7746 2.73 2.81 2.90 2.98 3.06 3.15 3.23 3.31 3.39 3.48 3.56 3.64 3.73 3.81 3.89 3.97 4.06 4.14 4.22 4.31 4.39 4.47 4.55 4.64 4.7248 2.68 2.77 2.85 2.93 3.01 3.10 3.18 3.26 3.35 3.43 3.51 3.59 3.68 3.76 3.84 3.93 4.01 4.09 4.17 4.25 4.34 4.42 4.50 4.59 4.6750 2.63 2.72 2.80 2.88 2.97 3.05 3.13 3.21 3.30 3.38 3.46 3.55 3.63 3.71 3.79 3.88 3.96 4.04 4.12 4.21 4.29 4.37 4.46 4.54 4.6252 2.59 2.67 2.75 2.83 2.92 3.00 3.08 3.17 3.25 3.33 3.41 3.50 3.58 3.66 3.74 3.83 3.91 3.99 4.08 4.16 4.24 4.32 4.41 4.49 4.5754 2.54 2.62 2.70 2.79 2.87 2.95 3.03 3.12 3.20 3.28 3.36 3.45 3.53 3.61 3.70 3.78 3.86 3.94 4.03 4.11 4.19 4.28 4.36 4.44 4.5256 2.49 2.57 2.65 2.74 2.82 2.90 2.98 3.07 3.15 3.23 3.32 3.40 3.48 3.56 3.65 3.73 3.81 3.90 3.98 4.06 4.14 4.23 4.31 4.39 4.4858 2.44 2.52 2.60 2.69 2.77 2.85 2.94 3.02 3.10 3.18 3.27 3.35 3.43 3.52 3.60 3.68 3.76 3.85 3.93 4.01 4.10 4.18 4.26 4.34 4.4360 2.39 2.47 2.55 2.64 2.72 2.80 2.89 2.97 3.05 3.14 3.22 3.30 3.38 3.47 3.55 3.63 3.72 3.80 3.88 3.96 4.05 4.13 4.21 4.29 4.3862 2.34 2.42 2.51 2.59 2.67 2.76 2.84 2.92 3.00 3.09 3.17 3.25 3.34 3.42 3.50 3.58 3.67 3.75 3.83 3.91 4.00 4.08 4.16 4.25 4.3364 2.29 2.38 2.46 2.54 2.62 2.71 2.79 2.87 2.96 3.04 3.12 3.20 3.29 3.37 3.45 3.53 3.62 3.70 3.78 3.87 3.95 4.03 4.11 4.20 4.2866 2.24 2.33 2.41 2.49 2.58 2.66 2.74 2.82 2.91 2.99 3.07 3.15 3.24 3.32 3.40 3.49 3.57 3.65 3.73 3.82 3.90 3.98 4.07 4.15 4.2368 2.20 2.28 2.36 2.44 2.53 2.61 2.69 2.77 2.86 2.94 3.02 3.11 3.19 3.27 3.35 3.44 3.52 3.60 3.69 3.77 3.85 3.93 4.02 4.10 4.1870 2.15 2.23 2.31 2.39 2.48 2.56 2.64 2.73 2.81 2.89 2.97 3.06 3.14 3.22 3.31 3.39 3.47 3.55 3.64 3.72 3.80 3.89 3.97 4.05 4.1372 2.10 2.18 2.26 2.35 2.43 2.51 2.59 2.68 2.76 2.84 2.93 3.01 3.09 3.17 3.26 3.34 3.42 3.51 3.59 3.67 3.75 3.84 3.92 4.00 4.0874 2.05 2.13 2.21 2.30 2.38 2.46 2.55 2.63 2.71 2.79 2.88 2.96 3.04 3.13 3.21 3.29 3.37 3.46 3.54 3.62 3.70 3.79 3.87 3.95 4.04*FEV1 in liters = 0.0414 H – 0.0244 A – 2.190. R2 = 0.64; SEE = 0.486; 95% confidence interval = 0.842. Definitions of abbreviations: R2 = coefficient of determination; SEE = standard error ofestimate; H = height in cm; A = age in years. BTPS = body temperature, ambient pressure, and saturated with water vapor at these conditions. Adapted from Crapo et al.2Chapter 598 Guides to the Evaluation of Permanent ImpairmentTable 5-5b Predicted Lower Limit of Normal Forced Expiratory Volume in the First Second (FEV1) for Women*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 2.399 2.459 2.529 2.599 2.669 2.739 2.809 2.869 2.939 3.009 3.079 3.149 3.219 3.289 3.349 3.419 3.489 3.559 3.629 3.699 3.759 3.829 3.899 3.969 4.03920 2.349 2.409 2.479 2.549 2.619 2.689 2.759 2.819 2.889 2.959 3.029 3.099 3.169 3.229 3.299 3.369 3.439 3.509 3.579 3.639 3.709 3.779 3.849 3.919 3.98922 2.289 2.359 2.429 2.499 2.569 2.639 2.699 2.769 2.839 2.909 2.979 3.049 3.109 3.179 3.249 3.319 3.389 3.459 3.529 3.589 3.659 3.729 3.799 3.869 3.93924 2.239 2.309 2.379 2.449 2.519 2.589 2.649 2.719 2.789 2.859 2.929 2.9993.059 3.129 3.199 3.269 3.339 3.409 3.469 3.539 3.609 3.679 3.749 3.819 3.87926 2.189 2.259 2.329 2.399 2.469 2.529 2.599 2.669 2.739 2.809 2.879 2.939 3.009 3.079 3.149 3.219 3.289 3.349 3.419 3.489 3.559 3.629 3.699 3.769 3.82928 2.139 2.209 2.279 2.349 2.409 2.479 2.549 2.619 2.689 2.759 2.829 2.889 2.959 3.029 3.099 3.169 3.239 3.299 3.369 3.439 3.509 3.579 3.649 3.709 3.77930 2.089 2.159 2.229 2.299 2.359 2.429 2.499 2.569 2.639 2.709 2.769 2.839 2.909 2.979 3.049 3.119 3.179 3.249 3.319 3.389 3.459 3.529 3.589 3.659 3.72932 2.039 2.109 2.179 2.239 2.309 2.379 2.449 2.519 2.589 2.649 2.719 2.789 2.859 2.929 2.999 3.069 3.129 3.199 3.269 3.339 3.409 3.479 3.539 3.609 3.67934 1.989 2.059 2.119 2.189 2.259 2.329 2.399 2.469 2.539 2.599 2.669 2.739 2.809 2.879 2.949 3.009 3.079 3.149 3.219 3.289 3.359 3.419 3.489 3.559 3.62936 1.939 2.009 2.069 2.139 2.209 2.279 2.349 2.419 2.479 2.549 2.619 2.689 2.759 2.829 2.889 2.959 3.029 3.099 3.169 3.239 3.309 3.369 3.439 3.509 3.57938 1.889 1.949 2.019 2.089 2.159 2.229 2.299 2.359 2.429 2.499 2.569 2.639 2.709 2.779 2.839 2.909 2.979 3.049 3.119 3.189 3.249 3.319 3.389 3.459 3.52940 1.839 1.899 1.969 2.039 2.109 2.179 2.249 2.309 2.379 2.449 2.519 2.589 2.659 2.719 2.789 2.859 2.929 2.999 3.069 3.129 3.199 3.269 3.339 3.409 3.47942 1.779 1.849 1.919 1.989 2.059 2.129 2.189 2.259 2.329 2.399 2.469 2.539 2.609 2.669 2.739 2.809 2.879 2.949 3.019 3.079 3.149 3.219 3.289 3.359 3.42944 1.729 1.799 1.869 1.939 2.009 2.079 2.139 2.209 2.279 2.349 2.419 2.489 2.549 2.619 2.689 2.759 2.829 2.899 2.959 3.029 3.099 3.169 3.239 3.309 3.36946 1.679 1.749 1.819 1.889 1.959 2.019 2.089 2.159 2.229 2.299 2.369 2.429 2.499 2.569 2.639 2.709 2.779 2.849 2.909 2.979 3.049 3.119 3.189 3.259 3.31948 1.629 1.699 1.769 1.839 1.899 1.969 2.039 2.109 2.179 2.249 2.319 2.379 2.449 2.519 2.589 2.659 2.729 2.789 2.859 2.929 2.999 3.069 3.139 3.199 3.26950 1.579 1.649 1.719 1.789 1.849 1.919 1.989 2.059 2.129 2.199 2.259 2.329 2.399 2.469 2.539 2.609 2.669 2.739 2.809 2.879 2.949 3.019 3.089 3.149 3.21952 1.529 1.599 1.669 1.729 1.799 1.869 1.939 2.009 2.079 2.139 2.209 2.279 2.349 2.419 2.489 2.559 2.619 2.689 2.759 2.829 2.899 2.969 3.029 3.099 3.16954 1.479 1.549 1.619 1.679 1.749 1.819 1.889 1.959 2.029 2.089 2.159 2.229 3.299 2.369 2.439 2.499 2.569 2.639 2.709 2.779 2.849 2.909 2.979 3.049 3.11956 1.429 1.499 1.559 1.629 1.699 1.769 1.839 1.909 1.969 2.039 2.109 2.179 2.249 2.319 2.379 2.449 2.519 2.589 2.659 2.729 2.799 2.859 2.929 2.999 3.06958 1.379 1.439 1.509 1.579 1.649 1.719 1.789 1.859 1.919 1.989 2.059 2.129 2.199 2.269 2.329 2.399 2.469 2.539 2.609 2.679 2.739 2.809 2.879 2.949 3.01960 1.329 1.389 1.459 1.529 1.599 1.669 1.739 1.799 1.869 1.939 2.009 2.079 2.149 2.209 2.279 2.349 2.419 2.489 2.559 2.619 2.689 2.759 2.829 2.899 2.96962 1.269 1.339 1.409 1.479 1.549 1.619 1.679 1.749 1.819 1.889 1.959 2.029 2.099 2.159 2.229 2.299 2.369 2.439 2.509 2.569 2.639 2.709 2.779 2.849 2.91964 1.219 1.289 1.359 1.429 1.499 1.569 1.629 1.699 1.769 1.839 1.909 1.979 2.039 2.109 2.179 2.249 2.319 2.389 2.449 2.519 2.589 2.659 2.729 2.799 2.85966 1.169 1.239 1.309 1.379 1.449 1.509 1.579 1.649 1.719 1.789 1.859 1.919 1.989 2.059 2.129 2.199 2.269 2.339 2.399 2.469 2.539 2.609 2.679 2.749 2.80968 1.119 1.189 1.259 1.329 1.389 1.459 1.529 1.599 1.669 1.739 1.809 1.869 1.939 2.009 2.079 2.149 2.219 2.279 2.349 2.419 2.489 2.559 2.629 2.689 2.75970 1.069 1.139 1.209 1.279 1.339 1.409 1.479 1.549 1.619 1.689 1.749 1.819 1.889 1.959 2.029 2.099 2.159 2.229 2.299 2.369 2.439 2.509 2.579 2.639 2.70972 1.019 1.089 1.159 1.219 1.289 1.359 1.429 1.499 1.569 1.629 1.699 1.769 1.839 1.909 1.979 2.049 2.109 2.179 2.249 2.319 2.389 2.459 2.519 2.589 2.65974 0.969 1.039 1.109 1.169 1.239 1.309 1.379 1.449 1.519 1.579 1.649 1.719 1.789 1.859 1.929 1.989 2.059 2.129 2.199 2.269 2.339 2.399 2.469 2.539 2.609*FEV1 values are given in liters. The values listed here reflect the FEV1 as listed in Table 5–5a minus 0.561 L (95% confidence interval). Adapted from Crapo et al.2Table 5-5a Predicted Normal Forced Expiratory Volume in the First Second (FEV1) in Liters for Women*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 2.96 3.02 3.09 3.16 3.23 3.30 3.37 3.43 3.50 3.57 3.64 3.71 3.78 3.85 3.91 3.98 4.05 4.12 4.19 4.26 4.32 4.39 4.46 4.53 4.6020 2.91 2.97 3.04 3.11 3.18 3.25 3.32 3.38 3.45 3.52 3.59 3.66 3.73 3.79 3.86 3.93 4.00 4.07 4.14 4.20 4.27 4.34 4.41 4.48 4.5522 2.85 2.92 2.99 3.06 3.13 3.20 3.26 3.33 3.40 3.47 3.54 3.61 3.67 3.74 3.81 3.88 3.95 4.02 4.09 4.15 4.22 4.29 4.36 4.43 4.5024 2.80 2.87 2.94 3.01 3.08 3.15 3.21 3.28 3.35 3.42 3.49 3.56 3.62 3.69 3.76 3.83 3.90 3.97 4.03 4.10 4.17 4.24 4.31 4.38 4.4426 2.75 2.82 2.89 2.96 3.03 3.09 3.16 3.23 3.30 3.37 3.44 3.50 3.57 3.64 3.71 3.78 3.85 3.91 3.98 4.05 4.12 4.19 4.26 4.33 4.3928 2.70 2.77 2.84 2.91 2.97 3.04 3.11 3.18 3.25 3.32 3.39 3.45 3.52 3.59 3.66 3.73 3.80 3.86 3.93 4.00 4.07 4.14 4.21 4.27 4.3430 2.65 2.72 2.79 2.86 2.92 2.99 3.06 3.13 3.20 3.27 3.33 3.40 3.47 3.54 3.61 3.68 3.74 3.81 3.88 3.95 4.02 4.09 4.15 4.22 4.2932 2.60 2.67 2.74 2.80 2.87 2.94 3.01 3.08 3.15 3.21 3.28 3.35 3.42 3.49 3.56 3.63 3.69 3.76 3.83 3.90 3.97 4.04 4.10 4.17 4.2434 2.55 2.62 2.68 2.75 2.82 2.89 2.96 3.03 3.10 3.16 3.23 3.30 3.37 3.44 3.51 3.57 3.64 3.71 3.78 3.85 3.92 3.98 4.05 4.12 4.1936 2.50 2.57 2.63 2.70 2.77 2.84 2.91 2.98 3.04 3.11 3.18 3.25 3.32 3.39 3.45 3.52 3.59 3.66 3.73 3.80 3.87 3.93 4.00 4.07 4.1438 2.45 2.51 2.58 2.65 2.72 2.79 2.86 2.92 2.99 3.06 3.13 3.20 3.27 3.34 3.40 3.47 3.54 3.61 3.68 3.75 3.81 3.88 3.95 4.02 4.0940 2.40 2.46 2.53 2.60 2.67 2.74 2.81 2.87 2.94 3.01 3.08 3.15 3.22 3.28 3.35 3.42 3.49 3.56 3.63 3.69 3.76 3.83 3.90 3.97 4.0442 2.34 2.41 2.48 2.55 2.62 2.69 2.75 2.82 2.89 2.96 3.03 3.10 3.17 3.23 3.30 3.37 3.44 3.51 3.58 3.64 3.71 3.78 3.85 3.92 3.9944 2.29 2.36 2.43 2.50 2.57 2.64 2.70 2.77 2.84 2.91 2.98 3.05 3.11 3.18 3.25 3.32 3.39 3.46 3.52 3.59 3.66 3.73 3.80 3.87 3.9346 2.24 2.31 2.38 2.45 2.52 2.58 2.65 2.72 2.79 2.86 2.93 2.99 3.06 3.13 3.20 3.27 3.34 3.41 3.47 3.54 3.61 3.68 3.75 3.82 3.8848 2.19 2.26 2.33 2.40 2.46 2.53 2.60 2.67 2.74 2.81 2.88 2.94 3.01 3.08 3.15 3.22 3.29 3.35 3.42 3.49 3.56 3.63 3.70 3.76 3.8350 2.14 2.21 2.28 2.35 2.41 2.48 2.55 2.62 2.69 2.76 2.82 2.89 2.96 3.03 3.10 3.17 3.23 3.30 3.37 3.44 3.51 3.58 3.65 3.71 3.7852 2.09 2.16 2.23 2.29 2.36 2.43 2.50 2.57 2.64 2.70 2.77 2.84 2.91 2.98 3.05 3.12 3.18 3.25 3.32 3.39 3.46 3.53 3.59 3.66 3.7354 2.04 2.11 2.18 2.24 2.31 2.38 2.45 2.52 2.59 2.65 2.72 2.79 3.86 2.93 3.00 3.06 3.13 3.20 3.27 3.34 3.41 3.47 3.54 3.61 3.6856 1.99 2.06 2.12 2.19 2.26 2.33 2.40 2.47 2.53 2.60 2.67 2.74 2.81 2.88 2.94 3.01 3.08 3.15 3.22 3.29 3.36 3.42 3.49 3.56 3.6358 1.94 2.00 2.07 2.14 2.21 2.28 2.35 2.42 2.48 2.55 2.62 2.69 2.76 2.83 2.89 2.96 3.03 3.10 3.17 3.24 3.30 3.37 3.44 3.51 3.5860 1.89 1.95 2.02 2.09 2.16 2.23 2.30 2.36 2.43 2.50 2.57 2.64 2.71 2.77 2.84 2.91 2.98 3.05 3.12 3.18 3.25 3.32 3.39 3.46 3.5362 1.83 1.90 1.97 2.04 2.11 2.18 2.24 2.31 2.38 2.45 2.52 2.59 2.66 2.72 2.79 2.86 2.93 3.00 3.07 3.13 3.20 3.27 3.34 3.41 3.4864 1.78 1.85 1.92 1.99 2.06 2.13 2.19 2.26 2.33 2.40 2.47 2.54 2.60 2.67 2.74 2.81 2.88 2.95 3.01 3.08 3.15 3.22 3.29 3.36 3.4266 1.73 1.80 1.87 1.94 2.01 2.07 2.14 2.21 2.28 2.35 2.42 2.48 2.55 2.62 2.69 2.76 2.83 2.90 2.96 3.03 3.10 3.17 3.24 3.31 3.3768 1.68 1.75 1.82 1.89 1.95 2.02 2.09 2.16 2.23 2.30 2.37 2.43 2.50 2.57 2.64 2.71 2.78 2.84 2.91 2.98 3.05 3.12 3.19 3.25 3.3270 1.63 1.70 1.77 1.84 1.90 1.97 2.04 2.11 2.18 2.25 2.31 2.38 2.45 2.52 2.59 2.66 2.72 2.79 2.86 2.93 3.00 3.07 3.14 3.20 3.2772 1.58 1.65 1.72 1.78 1.85 1.92 1.99 2.06 2.13 2.19 2.26 2.33 2.40 2.47 2.54 2.61 2.67 2.74 2.81 2.88 2.95 3.02 3.08 3.15 3.2274 1.53 1.60 1.67 1.73 1.80 1.87 1.94 2.01 2.08 2.14 2.21 2.28 2.35 2.42 2.49 2.55 2.62 2.69 2.76 2.83 2.90 2.96 3.03 3.10 3.17*FEV1 in liters = 0.0342 H – 0.0225A – 1.578. R2 = 0.80; SEE = 0.326; 95% confidence interval = 0.561. Definitions of abbreviations: R2 = coefficient of determination; SEE = standard error ofestimate; H = height in cm; A = age in years. BTPS = body temperature, ambient pressure, and saturated with water vapor at these conditions. Adapted from Crapo et al.2The Respiratory System 99Chapter 5Table 5-6b Predicted Lower Limit of Normal Diffusing Capacity for Carbon Monoxide (DCO) for Men*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 21.6 22.4 23.2 24.0 24.9 25.7 26.5 27.3 28.1 28.9 29.8 30.6 31.4 32.2 3 3.0 33.9 34.7 35.5 36.3 37.2 38.0 38.8 39.6 40.4 41.220 21.1 22.0 22.8 23.6 24.4 25.2 26.1 26.9 27.7 28.5 29.3 30.2 31.0 31.8 32.6 33.4 34.3 35.1 35.9 36.7 37.5 38.4 39.2 40.0 40.822 20.7 21.5 22.4 23.2 24.0 24.8 25.6 26.5 27.3 28.1 28.9 29.7 30.6 31.4 32.2 33.0 33.8 34.7 35.5 36.3 37.1 37.9 38.8 39.6 40.424 20.3 21.1 21.9 22.8 23.6 24.4 25.2 26.0 26.9 27.7 28.5 29.3 30.1 31.0 31.8 32.6 33.4 34.2 35.1 35.9 36.7 37.5 38.3 39.2 40.026 19.9 20.7 21.5 22.3 23.2 24.0 24.8 25.6 26.4 27.3 28.1 28.9 29.7 30.5 31.4 32.2 33.0 33.8 34.6 35.5 36.3 37.1 37.9 38.7 39.628 19.5 20.3 21.1 21.9 22.7 23.6 24.4 25.2 26.0 26.8 27.7 28.5 29.3 30.1 30.9 31.8 32.6 33.4 34.2 35.0 35.9 36.7 37.5 38.3 39.130 19.0 19.9 20.7 21.5 22.3 23.1 24.0 24.8 25.6 26.4 27.2 28.1 28.9 29.7 30.5 31.4 32.2 33.0 33.8 34.6 35.4 36.3 37.1 37.9 38.732 18.6 19.4 20.3 21.1 21.9 22.7 23.5 24.4 25.2 26.0 26.8 27.6 28.5 29.3 30.1 30.9 31.7 32.6 33.4 34.2 35.0 35.9 36.7 37.5 38.334 18.2 19.0 19.9 20.7 21.5 22.3 23.1 23.9 24.8 25.6 26.4 27.2 28.0 28.9 29.7 30.5 31.3 32.2 33.0 33.8 34.6 35.4 36.2 37.1 37.936 17.8 18.6 19.4 20.2 21.1 21.9 22.7 23.5 24.3 25.2 26.0 26.8 27.6 28.4 29.3 30.1 30.9 31.7 32.5 33.4 34.2 35.0 35.8 36.6 37.538 17.4 18.2 19.0 19.8 20.6 21.5 22.3 23.1 23.9 24.7 25.6 26.4 27.2 28.0 28.8 29.7 30.5 31.3 32.1 32.9 33.8 34.6 35.4 36.2 37.040 16.9 17.8 18.6 19.4 20.2 21.0 21.9 22.7 23.5 24.3 25.1 26.0 26.8 27.6 28.4 29.2 30.1 30.9 31.7 32.5 33.3 34.2 35.0 35.8 36.642 16.5 17.3 18.2 19.0 19.8 20.6 21.4 22.3 23.1 23.9 24.7 25.5 26.4 27.2 28.0 28.8 29.6 30.5 31.3 32.1 32.9 33.7 34.6 35.4 36.244 16.1 16.9 17.7 18.6 19.4 20.2 21.0 21.8 22.7 23.5 24.3 25.1 25.9 26.8 27.6 28.4 29.2 30.0 30.9 31.7 32.5 33.3 34.1 35.0 35.846 15.7 16.5 17.3 18.1 19.0 19.8 20.6 21.4 22.2 23.1 23.9 24.7 25.5 26.4 27.2 28.0 28.8 29.6 30.4 31.3 32.1 32.9 33.7 34.5 35.448 15.3 16.1 16.9 17.7 18.5 19.4 20.2 21.0 21.8 22.6 23.5 24.3 25.1 25.9 26.7 27.6 28.4 29.2 30.0 30.9 31.7 32.5 33.3 34.1 34.950 14.9 15.7 16.5 17.3 18.1 18.9 19.8 20.6 21.4 22.2 23.0 23.9 24.7 25.5 26.3 27.2 28.0 28.8 29.6 30.4 31.2 32.1 32.9 33.7 34.552 14.4 15.2 16.1 16.9 17.7 18.5 19.4 20.2 21.0 21.8 22.6 23.4 24.3 25.1 25.9 26.7 27.5 28.4 29.2 30.0 30.8 31.7 32.5 33.4 34.154 14.0 14.8 15.6 16.5 17.3 18.1 18.9 19.7 20.6 21.4 22.2 23.0 23.8 24.7 25.5 26.3 27.1 27.9 28.8 29.6 30.4 31.2 32.0 32.9 33.756 13.6 14.4 15.2 16.0 16.9 17.7 18.5 19.3 20.1 21.0 21.8 22.6 23.4 24.2 25.1 25.9 26.7 27.5 28.3 29.2 30.0 30.8 31.6 32.4 33.358 13.2 14.0 14.8 15.6 16.4 17.3 18.1 18.9 19.7 20.5 21.4 22.2 23.0 23.8 24.6 25.5 26.3 27.1 27.9 28.7 29.6 30.4 31.2 32.0 32.860 12.7 13.6 14.4 15.2 16.0 16.8 17.7 18.5 19.3 20.1 20.9 21.8 22.6 23.4 24.2 25.0 25.9 26.7 27.5 28.3 29.1 30.0 30.8 31.6 32.462 12.3 13.1 14.0 14.8 15.6 16.4 17.2 18.1 18.9 19.7 20.5 21.3 22.2 23.0 23.8 24.6 25.4 26.3 27.1 27.9 28.7 29.5 30.4 31.2 32.064 11.9 12.7 13.5 14.4 15.2 16.0 16.8 17.6 18.5 19.3 20.1 20.9 21.7 22.6 23.4 24.2 25.0 25.9 26.7 27.5 28.3 29.1 29.9 30.8 31.666 11.5 12.3 13.1 13.9 14.8 15.6 16.4 17.2 18.0 18.9 19.7 20.5 21.3 22.2 23.0 23.8 24.6 25.4 26.2 27.1 27.9 28.7 29.5 30.4 31.268 11.1 11.9 12.7 13.5 14.4 15.2 16.0 16.8 17.6 18.4 19.3 20.1 20.9 21.7 22.5 23.4 24.2 30.0 25.8 26.7 27.5 28.3 29.1 29.9 30.770 10.6 11.5 12.3 13.1 13.9 14.7 15.6 16.4 17.2 18.0 18.8 19.7 20.5 21.3 22.1 22.9 23.8 24.6 25.4 26.2 27.0 27.9 28.7 29.5 30.372 10.2 11.0 11.9 12.7 13.5 14.3 15.1 16.0 16.8 17.6 18.4 19.2 20.1 20.9 21.7 22.5 23.3 24.2 25.0 25.8 26.6 27.4 28.3 29.1 29.974 9.8 10.6 11.4 12.3 13.1 13.9 14.7 15.5 16.4 17.2 18.0 18.8 19.6 20.5 21.3 22.1 22.9 23.7 24.6 25.4 26.2 27.0 27.8 28.7 29.5*DCO Values are given in mL/min/mm Hg. The values listed here reflect the DCO as listed in Table 5–6a minus 8.2 (95% confidence interval). Adapted from Crapo and Morris.9Table 5-6a Predicted Normal Diffusing Capacity for Carbon Monoxide (DCO) for Men (STPD)*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 29.8 30.6 31.4 32.2 33.1 33.9 34.7 35.5 36.3 37.1 38.0 38.8 39.6 40.4 41.2 42.1 42.9 43.7 44.5 45.4 46.2 47.0 47.8 48.6 49.420 29.3 30.2 31.0 31.8 32.6 33.4 34.3 35.1 35.9 36.7 37.5 38.4 39.2 40.0 40.8 41.6 42.5 43.3 44.1 44.9 45.7 46.6 47.4 48.2 49.022 28.9 29.7 30.6 31.4 32.2 33.0 33.8 34.7 35.5 36.3 37.1 37.9 38.8 39.6 40.4 41.2 42.0 42.9 43.7 44.5 45.3 46.1 47.0 47.8 48.624 28.5 29.3 30.1 31.0 31.8 32.6 33.4 34.2 35.1 35.9 36.7 37.5 38.3 39.2 40.0 40.8 41.6 42.4 43.3 44.1 44.9 45.7 46.5 47.4 48.226 28.1 28.9 29.7 30.5 31.4 32.2 33.0 33.8 34.6 35.5 36.3 37.1 37.9 38.7 39.6 40.4 41.2 42.0 42.8 43.7 44.5 45.3 46.1 46.9 47.828 27.7 28.5 29.3 30.1 30.9 31.8 32.6 33.4 34.2 35.0 35.9 36.7 37.5 38.3 39.1 40.0 40.8 41.6 42.4 43.2 44.1 44.9 45.7 46.5 47.330 27.2 28.1 28.9 29.7 30.5 31.3 32.2 33.0 33.8 34.6 35.4 36.3 37.1 37.9 38.7 39.6 40.4 41.2 42.0 42.8 43.6 44.5 45.3 46.1 46.932 26.8 27.6 28.5 29.3 30.1 30.9 31.7 32.6 33.4 34.2 35.0 35.8 36.7 37.5 38.3 39.1 39.9 40.8 41.6 42.4 43.2 44.1 44.9 45.7 46.534 26.4 27.2 28.1 28.9 29.7 30.5 31.3 32.1 33.0 33.8 34.6 35.4 36.2 37.1 37.9 38.7 39.5 40.4 41.2 42.0 42.8 43.6 44.4 45.3 46.136 26.0 26.8 27.6 28.4 29.3 30.1 30.9 31.7 32.5 33.4 34.2 35.0 35.8 36.6 37.5 38.3 39.1 39.9 40.7 41.6 42.4 43.2 44.0 44.8 45.738 25.6 26.4 27.2 28.0 28.8 29.7 30.5 31.3 32.1 32.9 33.8 34.6 35.4 36.2 37.0 37.9 38.7 39.5 40.3 41.1 42.0 42.8 43.6 44.4 45.240 25.1 26.0 26.8 27.6 28.4 29.2 30.1 30.9 31.7 32.5 33.3 34.2 35.0 35.8 36.6 37.4 38.3 39.1 39.9 40.7 41.5 42.4 43.2 44.0 44.842 24.7 25.5 26.4 27.2 28.0 28.8 29.6 30.5 31.3 32.1 32.9 33.7 34.6 35.4 36.2 37.0 37.8 38.7 39.5 40.3 41.1 41.9 42.8 43.6 44.444 24.3 25.1 25.9 26.8 27.6 28.4 29.2 30.0 30.9 31.7 32.5 33.3 34.1 35.0 35.8 36.6 37.4 38.2 39.1 39.9 40.7 41.5 42.3 43.2 44.046 23.9 24.7 25.5 26.3 27.2 28.0 28.8 29.6 30.4 31.3 32.1 32.9 33.7 34.6 35.4 36.2 37.0 37.8 38.6 39.5 40.3 41.1 41.9 42.7 43.648 23.5 24.3 25.1 25.9 26.7 27.6 28.4 29.2 30.0 30.8 31.7 32.5 33.3 34.1 34.9 35.8 36.6 37.4 38.2 39.1 39.9 40.7 41.5 42.3 43.150 23.1 23.9 24.7 25.5 26.3 27.1 28.0 28.8 29.6 30.4 31.2 32.1 32.9 33.7 34.5 35.4 36.2 37.0 37.8 38.6 39.4 40.3 41.1 41.9 42.752 22.6 23.4 24.3 25.1 25.9 26.7 27.6 28.4 29.2 30.0 30.8 31.6 32.5 33.3 34.1 34.9 35.7 36.6 37.4 38.2 39.0 39.9 40.7 41.6 42.354 22.2 23.0 23.8 24.7 25.5 26.3 27.1 27.9 28.8 29.6 30.4 31.2 32.0 32.9 33.7 34.5 35.3 36.1 37.0 37.8 38.6 39.4 40.2 41.1 41.956 21.8 22.6 23.4 24.2 25.1 25.9 26.7 27.5 28.3 29.2 30.0 30.8 31.6 32.4 33.3 34.1 34.9 35.7 36.5 37.4 38.2 39.0 39.8 40.6 41.558 21.4 22.2 23.0 23.8 24.6 25.5 26.3 27.1 27.9 28.7 29.6 30.4 31.2 32.0 32.8 33.7 34.5 35.3 36.1 36.9 37.8 38.6 39.4 40.2 41.060 20.9 21.8 22.6 23.4 24.2 25.0 25.9 26.7 27.5 28.3 29.1 30.0 30.8 31.6 32.4 33.2 34.1 34.9 35.7 36.5 37.3 38.2 39.0 39.8 40.662 20.5 21.3 22.2 23.0 23.8 24.6 25.4 26.3 27.1 27.9 28.7 29.5 30.4 31.2 32.0 32.8 33.6 34.5 35.3 36.1 36.9 37.7 38.6 39.4 40.264 20.1 20.9 21.7 22.6 23.4 24.2 25.0 25.8 26.7 27.5 28.3 29.1 29.9 30.8 31.6 32.4 33.2 34.1 34.9 35.7 36.5 37.3 38.1 39.0 39.866 19.7 20.5 21.3 22.1 23.0 23.8 24.6 25.4 26.2 27.1 27.9 28.7 29.5 30.4 31.2 32.0 32.8 33.6 34.4 35.3 36.1 36.9 37.7 38.6 39.468 19.3 20.1 20.9 21.7 22.6 23.4 24.2 25.0 25.8 26.6 27.5 28.3 29.1 29.9 30.7 31.6 32.4 38.2 34.0 34.9 35.7 36.5 37.3 38.1 38.970 18.8 19.7 20.5 21.3 22.122.9 23.8 24.6 25.4 26.2 27.0 27.9 28.7 29.5 30.3 31.1 32.0 32.8 33.6 34.4 35.2 36.1 36.9 37.7 38.572 18.4 19.2 20.1 20.9 21.7 22.5 23.3 24.2 25.0 25.8 26.6 27.4 28.3 29.1 29.9 30.7 31.5 32.4 33.2 34.0 34.8 35.6 36.5 37.3 38.174 18.0 18.8 19.6 20.5 21.3 22.1 22.9 23.7 24.6 25.4 26.2 27.0 27.8 28.7 29.5 30.3 31.1 31.9 32.8 33.6 34.4 35.2 36.0 36.9 37.7*DCO in mL/min/mm Hg = 0.410 H – 0.210 A – 26.31. R2 = 0.60; SEE = 4.82; 95% confidence interval = 8.2. Definitions of abbreviations: R2 = coefficient of determination; SEE = standard errorof estimate; H = height in cm; A = age in years. STPD = temperature 0°C, pressure 760 mm Hg, and dry (0 water vapor). The regression analysis has been normalized to a standard hemoglobinof 146 g/L by means of Cotes' modification of the relationship described by Roughton and Forster. Adapted from Crapo and Morris.9Chapter 5100 Guides to the Evaluation of Permanent ImpairmentTable 5-7b Predicted Lower Limit of Normal Diffusing Capacity for Carbon Monoxide (DCO) for Women*Age Height(cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 20.26 20.76 21.26 21.86 22.36 22.86 23.46 23.96 24.46 25.06 25.56 26.16 26.66 27.16 27.76 28.26 28.76 29.36 29.86 30.36 30.96 31.46 31.96 32.56 33.0620 19.96 20.46 20.96 21.56 22.06 22.66 23.16 23.66 24.26 24.76 25.26 25.86 26.36 26.86 27.46 27.96 28.46 29.06 29.56 30.06 30.66 31.16 31.66 32.26 32.7622 19.66 20.16 20.76 21.26 21.76 22.36 22.86 23.36 23.96 24.46 24.96 25.56 26.06 26.56 27.16 27.66 28.16 28.76 29.26 29.76 30.36 30.86 31.36 31.96 32.4624 19.36 19.86 20.46 20.96 21.46 22.06 22.56 23.06 23.66 24.16 24.66 25.26 25.76 26.26 26.86 27.36 27.86 28.46 28.96 29.46 30.06 30.56 31.06 31.66 32.1626 19.06 19.56 20.16 20.66 21.16 21.76 22.26 22.76 23.36 23.86 24.36 24.96 25.46 25.96 26.56 27.06 27.56 28.16 28.66 29.16 29.76 30.26 30.76 31.36 31.8628 18.76 19.26 19.86 20.36 20.86 21.46 21.96 22.46 23.06 23.56 24.06 24.66 25.16 25.66 26.26 26.76 27.26 27.86 28.36 28.86 29.46 29.96 30.46 31.06 31.5630 18.46 18.96 19.56 20.06 20.56 21.16 21.66 22.16 22.76 23.26 23.76 24.36 24.86 25.36 25.96 26.46 26.96 27.56 28.06 28.56 29.16 29.66 30.16 30.76 31.2632 18.16 18.66 19.26 19.76 20.26 20.86 21.36 21.86 22.46 22.96 23.46 24.06 24.56 25.06 25.66 26.16 26.66 27.26 27.76 28.36 28.86 29.36 29.96 30.46 30.9634 17.86 18.36 18.96 19.46 19.96 20.56 21.06 21.56 22.16 22.66 23.16 23.76 24.26 24.86 25.36 25.86 27.46 26.96 27.46 28.06 28.56 29.06 29.66 30.16 30.6636 17.56 18.06 18.66 19.16 19.66 20.26 20.76 21.36 21.86 22.36 22.96 23.46 23.96 24.56 25.06 25.56 26.16 26.66 27.16 27.76 28.26 28.76 29.36 29.86 30.3638 17.26 17.86 18.36 18.86 19.46 19.96 20.46 21.06 21.56 22.06 22.66 23.16 23.66 24.26 24.76 25.26 25.86 26.36 26.86 27.46 27.96 28.46 29.06 29.56 30.0640 16.96 17.56 18.06 18.56 19.16 19.66 20.16 20.76 21.26 21.76 22.36 22.86 23.36 23.96 24.46 24.96 25.56 26.06 26.56 27.16 27.66 28.16 28.76 29.26 29.7642 16.66 17.26 17.76 18.26 18.86 19.36 19.86 20.46 20.96 21.46 22.06 22.56 23.06 23.66 24.16 24.66 25.26 25.76 26.26 26.86 27.36 27.86 28.46 28.96 29.4644 16.36 16.96 17.46 17.96 18.56 18.56 19.56 20.16 20.66 21.16 21.76 22.26 22.76 23.36 23.86 24.36 24.96 25.46 25.96 26.56 27.06 27.56 28.16 28.66 29.1646 16.06 16.66 17.16 17.66 18.26 18.76 19.26 19.86 20.36 20.86 21.46 21.96 22.46 23.06 23.56 24.06 24.66 25.16 25.66 26.26 26.76 27.26 27.86 28.36 28.8648 15.76 16.36 16.86 17.36 17.96 18.46 18.96 19.56 20.06 20.56 21.16 21.66 22.16 22.76 23.26 23.76 24.36 24.86 25.36 25.96 26.46 27.06 27.56 28.06 28.6650 15.46 16.06 16.56 17.06 17.66 18.16 18.66 19.26 19.76 20.26 20.86 21.36 21.86 22.46 22.96 23.56 24.06 24.56 25.16 25.66 26.16 26.76 27.26 27.76 28.3652 15.16 15.76 16.26 16.76 17.36 17.76 18.36 18.96 19.46 20.06 20.56 21.06 21.66 22.16 22.66 23.26 23.76 24.26 24.86 25.36 25.86 26.46 26.96 27.46 28.0654 14.86 15.46 15.96 16.56 17.06 17.56 18.16 18.66 19.16 19.76 20.26 20.76 21.36 21.86 22.36 22.96 23.46 23.96 24.56 25.06 25.56 26.16 26.66 27.16 27.7656 14.66 15.16 15.66 16.26 16.76 17.26 17.86 18.36 18.86 19.46 19.96 20.46 21.06 21.56 22.06 22.66 23.16 23.66 24.26 24.76 25.26 25.86 26.36 26.86 27.4658 14.36 14.86 15.36 15.96 16.46 16.96 17.56 18.06 18.56 19.16 19.66 20.16 20.76 21.26 21.76 22.36 22.86 23.36 23.96 24.46 24.96 25.56 26.06 26.56 27.1660 14.06 14.56 15.06 15.66 16.16 16.66 17.26 17.76 18.26 18.86 19.36 19.86 20.46 20.96 21.46 22.06 22.56 23.06 23.66 24.16 24.66 25.26 25.76 26.26 26.8662 13.76 14.26 14.76 15.36 15.86 16.36 16.96 17.46 17.96 18.56 19.06 19.56 20.16 20.66 21.16 21.76 22.26 22.76 23.36 23.86 24.36 24.96 25.46 25.96 26.5664 13.46 13.96 14.46 15.06 15.56 16.06 16.66 17.16 17.66 18.26 18.76 19.26 19.86 20.36 20.86 21.46 21.96 22.46 23.06 23.56 24.06 24.66 25.16 25.76 26.2666 13.16 13.66 14.16 14.76 15.26 15.76 16.36 16.86 17.36 17.96 18.46 18.36 19.56 20.06 20.56 21.16 21.66 22.26 22.76 23.26 23.86 24.36 24.86 25.46 25.9668 12.86 13.36 13.86 14.46 14.96 15.46 16.06 16.56 17.06 17.66 18.16 18.76 19.26 19.76 20.36 20.86 21.36 21.96 22.46 22.96 23.56 24.06 24.56 25.16 25.6670 12.56 13.06 13.56 14.16 14.66 15.26 15.76 16.26 16.86 17.36 17.76 18.46 18.96 19.46 20.06 20.56 21.06 21.66 22.16 22.66 23.26 23.76 24.26 24.86 25.3672 12.26 12.76 13.36 13.86 14.36 14.96 15.46 15.36 16.56 17.06 17.56 18.16 18.66 19.16 19.76 20.26 20.76 21.36 21.86 22.36 22.96 23.46 23.96 24.56 25.0674 11.96 12.46 13.06 13.56 14.06 14.66 15.16 15.66 16.26 16.76 17.26 17.86 18.36 18.86 19.46 19.96 20.46 21.06 21.56 22.06 22.66 23.16 23.66 24.26 24.76*DCO Values are given in mL/min/mm Hg. The values listed here reflect the DCO as listed in Table 5–7a minus 5.74 (95% confidence interval). Adapted from Crapo and Morris.9Table 5-7a Predicted Normal Diffusing Capacity for Carbon Monoxide (DCO) for Women (STPD)*Age Height (cm)146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 19418 26.0 26.5 27.0 27.6 28.1 28.6 29.2 29.7 30.2 30.8 31.3 31.9 32.4 32.9 33.5 34.0 34.5 35.1 35.6 36.1 36.7 37.2 37.7 38.3 38.820 25.7 26.2 26.7 27.3 27.8 28.4 28.9 29.4 30.0 30.5 31.0 31.6 32.1 32.6 33.2 33.7 34.2 34.8 35.3 35.8 36.4 36.9 37.4 38.0 38.522 25.4 25.9 26.5 27.0 27.5 28.1 28.6 29.1 29.7 30.2 30.7 31.3 31.8 32.3 32.9 33.4 33.9 34.5 35.0 35.5 36.1 36.6 37.1 37.7 38.224 25.1 25.6 26.2 26.7 27.2 27.8 28.3 28.8 29.4 29.9 30.4 31.0 31.5 32.0 32.6 33.1 33.6 34.2 34.7 35.2 35.8 36.3 36.8 37.4 37.926 24.8 25.3 25.9 26.4 26.9 27.5 28.0 28.5 29.1 29.6 30.1 30.7 31.2 31.7 32.3 32.8 33.3 33.9 34.4 34.9 35.5 36.0 36.5 37.1 37.628 24.5 25.0 25.6 26.1 26.6 27.2 27.7 28.2 28.8 29.3 29.8 30.4 30.9 31.4 32.0 32.5 33.0 33.6 34.1 34.6 35.2 35.7 36.2 36.8 37.330 24.2 24.7 25.3 25.8 26.3 26.9 27.4 27.9 28.5 29.0 29.5 30.1 30.6 31.1 31.7 32.2 32.7 33.3 33.8 34.3 34.9 35.4 35.9 36.5 37.032 23.9 24.4 25.0 25.5 26.0 26.6 27.1 27.6 28.2 28.7 29.2 29.8 30.3 30.8 31.4 31.9 32.4 33.0 33.5 34.1 34.6 35.1 35.7 36.2 36.734 23.6 24.1 24.7 25.2 25.7 26.3 26.8 27.3 27.9 28.4 28.9 29.5 30.0 30.6 31.1 31.6 33.2 32.7 33.2 33.8 34.3 34.8 35.4 35.9 36.436 23.3 23.8 24.4 24.9 25.4 26.0 26.5 27.1 27.6 28.1 28.7 29.2 29.7 30.3 30.8 31.3 31.9 32.4 32.9 33.5 34.0 34.5 35.1 35.6 36.138 23.0 23.6 24.1 24.6 25.2 25.7 26.2 26.8 27.3 27.8 28.4 28.9 29.4 30.0 30.5 31.0 31.6 32.1 32.6 33.2 33.7 34.2 34.8 35.3 35.840 22.7 23.3 23.8 24.3 24.9 25.4 25.9 26.5 27.0 27.5 28.1 28.6 29.1 29.7 30.2 30.7 31.3 31.8 32.3 32.9 33.4 33.9 34.5 35.0 35.542 22.4 23.0 23.5 24.0 24.6 25.1 25.6 26.2 26.7 27.2 27.8 28.3 28.8 29.4 29.9 30.4 31.0 31.5 32.0 32.6 33.1 33.6 34.2 34.7 35.244 22.1 22.7 23.2 23.7 24.3 24.3 25.3 25.9 26.4 26.9 27.5 28.0 28.5 29.1 29.6 30.1 30.7 31.2 31.7 32.3 32.8 33.3 33.9 34.4 34.946 21.8 22.4 22.9 23.4 24.0 24.5 25.0 25.6 26.1 26.6 27.2 27.7 28.2 28.8 29.3 29.8 30.4 30.9 31.4 32.0 32.5 33.0 33.6 34.1 34.648 21.5 22.1 22.6 23.1 23.7 24.2 24.7 25.3 25.8 26.3 26.9 27.4 27.9 28.5 29.0 29.5 30.1 30.6 31.1 31.7 32.2 32.8 33.3 33.8 34.450 21.2 21.8 22.322.8 23.4 23.9 24.4 25.0 25.5 26.0 26.6 27.1 27.6 28.2 28.7 29.3 29.8 30.3 30.9 31.4 31.9 32.5 33.0 33.5 34.152 20.9 21.5 22.0 22.5 23.1 23.5 24.1 24.7 25.2 25.8 26.3 26.8 27.4 27.9 28.4 29.0 29.5 30.0 30.6 31.1 31.6 32.2 32.7 33.2 33.854 20.6 21.2 21.7 22.3 22.8 23.3 23.9 24.4 24.9 25.5 26.0 26.5 27.1 27.6 28.1 28.7 29.2 29.7 30.3 30.8 31.3 31.9 32.4 32.9 33.556 20.4 20.9 21.4 22.0 22.5 23.0 23.6 24.1 24.6 25.2 25.7 26.2 26.8 27.3 27.8 28.4 28.9 29.4 30.0 30.5 31.0 31.6 32.1 32.6 33.258 20.1 20.6 21.1 21.7 22.2 22.7 23.3 23.8 24.3 24.9 25.4 25.9 26.5 27.0 27.5 28.1 28.6 29.1 29.7 30.2 30.7 31.3 31.8 32.3 32.960 19.8 20.3 20.8 21.4 21.9 22.4 23.0 23.5 24.0 24.6 25.1 25.6 26.2 26.7 27.2 27.8 28.3 28.8 29.4 29.9 30.4 31.0 31.5 32.0 32.662 19.5 20.0 20.5 21.1 21.6 22.1 22.7 23.2 23.7 24.3 24.8 25.3 25.9 26.4 26.9 27.5 28.0 28.5 29.1 29.6 30.1 30.7 31.2 31.7 32.364 19.2 19.7 20.2 20.8 21.3 21.8 22.4 22.9 23.4 24.0 24.5 25.0 25.6 26.1 26.6 27.2 27.7 28.2 28.8 29.3 29.8 30.4 30.9 31.5 32.066 18.9 19.4 19.9 20.5 21.0 21.5 22.1 22.6 23.1 23.7 24.2 24.1 25.3 25.8 26.3 26.9 27.4 28.0 28.5 29.0 29.6 30.1 30.6 31.2 31.768 18.6 19.1 19.6 20.2 20.7 21.2 21.8 22.3 22.8 23.4 23.9 24.5 25.0 25.5 26.1 26.6 27.1 27.7 28.2 28.7 29.3 29.8 30.3 30.9 31.470 18.3 18.8 19.3 19.9 20.4 21.0 21.5 22.0 22.6 23.1 23.5 24.2 24.7 25.2 25.8 26.3 26.8 27.4 27.9 28.4 29.0 29.5 30.0 30.6 31.172 18.0 18.5 19.1 19.6 20.1 20.7 21.2 21.1 22.3 22.8 23.3 23.9 24.4 24.9 25.5 26.0 26.5 27.1 27.6 28.1 28.7 29.2 29.7 30.3 30.874 17.7 18.2 18.8 19.3 19.8 20.4 20.9 21.4 22.0 22.5 23.0 23.6 24.1 24.6 25.2 25.7 26.2 26.8 27.3 27.8 28.4 28.9 29.4 30.0 30.5*DCO is mL/min/mm Hg = 0.267 H – 0.148 A – 10.34. R2 = 0.60; SEE = 3.40; 95% confidence interval = 5.74. Definitions of abbreviations: R2 = coefficient of determination; SEE = standarderror of estimate; H = height in cm; A = age in years. STPD = temperature 0°C, pressure 760 mm Hg, and dry (0 water vapor). The regression analysis has been normalized to a standardhemoglobin of 125 g/L (the original equation was normalized to a standard hemoglobin of 146 g/L) by means of Cotes' modification of the relationship described in Roughton and Forster.Adapted from Crapo and Morris.95.4f Cardiopulmonary Exercise TestingCardiopulmonary exercise testing is sometimes use-ful in assessing whether an individual’s complaint ofdyspnea (see Table 5-1) is a result of respiratory orother conditions. A person’s cardiac and conditioningstatus must be considered in performing the test andin interpreting the results.The cardiopulmonary exercise gas-exchange meas-urement can be an additional means of assessing theseverity and cause of exercise intolerance.Simultaneous measurement of carbon dioxide (CO2)production, minute ventilation, and heart rate allowsdetermination of whether exercise capacity limitationis due to cardiac, pulmonary, or coexisting impair-ments. When properly performed and interpreted,these tests can help differentiate pulmonary impair-ment from cardiac impairment or physical decondi-tioning effects.24Exercise capacity is measured by oxygen consump-tion per unit time (V̇O2) in milliliters per kilogram mul-tiplied by minutes (mL/[kg•min]) or in metabolicequivalents (METS), a unit of expended energy equalto 3.5 mL/(kg•min) oxygen consumption. MET is dis-cussed in Chapter 3 in the sections on the heart andaorta. Generally, an individual can sustain a work levelequal to 40% of his or her measured maximum V̇O2 foran 8-hour period.25 Table 5-8 shows the relationshipbetween work intensity and oxygen consumption.Use cardiopulmonary exercise testing judiciouslysince these studies can be difficult to perform, aremore expensive, and are sometimes more invasivethan conventional tests. Ordinarily, exercise capacitymeasurements are not used to study individuals withnormal results on routine pulmonary function tests.However, they can be helpful when the results ofpulmonary function tests do not correlate with theindividual’s symptoms or when additional informa-tion is needed to clarify the nature and severity of animpairment.27 Do not use exercise capacity measure-ments to study individuals with medical contraindi-cations such as unstable cardiac disease.Arterial Blood Gas AnalysisBecause of its invasive nature, use arterial blood gasanalysis only when necessary to evaluate pulmonaryimpairment. Arterial blood gas analysis results maybe outside the normal range for reasons other thanpulmonary disease. For most individuals withobstructive lung disease, exercise capacity correlatesbetter with FEV1 than arterial partial pressure of oxy-gen (PO2). For purposes of evaluating permanentimpairment, hypoxia must be measured on two sepa-rate occasions at least 4 weeks apart.Pulse oximetry, which is less invasive than arterialblood gas, often provides an adequate estimate ofhypoxia. Arterial blood gases, although more inva-sive, provide a more accurate measurement ofhypoxia. Physicians should use their clinical judg-ment as to which measurement is needed, based onindividual assessment.An arterial blood gas determination may indicate thepresence of severe impairment even when a person’scondition is stable and he or she is receiving optimaltherapy. An arterial PO2 of less than 55 mm Hg is evi-dence of severe impairment when an individual isexamined at rest while breathing room air at sealevel. Severe impairment may also be diagnosed with an arterial PO2 of less than 60 mm Hg if the person also has one or more of the following condi-tions: pulmonary hypertension, cor pulmonale,increasingly severe hypoxia during exercise testing,or erythrocytosis.5.4g Criteria for Rating Impairment Due to Respiratory DiseaseTable 5-12 presents criteria for estimating the perma-nent impairment rating for different respiratory con-ditions, discussed below. Perform spirometry andDCO on each person being evaluated.3 V̇O2max mayprovide additional information in selected individualswhen indicated. The person must meet all of thelisted criteria except for V̇O2max in order to be con-sidered nonimpaired. At least one of the listed criteriamust be fulfilled to place an individual in any classwith an impairment rating. As discussed in Chapter 1,in individuals where the preinjury or preillness valuesdiffer from the population-listed values, the examinerThe Respiratory System 101Chapter 5Table 5-8 Impairment Classification for ProlongedPhysical Work Intensity by Oxygen Consumption*Work Intensity Oxygen Excess for 70-kg Consumption Energy Person* ExpenditureLight work 7 mL/kg; 0.5 L/min 30 mL/kg; > 2.0 L/min > 8 METS*Adapted from Astrand and Rodahl.26 mL/kg indicates milliliter per kilogram; L/min, literper minute; and METS, metabolic equivalents (multiples of resting oxygen uptake).Chapter 5may depart from the population-listed normal valuesfor determining an impairment rating, using thepreinjury and preillness “normal” value, and explainthe reason for the departure.5.5 AsthmaAsthma is an airway inflammatory disease character-ized by episodic and variable airflow limitation andairway hyperresponsiveness. A diagnosis of asthmarequires relevant symptoms (eg, cough, sputum,wheeze, chest tightness, or breathlessness) and eitherevidence of airflow obstruction that is partially orcompletely reversible (either spontaneously or aftertreatment) or airway reactivity to methacholine orhistamine in the absence of airflow limitation.10Variable airflow obstruction can be detected withpulmonary function testing, which shows a reversibleobstructive airway pattern. Airway hyperresponsive-ness is detected by bronchial challenge testing withmethacholine or histamine.28 Airway hyperrespon-siveness is defined as a positive methacholine orhistamine challenge, as reflected by a decrease inFEV1 of 20% (PC20) from baseline, upon provocationwith less than or equal to 8 mg/mL of methacholineor histamine using the tidal breathing method or itsequivalent.1,18 The results from methacholine testingshould be expressed as the provocation concentrationto cause a fall in FEV1 of 20% (PC20).While different varieties of asthma exist, they allshare an underlying commonality of airway hyper-responsiveness. Occupational asthma represents aspecial subset of asthma subjects. This abnormalityhas now surpassed pneumoconiosis as the mostcommonly reported occupational lung diseaselinked to a particular occupational environment oragent. Besides directly causing occupational asthma,work exposures can acutely exacerbate an underly-ing asthmatic condition, which can subsequentlyreturn to preexposure baseline status with removalfrom exposure. Work exposures can also cause amore permanent change in an underlying asthmaticcondition, which can persist even after removal from exposure. If an individual’s asthma is worsen-ing at work, it is important to remove the individualfrom exposure or, at a minimum, reduce exposureand reevaluate his or her condition when it has stabilized. Although prevention is optimal, medica-tion can substantially modify symptoms and theclinical course of asthma.Occupational asthma can be caused by sensitizers orirritants. Sensitizers are classified as either high molec-ular weight or low molecular weight. High-molecular-weight sensitizers of animal or plant origin includeanimal dander or grain dust. Low-molecular-weightsensitizers, typically organic or inorganic chemicals,include diisocyanates. Sensitizers generally require alatency period for the development of immunologicresponsiveness. This latency period may last from afew weeks to several years after first exposure.29In the case of sensitizer-induced asthma (such astoluene diisocyanate or latex), there is a potential forsevere exacerbation or fatality upon reexposure.Although many individuals with occupationalasthma improve after removal from exposure toeither low-molecular-weight or high-molecular-weight sensitizers, more than half fail to recovercompletely, even after 2 or more years since the lastexposure. Those who are sensitized to occupationalagents ideally should discontinue further exposure.Both the individual and his or her physician need tomonitor the course of asthmatic symptoms, espe-cially if ongoing exposure occurs. Many can be iden-tified as having a particular type of asthma. For thosewho have allergic asthma, exercise-induced and irri-tant-induced components may be identified as well.Irritant-induced asthma, known as reactive airwaysdysfunction syndrome (RADS), may result from asingle high-level exposure to a highly irritating gas,fume, mist, or vapor. The diagnosis of RADSrequires (1) inhalation exposure to an acutely irritat-ing concentration of a substance, (2) onset of symp-toms (cough, wheezing cough, or dyspnea) within 24hours after exposure with persistent respiratorysymptoms, and (3) functional abnormalities (airwayhyperresponsiveness) for more than 3 months, withno preexisting respiratory disease.30Irritant-induced asthma often improves with time;some people may resume their former employment.However, some individuals experience persistent res-piratory impairment. Individual assessment is impor-tant because reducing the degree and duration ofexposure may control symptoms in some people, butcomplete removal from exposure may be necessaryto control symptoms in others.102 Guides to the Evaluation of Permanent ImpairmentOccupational and nonoccupational asthma impair-ment evaluations follow the same guidelines. Bothrequire a thorough review of current occupationaland home environments and the likelihood of similarexposures in subsequent workplaces. When assessingimpairment due to asthma, information is neededfrom both clinical and physiologic parameters. TheAMA recommends that the examiner follow ATSguidelines when assessing asthma impairment andinclude measurements of pulmonary mechanics,airway hyperresponsiveness, and medication require-ments.1 Table 5-9 lists the criteria for impairmentevaluation for asthma severity. The examiner evalu-ates the indices listed, including the minimum med-ication needed to control the individual’s asthma.Before performing an impairment rating for asthma,the examiner needs to determine that the pattern ofasthma is clinically stable and well treated, basedupon fulfilling the objectives of treatment as detailedby the expert panel report of the National AsthmaEducation Program.18,31 The objectives of treatmentare: (1) to achieve control or the best overall results(least symptoms, least need for ß-adrenergic agonistswhen taken only if required, best expiratory flowrates, least diurnal variation of flow rates, and leastside effects from medication); (2) to use the mini-mum amount of medication to maintain control orthe best overall results; and (3) to treat exacerbationsearly to prevent them from becoming severe.In 1993, the ATS developed guidelines for the evalu-ation of impairment and/or disability in individualswith asthma.1 According to the ATS statement,asthma necessitated special guidelines because of itsdistinct features, including: (1) variable airflowobstruction and change in clinical status over time;(2) partial or complete reversibility of airflowobstruction with therapy; (3) nonspecific airwayhyperresponsiveness to irritants such as dusts, gases,fumes, or smoke; and (4) sensitization to occupa-tional agents producing airway inflammation thatwith repeated exposure may become chronic andirreversible.In assessing an individual with suspected asthma, ifthe prebronchodilator FEV1 is above the lower limitof normal, use methacholine challenge to assess air-way responsiveness. The degree of airway hyper-responsiveness and scoring are illustrated in Table5-9. If the prebronchodilator FEV1 is below the lower limit of normal, the degree of reversibility isassessed with inhaled bronchodilators (see Table 5-9for scoring).To perform the evaluation at a state of maximal med-ical improvement, choose the optimal drug treatmentto minimize symptoms. The type and extent of nec-essary medication is one measure of impairmentseverity (see Table 5-9 for scoring). Use of medica-tion, as a score for impairment, is only used in indi-viduals who have a diagnosis of asthma.The scores for postbronchodilator FEV1, reversibilityof FEV1 (or PC20), and medication use are added toobtain a summary score for respiratory impairment(see Table 5-10). ATS criteria do not assign impair-ment percentages. If an impairment percentage isneeded, refer to Table 5-10, which assigns impair-ment classes and percentages to an asthma score. Theauthors of this chapter have assigned these impair-ment percentages according to the ATS criteria, basedon their clinical judgment. In determining the percentimpairment for a particular class, the examiner needsto consider how the person’s asthma affects the abil-ity to perform activities of daily living.The Respiratory System 103Chapter 5Chapter 5104 Guides to the Evaluation of Permanent ImpairmentTable 5-9 Impairment Classification for Asthma Severity*PC20 mg/mL or EquivalentPostbronchodilator % of FEV1 Change (Degree of AirwayScore FEV1 (Reversibility) or Hyperresponsiveness)† Minimum Medication‡0 ≥ lower limit of normal 8 mg/mL No medication1 ≥ 70% 10%-19% 8 mg/mL to Occasional but not daily bronchodilator and/or of predicted > 0.6 mg/mL occasional but not daily cromolyn2 60%-69% 20%-29% 0.6 mg/mL to Daily bronchodilator and/or daily cromolyn and/orof predicted > 0.125mg/mL daily low-dose inhaled corticosteroid (≤ 800 µg ofbeclomethasone or equivalent)3 50%-59% ≥ 30% ≤ 0.125 mg/mL Bronchodilator on demand and daily high-doseof predicted inhaled corticosteroid (>800 µg of beclomethasone orequivalent) or occasional course (one to three courses a year) of systemic corticosteroid4 1000 µg of beclomethasoneor equivalent) and daily or every other day systemiccorticosteroid*FEV1 indicates forced expiratory volume in the first second; PC20 is the provocative concentration that causes a 20% fall in FEV1. Add the scores for postbronchodilator FEV1, reversibility ofFEV1 (or PC20), and medication use to obtain a summary severity score for rating respiratory impairment.†When FEV1 is greater than the lower limit of normal, PC20 should be determined and used for rating of impairment; when FEV1 is less than 70% of the predicted, the degree of reversibilityshould be used; and when FEV1 is between 70% of the predicted and the lower limit of normal, either reversibility or PC20 can be used. The score for minimum medication use is added to theappropriate measurement criteria outlined above.‡Need for minimum medication should be demonstrated by the treating physician, for example, through previous records of exacerbation when medications have been reduced. Adapted fromATS guidelines.1Table 5-10 Impairment Rating for Asthma*Impairment% Impairment of the Whole Total Asthma Score Class Person0 1 0%1-5 2 10%-25%6-9 3 26%-50%10-11 or asthma not 4 51%-100%controlled despite maximal treatment, ie, FEV1 remaining 20 mg/day of prednisone*The impairment rating is calculated as the sum of the individual’s scores from Table 5-9.FEV1 indicates forced expiratory volume in the first second.5.6 Obstructive SleepApneaIndividuals with obstructive sleep apnea experienceintermittent, repetitive occlusions of the upper air-way during sleep, when the pharyngeal muscles arerelaxed. These occlusion periods produce airflowcessation at the nose and mouth that leads to progres-sive hypoxia, which then causes arousal from sleep.The affected person awakens briefly and reestab-lishes airway patency, resuming airflow with a loudsnore or snorting sound. Because of recurrent awak-enings during the night, there is disrupted sleeparchitecture, without restful sleep. Symptoms ofsleep apnea include a history of loud snoring, unsat-isfactory sleep pattern, daytime somnolence, cogni-tive dysfunction, and hypertension. Between 60%and 90% are obese and may have a large neck cir-cumference. When the disorder is severe, erythrocy-tosis, pulmonary hypertension, and cor pulmonalemay result.Even if total occlusion of the upper airway does notoccur during sleep, partial obstruction can lead to sig-nificant reduction in airflow and produce obstructivehypopnea, which causes oxyhemoglobin saturationreduction and similar clinical and physiologic abnor-malities as seen in obstructive sleep apnea.A variant of obstructive sleep apnea is the obesityhypoventilation syndrome. The weight of the chestwall in morbidly obese individuals may limit respira-tory movements during sleep and wakefulness. As aresult, both hypoxia and hypercapnia persist through-out the day as well as during sleep. The same physio-logic consequences occur in these individuals as inthose with obstructive sleep apnea. In fact, obstruc-tive sleep apnea and obesity hypoventilation syn-drome may coexist in the same person.People affected by obstructive sleep apnea are at sig-nificantly increased risk of being involved in motorvehicle collisions. Severe daytime somnolence mayprevent them from functioning adequately. Subtlechanges in neuropsychological function includememory abnormalities and worsened motor coordina-tion and mood that may affect the person’s daily life.A diagnosis of obstructive sleep apnea is confirmedby nocturnal polysomnography in an accreditedsleep laboratory. Once the diagnosis has been estab-lished, prescribe continuous positive airway pressure(CPAP) through a nasal device for use during sleepto maintain upper airway patency. Weight loss is themost effective means of long-term management anda possible cure for obstructive sleep apnea if a lowerbody mass index can be maintained.32Grading obstructive sleep apnea severity depends onthe number of apnea/hypopnea episodes observed inpolysomnography and the severity of hypoxia causedby these episodes. There are no standard, well-documented criteria for determining the level ofimpairment based on the results of polysomnography.For purposes of impairment rating as discussed in thischapter, refer to the judgment of a sleep specialist.5.7 HypersensitivityPneumonitisHypersensitivity pneumonitis, also known as extrin-sic allergic alveolitis, is a granulomatous interstitialand bronchiolar lung disease caused by immune sen-sitization to organic dusts and some low-molecular-weight chemical antigens. A wide variety ofantigenic substances are known to cause this disease.The acute disease is characterized by the onset ofrespiratory and constitutional symptoms beginning 4 to 8 hours after exposure to the offending material.Symptoms include chest tightness, cough, dyspnea,fever, chills, malaise, and myalgias. Pulmonary func-tion tests in the acute phase of the disease show vol-ume restriction and decreased diffusing capacity.Hypoxia may be demonstrated by pulse oximetry orarterial blood gas testing. Chest radiographs may benormal but often show diffuse micronodular changesin the pulmonary parenchyma. When the person isremoved from exposure, the symptoms, physiologicchanges, and chest radiographic abnormalities beginto resolve within 1 to 2 days, although they may take4 to 6 weeks for complete resolution.In the subacute and chronic presentations of hyper-sensitivity pneumonitis, the predominant symptomsinclude exertional dyspnea and cough; some reportsputum production, anorexia, fatigue, and weightloss. Pulmonary function studies often show mixedrestriction and obstruction with isolated obstructivechanges in some individuals. With repeated expo-sures, pulmonary fibrotic changes may occur as theabnormalities become chronic and irreversible.33The Respiratory System 105Chapter 5Chapter 5Permanently restrict individuals with hypersensitiv-ity pneumonitis from exposure to the sensitizingagent. If pulmonary fibrosis has not supervened, nor-mal pulmonary function may be reestablished.However, the onset of pulmonary fibrosis is likely toproduce respiratory impairment and may limit othertypes of employment. Once the acute episode hasresolved and the condition is stable, the examinermay rate the degree of permanent impairmentaccording to the criteria given in Table 5-12.Asthma, pneumoconiosis, and hypersensitivity pneu-monitis may require that the person refrain fromworking in a specific occupational setting where he orshe is exposed to the offending agent. If reassignedwhere no ongoing exposure occurs, the individualmay not have a permanent respiratory impairment.5.8 PneumoconiosisPneumoconiosis is a term used to describe diseasesresulting from the inhalation of mineral dusts such assilica, coal, and asbestos, and metals such as cobaltand beryllium. The radiologic and pathologic pat-terns of pneumoconiosis from these dusts are usuallyquite distinct and beyond the scope of this chapter.Latency between exposure to these dusts and devel-opment of disease varies, but disease can occur any-where from 10 up to 30 years after initial exposure.34The severity of impairment related to pneumoconiosisdepends on the characteristics of the specific dustinhaled, the dust burden retained in the lungs, the sus-ceptibility of the individual, and the length of timesince first exposure. Under some circumstances, theparenchymal changes on chest radiograph may beprogressive even after removal from exposure andmay or may not be associated with physiologicimpairment. Persons who developother independent, measurableabnormalities, are generally not given separateimpairment ratings. Chronic pain is discussed inChapter 18. Physicians recognize the local and dis-tant pain that commonly accompanies many disor-ders. Impairment ratings in the Guides already haveaccounted for commonly associated pain, includingthat which may be experienced in areas distant to thespecific site of pathology. For example, when a cer-vical spine disorder produces radiating pain downthe arm, the arm pain, which is commonly seen,has been accounted for in the cervical spine impair-ment rating.The Guides does not deny the existence or impor-tance of these subjective complaints to the individualor their functional impact. The Guides recommendsthat the physician ascertain and document subjectiveconcerns. Because the presence and severity of sub-jective concerns varies among individuals with thesame condition, the Guides has not yet identified anaccepted method within the scientific literature toascertain how these concerns consistently affectorgan or body system functioning. The physician isencouraged to discuss these concerns and symptomsin the impairment evaluation.Research is limited on the reproducibility and validity of the Guides.18-20 Anecdotal reports indicatethat adoption of the Guides results in a more stan-dardized impairment assessment process. As relevantresearch becomes available, subsequent editions ofthe Guides will incorporate these evidence-basedstudies to improve the Guides’ reliability and validity.10 Guides to the Evaluation of Permanent ImpairmentChapter 1Given the range, evolution, and discovery of newmedical conditions, the Guides cannot provide animpairment rating for all impairments. Also, sincesome medical syndromes are poorly understood andare manifested only by subjective symptoms, impair-ment ratings are not provided for those conditions.The Guides nonetheless provides a framework forevaluating new or complex conditions. Most adultconditions with measurable impairments can be eval-uated under the Guides. In situations where impair-ment ratings are not provided, the Guides suggeststhat physicians use clinical judgment, comparingmeasurable impairment resulting from the unlistedcondition to measurable impairment resulting fromsimilar conditions with similar impairment of func-tion in performing activities of daily living.The physician’s judgment, based upon experience,training, skill, thoroughness in clinical evaluation,and ability to apply the Guides criteria as intended,will enable an appropriate and reproducible assess-ment to be made of clinical impairment. Clinicaljudgment, combining both the “art” and “science” ofmedicine, constitutes the essence of medical practice.1.6 Causation,ApportionmentAnalysis, andAggravation1.6a CausationPhysicians may be asked to provide an opinion aboutthe likelihood that a particular factor (injury, illness,or preexisiting condition) caused the permanentimpairment. Determining causation is importantfrom a legal perspective, as it is a factor in determin-ing liability.The term causation has multiple meanings.Dorland’s Illustrated Medical Dictionary lists 12different types of “cause” including constitutional,exciting, immediate, local, precipitating, predispos-ing, primary, proximate, remote, secondary, specific,and ultimate.21 For purposes of the Guides, causationmeans an identifiable factor (eg, accident or expo-sure to hazards of a disease) that results in a med-ically identifiable condition.Medical or scientifically based causation requires adetailed analysis of whether the factor could havecaused the condition, based upon scientific evidenceand, specifically, experienced judgment as towhether the alleged factor in the existing environ-ment did cause the permanent impairment.22Determining medical causation requires a synthesisof medical judgment with scientific analysis.The legal standard for causation in civil litigationand in workers’ compensation adjudication variesfrom jurisdiction to jurisdiction.23 The physicianneeds to be aware of the different interpretations ofcausation and state the context in which the physi-cian’s opinion is being offered.1.6b Apportionment AnalysisApportionment analysis in workers’ compensationrepresents a distribution or allocation of causationamong multiple factors that caused or significantlycontributed to the injury or disease and resultingimpairment. The factor could be a preexisting injury,illness, or impairment. In some instances, the physi-cian may be asked to apportion or distribute a perma-nent impairment rating between the impact of thecurrent injury and the prior impairment rating. Beforedetermining apportionment, the physician needs toverify that all the following information is true for an individual:1. There is documentation of a prior factor.2. The current permanent impairment is greater as aresult of the prior factor (ie, prior impairment,prior injury, or illness).3. There is evidence indicating the prior factorcaused or contributed to the impairment, based ona reasonable probability (> 50% likelihood).Philosophy, Purpose, and Appropriate Use of the Guides 11Chapter 1The apportionment analysis must consider the natureof the impairment and its possible relationship toeach alleged factor, and it must provide an explana-tion of the medical basis for all conclusions andopinions. Most states have their own customizedmethods for calculating apportionment. Generally,the most recent permanent impairment rating is cal-culated, and then the prior impairment rating is cal-culated and deducted. The remaining impairmentrating would be attributed or apportioned to the cur-rent injury or condition.A common verbal formulation in the workers’ com-pensation context might state, “in cases of permanentdisability less than total, if the degree of disabilityresulting from an industrial injury or occupationaldisease is increased or prolonged because of a pre-existing physical impairment, the employer shall beliable only for the additional disability from theinjury or occupational disease.” 5For example, in apportioning a spine impairment rating in an individual with a history of a spine con-dition, one should calculate the current spine impair-ment. Then calculate the impairment from anypreexisting spine problem. The preexisting impair-ment rating is then subtracted from the presentimpairment rating to account for the effects of theformer. This approach requires accurate and compa-rable data for both impairments.231.6c AggravationAggravation, for the purposes of the Guides, refersto a factor(s) (eg, physical, chemical, biological, ormedical condition) that alters the course or progres-sion of the medical impairment. For example, anindividual develops low back pain and sciatica asso-ciated with the finding of an L3-L4 herniated disk.Symptoms continue but are intermittent and do notinterfere with performing activities of daily living. Afew years later, the individual twists his body whilelifting a heavy package and develops constant,severe, acute low back pain and sciatica. Imagingstudies show no change in the herniated disk com-pared to earlier studies. The lifting is considered tohave aggravated a preexisting condition.Terms such as causation, apportionment, and aggravation may all have unique legal definitions inthe context of the system in which they are used. Thephysician is advised to compare these definitionswith terminology accepted by the appropriate state orsystem.1.7 Use of the GuidesBecause of the scope, depth, standardized approach,and foundation in science and medical consensus,the Guides is used worldwide to estimate adult per-manent impairment. A survey completed in 1999indicates that in the United States, 40 of 51 jurisdic-tions (50 states and the District of Columbia) use theGuides in workers’ compensationpneumoconiosisshould limit further exposure to the offending agent,particularly if radiographic changes have occurred ata relatively young age or if there is associated physio-logic impairment. However, these individuals may becapable of working at other jobs where the offendingdust is not present. See Table 5-12 for criteria forassessment of impairment due to pneumoconiosis.5.9 Lung CancerAll persons with lung cancer are severely impaired atdiagnosis. At reevaluation 1 year after the diagnosisis established, if the person is found to be free of allevidence of tumor recurrence, then he or she is eval-uated according to criteria listed in Table 5-12. Ifthere is still evidence of tumor, the he or she is con-sidered to be severely impaired (class 4 impairment);if the tumor recurs, the person will also be consid-ered to be severely impaired (class 4 impairment).Table 5-11 (the Karnofsky scale), specifically devel-oped to describe the capabilities of individuals withcancer, may be used to further describe the capabili-ties of a person with lung cancer and enable catego-rization within a particular class.106 Guides to the Evaluation of Permanent ImpairmentTable 5-11 Scale for Judging Capabilities of SubjectsWith Cancer*Grade Description0 Fully active; able to carry on all predisease activities with-out restrictions1 Restricted in physically strenuous activity but ambulatoryand able to carry out light tasks, such as light work inhome or office2 Requires occasional to considerable care for most needsand frequent medical care3 Capable only of limited self-care and confined to bed orchair at least half of waking hours4 Almost totally impaired; cannot care for self, and totallyconfined to bed or chairAdapted from Moossa et al.355.10 PermanentImpairment Due to RespiratoryDisordersTable 5-12 lists criteria for estimating the permanentimpairment rating due to respiratory disorders, usingpulmonary function and exercise test results.Perform spirometry and DCO on each person beingevaluated.3 V̇O2max may provide additional informa-tion in selected individuals when indicated.Determine the predicted values for FVC, FEV1, andDCO using Tables 5-2a through 5-7a, and calculatethe percent predicted (observed/predicted value).Determine the lower limit of normal for FVC, FEV1,and DCO using Tables 5-2b through 5-7b. The personmust meet all of the listed criteria except for V̇O2maxin order to be considered nonimpaired. At least oneof the listed criteria must be fulfilled to place an indi-vidual in any class with an impairment rating. Asdiscussed in Chapter 1, in individuals where thepreinjury or preillness values differ from the popula-tion-listed values, the examiner may depart from thepopulation-listed normal values for determining animpairment rating, using the preinjury and preillness“normal” value, and explain the reason for the departure.The classification system in Table 5-12 considersonly pulmonary function measurements for animpairment rating. It is recognized that pulmonaryimpairment can occur that does not significantlyimpact pulmonary function and exercise test resultsbut that does impact the ability to perform activitiesof daily living, such as with bronchiectasis.In these limited cases, the physician may assign animpairment rating based on the extent and severity ofpulmonary dysfunction and the inability to performactivities of daily living (see Table 1-2). Measuredlosses of pulmonary function, and correspondingimpairment classes, result in a loss in the ability toperform some activities of daily living. The physi-cian can use these associations as a reference. Adetailed description with supporting, objective docu-mentation of the type of pulmonary impairment andits impact on the ability to perform activities of dailyliving is required. The Respiratory System 107Chapter 5Table 5-12 Impairment Classification for Respiratory Disorders, Using Pulmonary Function and Exercise Test Results*Class 1 Class 2 Class 3 Class 4Pulmonary 0% Impairment 10%-25% Impairment 26%-50% Impairment 51%-100% Impairment Function Test of the Whole Person of the Whole Person of the Whole Person of the Whole PersonFVC Measured FVC ≥ lower ≥ 60% of predicted and ≥ 51% and ≤ 59% ≤ 50% of predictedlimit of normal (see 7.1 METS 5.7-7.1 METS 4.3 tocases because ofstatute or regulations, or by administrative/legalpractice.24The Guides is formally accepted through adoptivelanguage in each jurisdiction’s statutes (laws passedby a state legislature or the US Congress), court-made law (case law or precedent), or administrativeagency regulation (rules promulgated by administra-tive agencies such as a state workers’ compensationboard). It is this statutory, judicial, or regulatoryadoptive language that determines which edition ofthe Guides is mandated in a particular jurisdiction.Some states, such as Oregon and Florida, have devel-oped their own impairment criteria, modeled on theconcepts and material in the Guides. The Guides isalso extensively used by the federal systems, eg,FECA (Federal Employees’ Compensation Act). Themost recent edition of the Guides is recommended asthe latest blend of science and medical consensus.Beyond the United States, the Guides is used inCanada, Australia, New Zealand, South Africa, andEuropean countries for different applications, includ-ing workers’ compensation, personal injury, and dis-ability claim management. There is a growinginternational trend to adopt a standardized, medicallyaccepted approach to impairment assessment such asin the Guides. As previously stated, the Guides is notto be used for direct financial awards nor as the solemeasure of disability. The Guides provides a stan-dard medical assessment for impairment determina-tion and may be used as a component in disabilityassessment.12 Guides to the Evaluation of Permanent ImpairmentChapter 11.8 ImpairmentEvaluations inWorkers’CompensationIn the United States, workers’ compensation is a no-fault system for providing cash benefits, medicalcare, and rehabilitation services to individuals withwork-related injuries and diseases. All 50 states andthe District of Columbia have workers’ compensationacts. Most acts share similar features, although notwo are exactly alike. An employee normally mustexperience a “personal injury by accident arising outof and in the course of employment” to be eligiblefor benefits. All states provide benefits for workerswith occupational diseases, but that coverage isrestricted in many states. The claimant receives pay-ments to compensate for lost wages due to temporarytotal, temporary partial, permanent total, and perma-nent partial disability. Survivors receive death bene-fits. For each category of benefits, the stateprescribes a maximum and minimum weekly benefit.Many states stipulate partial compensation for a par-tial loss, based upon a proportion of the number ofweeks’ compensation allowed for total loss of thebody part.25 Determining eligibility of benefits andthe extent of disability is specified by statute andcase law.Because schedules usually do not cover all condi-tions arising from injuries, many laws allow orrequire that, in unlisted cases of permanent disability,the jurisdiction must determine the percentage bywhich the “whole man” or “industrial use” of theemployee’s body was impaired. The board, commis-sion, or court also must consider the nature of theinjury and the employee’s occupation, experience,training, and age and then award proportional com-pensation. Medical information is essential for thedecision process in these cases.Physicians who perform impairment and/or disabilityassessments for workers’ compensation purposesneed to identify the state workers’ compensation lawthat applies to the situation, which is usually the statewhere the incident occurred. The physician needs todetermine which edition of the Guides or other stateguidelines are required for these assessments. Thisinformation can usually be obtained from the stateworkers’ compensation board or the state medicalsociety. If the Guides is recommended or required,copies may be ordered through the AMA (see copy-right page) or other vendors.Unfortunately, there is no validated formula thatassigns accurate weights to determine how a medicalcondition can be combined with other factors,including education, skill, and the like, to calculatethe effect of the medical impairment on futureemployment. Therefore, each commissioner or hear-ing official bases a decision on the assessment of theavailable medical and nonmedical information. TheGuides may help resolve such a situation, but it can-not provide complete and definitive answers. Eachadministrative or legal system that bases disabilityratings on permanent impairment defines its ownprocess of converting impairment ratings into a dis-ability rating that reflects the degree to which theimpairment limits the capacity to meet personal,social, occupational, and other demands, or to meetstatutory requirements. The Guides is a tool for eval-uation of permanent impairment.26, 27Impairment percentages derived from the Guidescriteria should not be used as direct estimates ofdisability. Impairment percentages estimate theextent of the impairment on whole person func-tioning and account for basic activities of dailyliving, not including work. The complexity ofwork activities requires individual analyses.Impairment assessment is a necessary first stepfor determining disability.1.9 EmployabilityDeterminationsPhysicians with the appropriate skills, training, andknowledge may address some of the implications ofthe medical impairment toward work disability andfuture employment. The physician may be askedwhether an impaired individual can return to work ina particular job. The employer can provide a detailedjob analysis, with the actual and anticipated essentialrequirements of the job and a review of the workenvironment, including potential hazards and theneed for personal protective equipment. The physi-cian can then determine whether the individual’sabilities match the job demands. The physician needsto determine that the individual, in performing essen-tial job functions, will not either be endangered orendanger colleagues or the work environment. Forexample, it would be unsafe for an individual with anew, unstable seizure disorder to operate mechanicalequipment. The physician and other responsible per-sons should keep in mind the potential for impair-ment aggravation, as well as the possibility ofPhilosophy, Purpose, and Appropriate Use of the Guides 13Chapter 1changing an individual’s job responsibilities. After reviewing all the necessary information, thephysician may then make an objective and repro-ducible assessment of the ability of the individual tosafely perform the essential functions of the job.More complicated are the cases in which the physi-cian is requested to make a broad judgment regard-ing an individual’s ability to return to any job in hisor her field. A decision of this scope usually requiresinput from medical and nonmedical experts, such asvocational specialists, and the evaluation of both sta-ble and changing factors, such as the person’s educa-tion, skills, and motivation, the state of the jobmarket, and local economic considerations.Physicians who follow the procedures outlined in theGuides, who review the same information from med-ical and employment records, and who examine thesame patient with a stable condition should obtainapproximately the same findings.1.10 Railroad andMaritime WorkersState workers’ compensation laws are not the onlymeans by which employees are compensated forinjuries or illnesses. In 1908, Congress passed theFederal Employer’ s Liability Act (FELA), which putin place a comprehensive injury compensation sys-tem for railroad workers. FELA provides a modifiedtort system for injured railroad workers, and it super-sedes state workers’ compensation laws. The JonesAct, passed in 1920, covers compensation for mar-itime workers injured due to a ship owner’s negli-gence. That law provides for the same rights andremedies that were extended through FELA.A lawsuit filed under FELAmust be based on therailroad’s negligence in providing the employee witha safe workplace. An injured employee must provethat the railroad should have foreseen that a condi-tion or activity might cause the injury or disease. Thetest determines whether the employer’s negligenceplayed any part in producing the injury. Recoverableamounts include those for necessary medicalexpenses, pain and suffering, loss of past earnings,and future losses due to diminished earning capacity.An important condition for recovery is that a physi-cian must diagnose the effects of the injury.Under FELA, all cases must go before a jury orjudge, and there are no limits to the amount awarded.In contrast, the awards under state workers’ compen-sation systems are fixed and limited. Under FELA,the jury decides on the degree of the injured person’sdisability. The physician is obligated to obtain a reli-able history, confirm past employment by obtainingrecords, and collect all available medical information.1.11 The Physician’sRole Based on theAmericans withDisabilities Act(ADA)Physicians, particularly occupational physicians, arefrequently asked questions pertaining to work dis-ability and capacity, in light of increasing attention tocompliance with the Americans with DisabilitiesAct (ADA). The ADA is a civil rights law thatPresident Bush signed in 1990.28 It was intended “toprovide a clear and comprehensive national mandateto end discrimination against individuals with dis-abilities and bring those individuals into the eco-nomic and social mainstream of American life.”18Under the ADA, individuals with disabilities are pro-tected against discrimination in such diverse areas asemployment, government service entitlement, andaccess to public accommodations (eg, health careservices, lodging).The ADA defines disability as a physical or mentalimpairment that substantially limits one or more ofthe major life activities of an individual; a record ofimpairment; or being regarded as having an impair-ment (see Table 1-1). A person needs to meet onlyone of the three criteria in the definition to gain theADA’s protection against discrimination. The physi-cian’s input often is essential for determining the firsttwo criteria and valuable for determining the third.14 Guides to the Evaluation of Permanent ImpairmentChapter 1To be deemed “disabled” for purposes of ADA pro-tection, an individual generally must have a physicalor mental impairment that substantially limits one ormore major life activities. A “physical or mentalimpairment” could be any mental, psychological, orphysiological disorder or condition, cosmetic disfig-urement, or anatomical loss that affects one or moreof the following body systems: neurologic, specialsense organs, musculoskeletal, respiratory (includingspeech organs), reproductive, cardiovascular, hema-tologic and lymphatic, digestive, genitourinary, skin,and endocrine.29Conditions that are temporary or not considered tobe severe (eg, normal pregnancy) are not consideredimpairments under the ADA. Other nonimpairmentsinclude features and conditions such as hair or eyecolor, left-handedness, old age, sexual orientation,exhibitionism, pedophilia, voyeurism, sexual addic-tion, kleptomania, pyromania, compulsive gambling,gender identity disorders not resulting from physicalimpairment, smoking, and current illegal drug use orresulting psychoactive disorders.On June 23, 1999, in answer to a case seeking refine-ment of the definition of “who is disabled” under theADA, the Supreme Court stated that individuals whofunction normally with aids such as glasses or med-ication could not generally be considered disabled,despite their physical impairments.30To have the protection of the ADA, a physical ormental impairment must substantially limit the abil-ity to perform a “major life activity.” Major lifeactivities include “basic activities that the averageperson in the general population can perform withlittle or no difficulty,” including caring for oneself,manual tasks, hearing, walking, learning, speaking,breathing, working, and reproduction. Major lifeactivities do not have to occur frequently or be partof daily life.31 Note that the major life activities listedhere include work, unlike the Guides’ impairmentcriteria.The person must be presently, or perceived to be (notpotentially or hypothetically), substantially limited inorder to demonstrate a disability. It is difficult todetermine if an impairment “substantially limits” amajor life activity. An impairment’s nature, extent,duration, impact, and effect on the individual are allconsiderations in assessing the “substantiality” of thelimitations.32For some major life activities, such as work, thephysician may provide an opinion on the medicalimpairment’s limitations. However, as indicated bythe recent Supreme Court ruling, how much a limita-tion of a major life activity results in a determinationof disability depends on the interaction between theremaining functional abilities and the possible typesof accommodation being sought.33The third criterion that may establish protectionunder the ADA is an erroneous perception that theindividual is substantially limited in a major lifeactivity or is being discriminated against on the basisof a real or perceived characteristic that does not sub-stantially limit a major life activity.It is the physician’s responsibility to determine if theimpairment results in functional limitations. Thephysician is responsible for informing the employerabout an individual’s abilities and limitations. It isthe employer’s responsibility to identify and deter-mine if reasonable accommodations are possible toenable the individual’s performance of essential jobactivities.1.12 SummaryThe purpose of this chapter is to discuss the philo-sophical assumptions and appropriate use of theGuides. The physician needs to comply with pre-scribed local, state, and federal practices for impair-ment evaluations. Generally, the physician evaluatesall available information and provides as comprehen-sive a medical picture of the patient as possible,addressing the components listed in the Report ofMedical Evaluation form discussed in Chapter 2. A complete impairment evaluation provides valuableinformation beyond an impairment percentage, and itincludes a discussion about the person’s abilities andlimitations, including the ability to perform commonactivities as listed in Table 1-2. Combining the med-ical and nonmedical information, and includingdetailed information about essential work activities ifrequested, is a basis for improved understanding ofthe degree to which the impairment may affect theindividual’s work ability.Philosophy, Purpose, and Appropriate Use of the Guides 15Chapter 1References1. American Medical Association. Glossary. In: Guides tothe Evaluation of Permanent Impairment. Chicago, Ill:American Medical Association; 1971.2. American Medical Association. Guides to the Evaluationof Permanent Impairment. 4th ed. Chicago, Ill: AmericanMedical Association; 1993.3. Berkowitz M, Burton J. Permanent Disability Benefits inWorkers’ Compensation. Kalamazoo, Mich: UpjohnInstitute for Employment Research; 1987.4. Cocchiarella L, Deitchman M, Nielsen N. Establishingdisability in various stages of HIV infection. Report of theCouncil on Scientific Affairs, American MedicalAssociation. Paper presented at: Interim Meeting of theAmerican Medical Association House of Delegates;December 1999; Chicago, Ill. Approved.5. Idaho Code Section 406(1).6. American Medical Association. Guides to the Evaluationof Permanent Impairment. 2nd ed. Chicago, Ill: AmericanMedical Association; 1984.7. McDowell I, Newell C. Measuring Health: A Guide toRating Scales and Questionnaires. 2nd ed. New York, NY:Oxford University Press; 1996.8. McWhinnie JR. Disability assessment in population sur-veys: resultsof the OECD common development effort.Rev Epidemiol Sante Publique. 1981;29:413-419.9. Fries JF, Spitz PW, Young DY. The dimensions of healthoutcomes: the Health Assessment Questionnaire, disabil-ity and pain scales. J Rheumatol. 1982;9:789-793.10. Hamilton BB, Granger CV, Sherwin FS, et al. A uniformnational data system for medical rehabilitation. In: FuhrerMJ, ed. Rehabilitation Outcomes: Analysis and Measurement. Baltimore, Md: Paul H. Brooks;1987:137-147.11. Mahoney FI, Wood OH, Barthel DW. Rehabilitation ofchronically ill patients: the influence of complications onthe final goal. South Med J. 1958;51:605-609.12. Katz S, Akpom CA. A measure of primary sociobiologicalfunctions. Int J Health Serv 1976;6:493-507.13. Forer SK. Revised Functional Status Rating Instrument.Glendale, Calif: Rehabilitation Institute, GlendaleAdventist Medical Center; December 1981.14. Fillenbaum GG. Multidimensional Functional Assessmentof Older Adults: The Duke Older Americans Resourcesand Services Procedures. Hillsdale, NJ: LawrenceErlbaum Associates; 1988.15. Stewart AL, Kamberg CJ. Physical functioning measures.In: Stewart AL, Ware JE Jr, eds. Measuring Functioningand Well-being: The Medical Outcomes Study Approach.Durham, NC: Duke University Press; 1992:86-101.16. Brandt EN Jr, Pope AM. Enabling America: Assessing theRole of Rehabilitation Science and Engineering.Washington, DC: National Academy Press; 1997.17. World Health Organization. ICIDH: InternationalClassification of Impairments, Activities andParticipation: A Manual of Dimensions of Disablementand Health. (Beta-2 Draft). Available at:http://www.who.org/msa/mnh/ems/icidh/introduction.htm. Accessed October 7, 1999.18. Gloss DS, Wardle MG. Reliability and validity ofAmerican Medical Association’s Guide to Ratings ofPermanent Impairment. JAMA.1982;248:2292-2296.19. Rondinelli RD, Dunn W, Hassanein KM, et al. A simula-tion of hand impairments: effects on upper extremityfunction and implications towards medical impairmentrating and disability determination. Arch Phys MedRehabil. 1997;78:1358-1363.20. McCarthy ML, et al. Correlation between the measures ofimpairment, according to the modified system of theAmerican Medical Association, and function. J Bone JointSurg Am. 1998;80(7):1034-1042.21. Dorland’s Illustrated Medical Dictionary, 28th ed.Philadelpha, Pa: WB Saunders; 1994.22. Rothman KJ, ed. Modern Epidemiology. 2nd ed.Philadelphia, Pa: Lippincott-Williams and Wilkins; 1998.23. The Industrial Commission of Utah. Utah’s 1997Impairment Guides. Salt Lake City, Utah: The IndustrialCommission of Utah; 199724. Barth PS, Niss M. Permanent Partial Disability Benefits:Interstate Differences: Workers Compensation ResearchInstitute; 1999.25. Bunn WB, Berté AP. The role of the physician in theworker’s compensation process. In: Hadler NM, BunnWB, eds. Occupational Problems in Medical Practice.New York, NY: Medical Publications, Inc; 1990:133-144.26. Spieler EA, Barth PS, Burton JF Jr, Himmelstein J,Rudolph L. Recommendations to guide revision of theGuides to the Evaluation of Permanent Impairment.JAMA. 2000;283:519-523.27. Cocchiarella L, Turk MA, Andersson G. Improving theevaluation of permanent impairment. JAMA. 2000;283:532-533.28. Americans with Disabilities Act, HR Rep No. 101-485,pt 3, at 23 (1990), reprinted in 1990 USCCN 445, 446.29. 29 CFR 1630.2(h)(1)(1997); HR Rep No. 101-485, pt 3,at 28 (1990), reprinted in 1990 USCCN 445, 450.30. Sutton v United Airlines, 97 US 1943 (1999).31. Interpretive Guidance on Title One, ADA, 29 CFR App1630.2.32. 29 CFR 1630.2 (j) (2).33. American Medical Association in Cooperation with theAmerican Academy of Physical Medicine andRehabilitation. The Americans with Disabilities Act: APractice of Accommodation. Chicago, Ill: AmericanMedical Association; 1998.16 Guides to the Evaluation of Permanent ImpairmentChapter 1Chapter 2172.1 Defining Impairment Evaluations2.2 Who Performs Impairment Evaluations?2.3 Examiners’ Roles and Responsibilities2.4 When Are Impairment Ratings Performed?2.5 Rules for Evaluation2.6 Preparing ReportsIntroductionThis chapter describes how to use the Guides forconsistent and reliable acquisition, analysis, commu-nication, and utilization of medical informationthrough a single set of standards. Two physicians,following the methods of the Guides to evaluate thesame patient, should report similar results and reachsimilar conclusions. Moreover, if the clinical find-ings are fully described, any knowledgeable observermay check the findings with the Guides criteria. Thischapter provides information about the practicalapplication of the Guides and is to be used in con-junction with Chapter 1, which provides the concep-tual framework upon which the instructions in thischapter are based.Practical Application of the GuidesChapter 2Chapter 22.1 DefiningImpairmentEvaluationsAn impairment evaluation is a medical evaluationperformed by a physician, using a standard methodas outlined in the Guides to determine permanentimpairment associated with a medical condition. Animpairment evaluation may include a numericalimpairment percentage or rating, as defined in theGuides. An impairment evaluation is not the same asan independent medical evaluation (IME), whichis performed by an independent medical examinerwho evaluates but does not provide care for the indi-vidual. Impairment evaluations may be less compre-hensive than IMEs and may be performed by atreating physician or a nontreating physician,depending upon the state’s requirements and thepreferences of the individual, physician, and request-ing party. Examples of an impairment evaluation andcomponents of a comprehensive IME will be dis-cussed later in this chapter.2.2 Who PerformsImpairmentEvaluations?Impairment evaluations are performed by a licensedphysician. The physician may use information fromother sources, such as hearing results obtained fromaudiometry by a certified technician. However, thephysician is responsible for performing a medicalevaluation that addresses medical impairment in thebody or organ system and related systems. A statemay restrict the type of practitioner allowed to per-form an impairment evaluation, and some requireadditional state certification and other criteria, suchas a minimum number of hours of practice, beforethe physician is approved as an impairment evalua-tor. The physician is encouraged to check with thelocal workers’ compensation agency, industrial acci-dent board, or industrial commission concerningtheir prerequisites.2.3 Examiners’ Rolesand ResponsibilitiesThe physician’s role in performing an impairmentevaluation is to provide an independent, unbiasedassessment of the individual’s medical condition,including its effect on function, and identify abilitiesand limitations to performing activities of daily liv-ing as listed in Table 1-2. Performing an impairmentevaluation requires considerable medical expertiseand judgment. Full and complete reporting providesthe best opportunity for physicians to explain healthstatus and consequences to patients, other medicalprofessionals, and other interested parties such asclaims examiners and attorneys. Thorough documen-tation of medical findings and their impact will alsoensure that reporting is fair and consistent and thatindividuals have the information needed to pursueany benefits to which they are entitled.The skills required for impairment evaluation areusually not taught during basic medical training,although some specialties such as occupational med-icine, physical medicine and rehabilitation, andorthopedics have emphasized elements of the evalua-tion such as occupational, functional, or anatomicalassessment.In some cases, physicians may be asked to assess themedical impairment’s impact on the individual’sability to work. In the latter case, physiciansneed tounderstand the essential functions of the occupationand specific job, as well as how the medical condi-tion interacts with the occupational demands. Inmany cases, the physician may need to obtain addi-tional expertise to define functional abilities and lim-itations, as well as vocational demands.As an impairment evaluator, the physician has theresponsibility to understand the regulations that per-tain to medical practice in his or her specific area, asin workers’ compensation or personal injury evalua-tions. It is also the responsibility of the physician toprovide the necessary medical assessment to theparty requesting the evaluation, with the examinee’sconsent. The physician needs to ensure that theexaminee understands that the evaluation’s purposeis medical assessment, not medical treatment.However, if new diagnoses are discovered, the physi-cian has a medical obligation to inform the request-ing party and individual about the condition andrecommend further medical assessment.18 Guides to the Evaluation of Permanent ImpairmentChapter 22.4 When AreImpairment RatingsPerformed?An impairment should not be considered permanentuntil the clinical findings indicate that the medicalcondition is static and well stabilized, often termedthe date of maximal medical improvement (MMI).It is understood that an individual’s condition isdynamic. Maximal medical improvement refers to adate from which further recovery or deterioration isnot anticipated, although over time there may besome expected change. Once an impairment hasreached MMI, a permanent impairment rating may beperformed. The Guides attempts to take into accountall relevant considerations in rating the severity andextent of permanent impairment and its effect on theindividual’s activities of daily living. Impairments often involve more than one body sys-tem or organ system; the same condition may be dis-cussed in more than one chapter. Generally, the organsystem where the problems originate or where thedysfunction is greatest is the chapter to be used forevaluating the impairment. Thus, consult the visionchapter for visual problems due to optic nerve dys-function. Refer to the extremity chapters for neuro-logical and musculoskeletal extremity impairmentfrom an injury. However, if the impairment is due to astroke, the neurology chapter is most appropriate.Whenever the same impairment is discussed in differ-ent chapters, the Guides tries to use consistent impair-ment ratings across the different organ systems.2.5 Rules for Evaluation2.5a ConfidentialityPrior to performing an impairment evaluation, thephysician obtains the individual’s consent to sharethe medical information with other parties that willbe reviewing the evaluation. If the evaluating physi-cian is also that person’s treating physician, thephysician needs to indicate to the individual whichinformation from his or her medical record will be shared.2.5b Combining Impairment RatingsTo determine whole person impairment, the physi-cian should begin with an estimate of the individual’smost significant (primary) impairment and evaluateother impairments in relation to it. It may be neces-sary for the physician to refer to the criteria and esti-mates in several chapters if the impairing conditioninvolves several organ systems. Related but separateconditions are rated separately and impairment rat-ings are combined unless criteria for the secondimpairment are included in the primary impairment.For example, an individual with an injury causingneurologic and muscular impairment to his upperextremity would be evaluated under the upperextremity criteria in Chapter 16. Any skin impairmentdue to significant scarring would be rated separatelyin the skin chapter and combined with the impairmentfrom the upper extremity chapter. Loss of nerve func-tion would be rated within either the musculoskeletalchapters or neurology chapter.In the case of two significant yet unrelated condi-tions, each impairment rating is calculated sepa-rately, converted or expressed as a whole personimpairment, then combined using the CombinedValues Chart (p. 604). The general philosophy of theCombined Values Chart is discussed in Chapter 1.2.5c ConsistencyConsistency tests are designed to ensure reproducibil-ity and greater accuracy. These measurements, suchas one that checks the individual’s lumbosacral spinerange of motion (Section 15.9) are good but imperfectindicators of people’s efforts. The physician must usethe entire range of clinical skill and judgment whenassessing whether or not the measurements or testsresults are plausible and consistent with the impair-ment being evaluated. If, in spite of an observation ortest result, the medical evidence appears insufficientto verify that an impairment of a certain magnitudeexists, the physician may modify the impairment rating accordingly and then describe and explain thereason for the modification in writing.Practical Application of the Guides 19Chapter 22.5d Interpolating, Measuring, andRounding OffIn deciding where to place an individual’s impair-ment rating within a range, the physician needs toconsider all the criteria applicable to the condition,which includes performing activities of daily living,and estimate the degree to which the medical impair-ment interferes with these activities. In some cases,the physician may need additional information todetermine where to place an individual in the range.As with any biological measurements, some variabil-ity and normal fluctuations are inherent in permanentimpairment ratings. Two measurements made by thesame examiner using the Guides that involve an indi-vidual or an individual’s functions would be consis-tent if they fall within 10% of each other.Measurements should also be consistent betweentwo trained observers or by one observer on two sep-arate occasions, assuming the individual’s conditionis stable. Repeating measurements may decreaseerror and result in a measurement that is closer toaverage function. The final calculated whole personimpairment rating, whether it is based on the evalua-tion of one organ system or several organ systems,should be rounded to the nearest whole number.2.5e PainThe impairment ratings in the body organ systemchapters make allowance for any accompanyingpain. Chronic pain, also called chronic pain syn-drome, is discussed in the chapter on pain (Chapter 18).2.5f Using Assistive Devices in EvaluationsIf an individual’s prosthesis or assistive device canbe removed or its use eliminated relatively easily, thephysician should usually test and evaluate the organsystem without the device. For example, ask thepatient to remove a hearing aid before testing audi-tory acuity. The examiner may choose also to test thesystem with the assistive device in place and thenreport both sets of results. The physician may alsochoose to report alterations in the individual’s organfunction with and without use of the device and chal-lenges that are posed by using the device, if any.If the assistive device is not easily removable, aswith an implanted lens, evaluate the organ system’sfunctioning with the device in place. Test the visualsystem with the patient’s glasses or contact lenses inplace if they are used.2.5g Adjustments for Effects of Treatmentor Lack of TreatmentIn certain instances, the treatment of an illness mayresult in apparently total remission of the person’ssigns and symptoms. Examples include the treatmentof hypothyroidism with levothyroxine and the treat-ment of type 1 diabetes mellitus with insulin. Yet it isdebatable whether, with treatment, the patient hasactually regained the previous status of normal goodhealth. In these instances, the physician may chooseto increase the impairment estimate by a small per-centage (eg, 1% to 3%).In some instances, as with organ transplant recipientswho are treated