Permanent ImpairmentGuidelines attachedNovember 2016The attached Permanent Impairment Guidelines – Guidelines for the assessment ofpermanent impairment of a person injured as a result of a motor vehicle accident –of the former Motor Accidents Authority are current and remain in force.The Guidelines are used to assess a person’s degree of permanent impairmentfollowing a motor vehicle accident.The State Insurance Regulatory Authority assumed the functions of the formerMotor Accidents Authority as the regulator of the NSW compulsory third partyinsurance scheme on 1 September 2015.If you have any questions about the Guidelines, please contact:Motor Accidents Insurance RegulationState Insurance Regulatory AuthorityLevel 25, 580 George Street, Sydney NSW 2000General phone enquiries 1300 137 131 or Claims Advisory Service 1300 656 919Website: [email protected]

MOTOR ACCIDENTSAUTHORITY1 OCTOBER 2007PermanentImpairment GuidelinesGuidelines for the assessment of permanentimpairment of a person injured as a resultof a motor vehicle accident

Guidelines for the assessment of the degreeof permanent impairment1 October 2007

Guidelines for the assessment of the degree of permanentimpairment of an injured personExplanatory NoteThese Motor Accidents Authority (MAA) Guidelines are issued pursuant to section 44(1)(c) of the MotorAccidents Compensation Act 1999 (“the Act”) and apply in respect of a motor accident occurring on or after 5October 1999. These Guidelines replace the MAA “Guidelines for the assessment of the degree ofpermanent impairment of an injured person” published in Government Gazette No 92 of 22 July 2005 atpage 3858.The Act requires that damages for non-economic loss only be awarded where the permanent impairment ofthe injured person caused by the motor accident is greater than 10%. Further, the assessment of the degreeof permanent impairment is to be made in accordance with the MAA Medical Guidelines issued for thatpurpose.These Guidelines have been developed to fulfil that role. They use the American Medical AssociationGuides to the Evaluation of Permanent Impairment, Fourth Edition, Third Printing (1995) (AMA 4 Guides) astheir basis. The AMA 4 Guides are widely used as an authoritative source for the assessment of permanentimpairment. However, these MAA Guidelines make significant changes to the AMA 4 Guides to align themwith Australian clinical practice and to better suit them to the purposes of the Act.These Guidelines commence on 1 October 2007David BowenGeneral ManagerMotor Accidents AuthorityiMAA Permanent Impairment Guidelines1 October 2007

Table of ContentsChapter 1 - Introduction to the MAA Guidelines .iChapter 2 - Upper Extremity Impairment .9Chapter 3 - Lower Extremity Impairment .13Chapter 4 - Spinal Impairment .21Chapter 5 - Nervous System Impairment.30Chapter 6 - Ear, Nose and Throat and Related Structures Impairment .35Chapter 7 - Mental and Behavioural Disorders Impairment .38Chapter 8 - Impairment of Other Body SystemsThe Respiratory System.48The Cardiovascular System .49The Haematopoietic System .50The Visual System .50The Digestive System .50The Urinary and Reproductive Systems.51The Endocrine System.51The Skin .511 October 2007MAA Permanent Impairment Guidelinesii

Chapter 1Introduction to the MAA GuidelinesIntroduction1.1These MAA Guidelines have been developed for the purpose of assessing the degree of permanentimpairment arising from the injury caused by a motor accident, in accordance with section 133(2)(a)of the New South Wales Motor Accidents Compensation Act 1999.1.2The MAA Guidelines are based on the American Medical Association publication “Guides to theEvaluation of Permanent Impairment”, 4th Edition, 3rd Printing (1995) (AMA 4 Guides). However, inthese Guidelines there are some very significant departures from that document.Personsundertaking impairment assessments for the purposes of the NSW Motor Accidents CompensationAct 1999 must read these MAA Guidelines in conjunction with the AMA 4 Guides. These MAAGuidelines are definitive with regard to the matters they address. Where they are silent on anissue, the AMA 4 Guides should be followed. In particular, Chapters 1 and 2 of the AMA 4Guides should be read carefully in conjunction with this Chapter of the MAA Guidelines.Some of the examples in AMA 4 are not valid for the assessment of impairment under theMotor Accidents Compensation Act 1999.It may be helpful for assessors to mark theirworking copy of the AMA 4 Guides with the changes required by these MAA Guidelines.1.3The convention used in these MAA Guidelines is that if the text is in bold, it is a directive as to howthe assessment should be performed.Application of Guidelines1.4Original Assessments - These Guidelines apply to all assessments of the degree of permanentimpairment (under s58(1)(d) of the Act) conducted by a medical assessor on or after thecommencement date.1.5Further Assessments - These Guidelines apply to a further medical assessment of the degree ofpermanent impairment (under s62 of the Act) conducted by a medical assessor on or after thecommencement date.If an original assessment under s58(1)(d) was conducted under a previous version of theseGuidelines resulting in a certificate being issued that the claimant’s injuries exceed the WPIthreshold, an application may not be made under s62 for a further assessment if it is based solely ona change made in these Guidelines.1MAA Permanent Impairment Guidelines1 October 2007

1.6Reviews of Assessments – These Guidelines apply in the review of an assessment (under s63 ofthe Act) as follows:(a)Decisions of the Proper Officer under s63(1)(2)(3)i)Where the assessment by the single medical assessor in question was made inaccordance with these Guidelines, these Guidelines apply; orii)Where the assessment by the single medical assessor in question was made inaccordance with a previous version of these Guidelines, that previous version ofthese Guidelines apply;(b)Review Panel assessments under s63(4)These Guidelines apply to all review panel assessments of the degree of permanentimpairment (under s58(1)(d) of the Act) conducted by a review panel on or after thecommencement date.Causation of injury1.7An assessment of permanent impairment is as prescribed under section 58 (1)(d) of the MotorAccidents Compensation Act 1999. The assessment should determine the degree of permanentimpairment of the injured person as a result of the injury caused by the motor accident.Adetermination as to whether the claimant’s symptoms and impairment are related to the accident inquestion is therefore implied in all such assessments. Assessors should be aware of the relevantprovisions of the AMA 4 Guides, as well as the common law principles that would be applied by acourt (or claims assessor) in considering such issues.1.8Causation is defined in the Glossary at page 316 of the AMA 4 Guides as follows: "Causationmeans that a physical, chemical, or biologic factor contributed to the occurrence of a medicalcondition.To decide that a factor alleged to have caused or contributed to the occurrence orworsening of a medical condition has, in fact, done so, it is necessary to verify both of the following.(a)The alleged factor could have caused or contributed to worsening of the impairment, whichis a medical determination.(b)The alleged factor did cause or contribute to worsening of the impairment, which is a nonmedical determination".This therefore involves a medical decision and a non-medical informed judgement.1.9There is no simple common test of causation that is applicable to all cases, but the acceptedapproach involves determining whether the injury (and the associated impairment) was caused ormaterially contributed to by the motor accident. The motor accident does not have to be a solecause as long as it is a contributing cause, which is more than negligible. Considering the question“Would this injury (or impairment) have occurred if not for the accident?” may be useful in somecases, although this is not a definitive test and may be inapplicable in circumstances where thereare multiple contributing causes.1 October 2007MAA Permanent Impairment Guidelines2

Impairment and disability1.10It is critically important to clearly define the term impairment and distinguish it from the disability thatmay result.1.11Impairment is defined as an alteration to a person’s health status. It is a deviation from normality ina body part or organ system and its functioning. Hence, impairment is a medical issue and isassessed by medical means.1.12This definition is consistent with that of the World Health Organisation (WHO) which has definedimpairment as “any loss or abnormality of psychological, physiological or anatomical structure orfunction.” (1)1.13Disability, on the other hand, is a consequence of an impairment. The WHO definition is “anyrestriction or lack of ability to perform an activity in the manner or within the range considered normalfor a human being”. (1)1.14Confusion between the two terms can arise because in some instances the clearest way to measurean impairment is by considering the effect on a person’s ‘activities of daily living’ (that is, on theconsequent disability). The AMA 4 Guides, in several places, refer to restrictions in the activities ofdaily living of a person. Hence the disability is being used as an indicator of severity of impairment.1.15Where alteration in activities of daily living forms part of the impairment evaluation, for examplewhen assessing brain injury or scarring, refer to the Table of Activities of Daily Living on page 317 ofAMA 4 Guides. The assessor should explain how the injury impacts on activities of daily living in theimpairment evaluation report.1.16Two examples may help emphasise the distinction between impairment and disability.(i)The loss of the little finger of the right hand would be an equal impairment for both a bankmanager and a concert pianist and so, for these Guidelines, the impairment is identical. Butthe concert pianist has sustained a greater disability.(ii)An upper arm injury might make it impossible for an injured person to contract the fingers ofthe right hand. That loss of function is an impairment. However, the consequences of thatimpairment, such as an inability to hold a cup of coffee, or button up clothes, constitute adisability.1.17A handicap is a further possible consequence of an impairment or disability, being a disadvantagethat limits or prevents fulfilment of a role that is/was normal for that individual. The concert pianist inthe example above is likely to be handicapped by his/her impairment.1.18It must be emphasised, in the context of these MAA Guidelines, that it is not the role of the assessorto determine disability, other than as described in 1.14 above.Evaluation of impairment1.193The assessor should consider the available evidence and be satisfied that there:(i)was an injury to the part being assessed caused by the accident;(ii)is a defined diagnosis that can be confirmed by examination; and(iii)is an impairment as defined at 1.11 of the MAA Guidelines.MAA Permanent Impairment Guidelines1 October 2007

1.20An assessment of the degree of permanent impairment involves three stages:(i)A review of medical and hospital records, including:- all available treating and medico-legal doctor notes and reports (general practitioner,specialist and allied health), both prior to and following the accident; and- diagnostic findings from all available relevant investigations.(ii)An interview and a clinical examination, wherever possible, to obtain the informationspecified in the MAA Guidelines and the AMA 4 Guides necessary to determine thepercentage impairment; and(iii)The preparation of a report using the methods specified in these MAA Guidelines whichdetermines the percentage permanent impairment together with the evidence, calculationsand reasoning on which the determination is based.The applicable parts of the MAAGuidelines and the AMA 4 Guides should be referenced.Permanent impairment1.21Before an impairment evaluation is undertaken, it must be shown that the impairment has beenpresent for a period of time, is static, well stabilised and unlikely to change substantially regardlessof treatment. The AMA 4 Guides (page 315) state that permanent impairment is impairment that hasbecome static or well stabilised with or without medical treatment and is not likely to remit despitemedical treatment. A permanent impairment is considered to be unlikely to change substantially ( more than 3% whole person impairment) in the next year with or without medical treatment. If animpairment is not permanent, it is inappropriate to characterise it as such and evaluate it accordingto the Guidelines.1.22Generally, when an impairment is considered permanent, the injuries will also be stabilised.However, there could be cases where an impairment is considered permanent because it is unlikelyto change in future months regardless of treatment, but the injuries are not stabilised because futuretreatment is intended and the extent of this is not predictable. Amputation and paraplegia arepossible examples – the impairment is permanent and may be able to be assessed soon after theinjury, as it is not expected to change regardless of treatment. However the injuries may not bestabilised for some time as the extent of future treatment and rehabilitation are not known.1.23The evaluation should only consider the impairment as it is at the time of the assessment.1.24The evaluation should not include any allowance for a predicted deterioration, such as osteoarthritisin a joint many years after an intra-articular fracture, as it is impossible to be precise about any suchlater alteration. However, it may be appropriate to comment on this possibility in the impairmentevaluation report.1 October 2007MAA Permanent Impairment Guidelines4

Non-assessable injuries1.25Certain injuries may not result in an assessable impairment covered by the MAA Guidelines andAMA 4 Guides. For example, uncomplicated healed sternal and rib fractures do not result in anyassessable impairment.Impairments not covered by MAA Guidelines and AMA 4 Guides1.26A condition may present which is not covered in the MAA Guidelines or the AMA 4 Guides.If objective clinical findings of such a condition are present, indicating the presence of animpairment, then assessment by analogy to a similar condition is appropriate. Include therationale for the methodology chosen in the impairment evaluation report.Adjustments for effects of treatment or lack of treatment1.27The results of past treatment (e.g. operations) must be considered, since the claimant is beingevaluated as they present at the time of assessment.1.28Where the effective long-term treatment of the effects of an injury result in apparent,substantial or total elimination of a physical permanent impairment, but the claimant is likelyto revert to the fully impaired state if treatment is withdrawn, the assessor may increase thepercentage of whole person impairment by 1, 2 or 3% whole person impairment.Thispercentage should be combined with any other impairment percentage using the CombinedValues Chart (pp 322-324, AMA 4 Guides). An example might be long-term drug treatment forepilepsy. This paragraph does not apply to the use of analgesics or anti-inflammatory drugsfor pain relief.1.29For adjustments for the effect of treatment on a permanent psychiatric impairment refer to7.21 in Chapter 7 Mental and Behavioural Disorders Impairments of these Guidelines.1.30If a claimant has declined a particular treatment or therapy that the medical assessor believes wouldbe beneficial, this should not change the impairment estimate. However, a comment on the mattershould be included in the impairment evaluation report.1.31Equally, if the assessor believes substance abuse is a factor influencing the clinical state of theclaimant that should be noted in the impairment evaluation report.Adjustments for the effects of prostheses or assistive devices1.32Whenever possible, the impairment assessment should be conducted without assistive devices,except where these cannot be removed. However, the visual system should be assessed inaccordance with 8.14 to 8.17.5MAA Permanent Impairment Guidelines1 October 2007

Pre-existing impairment1.33The evaluation of the permanent impairment may be complicated by the presence of an impairmentin the same region that existed prior to the relevant motor accident. If there is objective evidence ofa pre-existing symptomatic permanent impairment in the same region at the time of the accident,then its value should be calculated and subtracted from the current whole person impairment value.If there is no objective evidence of pre-existing symptomatic permanent impairment, then its possiblepresence should be ignored.1.34The capacity of an assessor to determine a change in physical impairment will depend upon thereliability of clinical information on the pre-existing condition. To quote the AMA 4 Guides page 10,“For example, in apportioning a spine impairment, first the current spine impairment would beestimated, and then impairment from any pre-existing spine problem would be estimated. Theestimate for the pre-existing impairment would be subtracted from that for the present impairment toaccount for the effects of the former. Using this approach to apportionment would require accurateinformation and data on both impairments”.Refer to 7.18 for the approach to a pre-existingpsychiatric impairment.1.35Pre-existing impairments should not be assessed if they are unrelated or not relevant to theimpairment arising from the motor vehicle accident.Subsequent injuries1.36The evaluation of permanent impairment may be complicated by the presence of an impairment inthe same region that has occurred subsequent to the relevant motor accident. If there is objectiveevidence of a subsequent and unrelated injury or condition resulting in permanent impairment in thesame region its value should be calculated. The permanent impairment resulting from the relevantmotor accident should also be calculated.If there is no objective evidence of the subsequentimpairment its possible presence should be ignored.Psychiatric impairment1.37Psychiatric impairment is assessed in accordance with Chapter 7 of these MAA Guidelines.Psychiatric and physical impairments1.38Impairment resulting from a physical injury is to be assessed separately from the impairmentresulting from psychiatric or psychological injury.1.39When determining whether the degree of permanent impairment of the injured personresulting from the motor accident is greater than 10%, the impairment rating for a physicalinjury cannot be combined with the impairment rating for a psychiatric or psychologicalinjury.1 October 2007MAA Permanent Impairment Guidelines6

Pain1.40Some Tables require the pain associated with a particular neurological impairment to be assessed.Because of the difficulties of objective measurement, assessors should make no separateallowance for permanent impairment due to pain, and Chapter 15 of the AMA 4 Guides shouldnot be used. However, each chapter of the AMA 4 Guides includes an allowance for associatedpain in the impairment percentages.Rounding up or down1.41The AMA 4 Guides (p 9) permit (but do not require) that a final whole person impairment may berounded to the nearest percentage ending in 0 or 5. This could cause inconsistency between twootherwise identical assessments.For this reason assessors must not round whole personimpairment values at any point of the assessment process.During the impairmentcalculation process however, fractional values might occur when evaluating the regionalimpairment (e.g. an upper extremity impairment value of 13.25%) and this should be rounded(in this case to 13%). Whole person impairment values can only be integers (not fractions).Consistency1.42Tests of consistency, such as using a goniometer to measure range of motion, are good butimperfect indicators of claimants’ efforts. The assessor must utilise the entire gamut of clinical skilland judgement in assessing whether or not the results of measurements or tests are plausible andrelate to the impairment being evaluated. If, in spite of an observation or test result, the medicalevidence appears not to verify that an impairment of a certain magnitude exists, the assessor shouldmodify the impairment estimate accordingly, describing the modification and outlining the reasons inthe impairment evaluation report.1.43Where there are inconsistencies between the assessor’s clinical findings and information obtainedthrough medical records and/or observations of non-clinical activities, the inconsistencies should bebrought to the claimant’s attention, e.g. inconsistency demonstrated between range of shouldermotion when undressing and range of active shoulder movement during the physical examination.The claimant will then have an opportunity to confirm the history and/or respond to the inconsistentobservations to ensure accuracy and procedural fairness.Assessment of children1.44The determination of the degree of permanent impairment in children may be impossible in someinstances, due to the natural growth and development of the child (examples are injuries to growthplates of bones or brain damage). In some cases the effects of the injury may not be consideredstable and the assessment of permanent impairment may be delayed until growth and developmentis complete.7MAA Permanent Impairment Guidelines1 October 2007

Additional investigations1.45The claimant who is being assessed should attend with the results of all diagnostic tests. It is notappropriate for an assessor to order additional investigations such as further spinal imaging otherthan those required as part of the impairment assessment. If it is strongly believed there are clinicalreasons to order an investigation, the suggestion should be made in the impairment evaluationreport.1.46There are some circumstances where testing is required as part of the impairment assessment e.g.respiratory, cardiovascular, ENT and ophthalmology. In these cases it is appropriate to conduct theprescribed tests as part of the assessment.Combining values1.47In general, when separate impairment percentages are obtained for various impairmentsbeing assessed these are not simply added together, but must be combined using theCombined Values Chart (pp 322-324, AMA 4 Guides). This process is necessary to ensure thetotal whole person or regional impairment does not exceed 100% of the person or region. Thecalculation becomes straightforward after working through a few examples (for instance, see page53 of the AMA 4 Guides). Note, however, that in a few specific instances, for example, for ranges ofmotion of the thumb joints, (AMA 4 Guides p16), the impairment values are directly added. Multipleimpairment scores should be treated precisely as the AMA 4 Guides or MAA Guidelines instruct.Lifetime Care and Support Scheme1.48A claimant who has been accepted as a lifetime participant of the Lifetime Care and SupportScheme under section 9 of the Motor Accidents (Lifetime Care and Support) Act 2006 has a degreeof permanent impairment greater than 10%.References:1.World Health Organisation. International Classification of Impairments, Disabilities and Handicaps.Geneva, 1980.1 October 2007MAA Permanent Impairment Guidelines8

Chapter 2Upper Extremity ImpairmentIntroduction2.1The hand and upper extremity is discussed in section 3.1 of Chapter 3 of the AMA 4 Guides (pp 1574). This section provides guidelines on methods of assessing permanent impairment involving theupper extremity.It is a complex section that requires an organised approach with carefuldocumentation of findings on a worksheet.The approach to assessment of the upper extremity and hand2.2Assessment of the upper extremity involves a physical evaluation that can utilise a variety ofmethods. The assessment, in this Chapter, does not include a cosmetic evaluation, which should bedone with reference to Chapter 13 of the AMA 4 Guides.2.3The assessed impairment of a part or region can never exceed the impairment due to amputation ofthat part or region. For an upper limb, therefore, the maximum evaluation is 60% whole personimpairment.2.4Although range of motion appears to be a suitable method for evaluating impairment, it can besubject to variation because of pain during motion at different times of examination and/or possiblelack of co-operation by the person being assessed.Range of motion is assessed as follows:(i)A goniometer should be used where clinically indicated.(ii)Passive range of motion may form part of the clinical examination to ascertain clinical statusof the joint, but impairment should only be calculated using active range of motionmeasurements.(iii)If the assessor is not satisfied that the results of a measurement are reliable, active range ofmotion should be measured with at least three consistent repetitions.(iv)If there is inconsistency in range of motion then it should not be used as a valid parameter ofimpairment evaluation. Refer to section 1.43 of these Guidelines.(v)If range of motion measurements at examination cannot be used as a valid parameter ofimpairment evaluation, the assessor should then use discretion in considering what weightto give other available evidence to determine if an impairment is present.2.5If the contralateral uninjured joint has a less than average mobility, the impairment value(s)corresponding with the uninjured joint can serve as a baseline and are subtracted from thecalculated impairment for the injured joint only if there is a reasonable expectation theinjured joint would have had similar findings to the uninjured joint before injury.Therationale for this decision should be explained in the impairment evaluation report.9MAA Permanent Impairment Guidelines1 October 2007

2.6To achieve an accurate and comprehensive assessment of the upper extremity, findings should bedocumented on a standard form. Figure 1 of the AMA 4 Guides (pp 16-17) is extremely useful todocument findings and guide assessment of the upper extremity.Note however, that the final summary part of Figure 1 (pp 16-17, AMA 4 Guides) does notmake it clear that impairments due to peripheral nerve injuries cannot be combined withother impairments in the upper extremities unless they are separate injuries.2.7The hand and upper extremity are divided into the regions of the thumb, fingers, wrist, elbow, andshoulder. Close attention needs to be paid to the instructions in Figure 1 (pp 16-17, AMA 4 Guides)regarding adding or combining impairments.2.8Table 3 (p 20, AMA 4 Guides) is used to convert upper extremity impairment to whole personimpairment.Note that 100% upper extremity impairment is equivalent to 60% whole personimpairment.2.9If the condition is not in the AMA 4 Guides it may be assessed using another like condition.For example, a rotator cuff injury may be assessed by impairment of shoulder range of movement orother disorders of the upper extremity (pp 58-65, AMA 4 Guides).Specific Interpretation of the AMA 4 GuidesImpairment of the upper extremity due to peripheral nerve disorders2.10If an impairment results solely from a peripheral nerve injury the assessor should notevaluate impairment from Sections 3.1f to 3.1j (pp 24-45, AMA 4 Guides). Sections 3.1k andsubsequent sections should be used for evaluation of such impairment.For peripheral nerve lesions use Table 15 (p 54, AMA 4 Guides) together with Tables 11a and12a (pp 48-49, AMA 4 Guides) for evaluation. Table 16 (p 57, AMA 4 Guides) must not beused.2.11When applying Tables 11a and 12a (pp 48-49, AMA 4 Guides) the maximum value for eachgrade should be used unless assessing Complex Regional Pain Syndrome.2.12For purposes of interpreting Table 11 (p 48, AMA 4 Guides) “abnormal sensation” includesdisturbances in sensation such as dysaesthesia, paraesthesia and cold intolerance.“Decreased sensibility” includes anaesthesia and hypoaesthesia.Impairment of the upper extremity due to complex regional pain syndrome2.13The section, "Causalgia and Reflex Sympathetic Dystrophy" (p 56, AMA 4 Guides) should notbe used. These conditions have been better defined since publication of the AMA 4 Guides. Thecurrent terminology is Complex Regional Pain Syndrome (CRPS) type I (referring to what wastermed Reflex Sympathetic Dystrophy) and Complex Regional Pain Syndrome type II (referring towhat was termed Causalgia).1 October 2007MAA Permanent Impairment Guidelines10

2.14For a diagnosis of Com

These Guidelines have been developed to fulfil that role. They use the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition, Third Printing (1995) (AMA 4 Guides) as their basis. The AMA 4 Guides are widely used as an authori