NSW workers compensation guidelines for the evaluation of permanent impairment

These guidelines explain permanent impairment assessment in the NSW workers compensation system. This is the fourth edition of these guidelines, reissued 1 March 2021.

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The State Insurance Regulatory Authority has reissued the 4th edition of the NSW workers compensation guidelines for the evaluation of permanent impairment (catalogue no. WC00970) (the Guidelines) for assessing the degree of permanent impairment arising from an injury or disease within the context of workers’ compensation. When a person sustains a permanent impairment, trained medical assessors must use the Guidelines to ensure an objective, fair and consistent method of evaluating the degree of permanent impairment.

The reissued Guidelines have been made to include some minor changes including changes consequent to the enactment of the Personal Injury Commission Act 2020 (PIC Act). No changes are made to the provisions in these guidelines relating to the evaluation of permanent impairment as developed in consultation with the medical Colleges under s 377(2) of the Workplace Injury Management and Workers Compensation Act 1998 and as set out in cl 13 of the Guidelines.

The Guidelines are based on a template that was developed through a national process facilitated by Safe Work Australia. They were initially developed for use in the NSW system and incorporate numerous improvements identified by the then WorkCover NSW Whole Person Impairment Coordinating Committee over 13 years of continuous use. Members of this committee and of the South Australia Permanent Impairment Committee (see list in Appendix 2) dedicated many hours to thoughtfully reviewing and improving the Guidelines. This work is acknowledged and greatly appreciated.

The methodology in the Guidelines is largely based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 5th Edition (AMA5). The AMA guides are the most authoritative and widely used in evaluating permanent impairment around the world. Australian medical specialists representing Australian medical associations and colleges have extensively reviewed AMA5 to ensure it aligns with clinical practice in Australia.

The Guidelines consist of an introductory chapter followed by chapters dedicated to each body system.

The Introduction is divided into three parts. The first outlines the background and development of the Guidelines, including reference to the relevant legislative instrument that gives effect to the Guidelines. The second covers general assessment principles for medical practitioners applying the Guidelines in assessing permanent impairment resulting from work-related injury or disease. The third addresses administrative issues relating to the use of the Guidelines.

As the template national guideline has been progressively adapted from the NSW Guideline and is to be adopted by other jurisdictions, some aspects have been necessarily modified and generalised. Some provisions may differ between different jurisdictions. For further information, please see the Comparison of Workers’ Compensation Arrangements in Australia and New Zealand report, which is available on Safe Work Australia’s website.

Publications such as this only remain useful to the extent that they meet the needs of users and those who sustain a permanent impairment. It is, therefore, important that the protocols set out in the Guidelines are applied consistently and methodically. Any difficulties or anomalies need to be addressed through modification of the publication and not by idiosyncratic reinterpretation of any part. All queries on the Guidelines or suggestions for improvement should be addressed to SIRA at [email protected].

6. Ear, nose, throat and related structures

AMA5 Chapter 11 (p 245), applies to the assessment of permanent impairment of the ear (with the exception of hearing impairment), nose, throat and related structures, subject to the modifications set out below. Before undertaking an impairment assessment, users of the Guidelines must be familiar with:

the Introduction in the Guidelines
chapters 1 and 2 of AMA5
the appropriate chapter(s) of the Guidelines for the body system they are assessing.
the appropriate chapter(s) of AMA5 for the body system they are assessing.

The Guidelines take precedence over AMA5.

Introduction

6.1 AMA5 Chapter 11 (pp 245–75) details the assessment of the ear, nose, throat and related structures. With the exception of hearing impairment, which is dealt with in Chapter 9 of the Guidelines, AMA5 Chapter 11 should be followed in assessing permanent impairment, with the variations included below.

6.2 The level of impairment arising from conditions that are not work-related needs to be assessed by the medical assessor and taken into consideration in determining the level of permanent impairment. The level at which pre-existing conditions and lifestyle activities, such as smoking, contribute to the level of permanent impairment requires judgement on the part of the clinician undertaking the impairment assessment. The manner in which any deduction for these is applied needs to be recorded in the assessing specialist’s report.

The ear

6.3 Equilibrium is assessed according to AMA5 Section 11.2b (pp 252–55), but add these words to AMA5 Table 11-4, class 2 (p 253): ‘without limiting the generality of the above, a positive Hallpikes test is a sign and an objective finding’.

The face (AMA5, pp 255-59)

6.4 AMA5 Table 11-5 (p 256) should be replaced with Table 6.1, below, when assessing permanent impairment due to facial disorders and/or disfigurement.

Table 6.1: Criteria for rating permanent impairment due to facial disorders and/or disfigurement

Class 1 0-5% impairment of the whole person	Class 2 6-10% impairment of the whole person	Class 3 11-15% impairment of the whole person	Class 4 16-50% impairment of the whole person
Facial abnormality limited to disorder of cutaneous structures, such as visible scars (not hypertrophic or atrophic) or abnormal pigmentation (refer toAMA5 Chapter 8 for skin disorders) or mild, unilateral, facial paralysis affecting most branches or nasal distortion that affects physical appearance or partial loss or deformity of the outer ear.	Facial abnormality involves loss of supporting structure of part of the face, with or without cutaneous disorder (eg depressed cheek, nasal, or frontal bones) or near complete loss of definition of the outer ear.	Facial abnormality involves absence of normal anatomic part or area of face, such as loss of eye or loss of part of nose, with resulting cosmetic deformity, combine with any functional loss, eg vision (AMA4 Chapter 8) or severe unilateral facial paralysis affecting most branches or mild, bilateral, facial paralysis affecting most branches.	Massive or total distortion of normal facial anatomy with disfigurement so severe that it precludes social acceptance or severe, bilateral, facial paralysis affecting most branches or loss of a major portion of or entire nose.

Class 1
0-5% impairment of the whole person

Class 2
6-10% impairment of the whole person

Class 3
11-15% impairment of the whole person

Class 4
16-50% impairment of the whole person

Facial abnormality limited to disorder of cutaneous structures, such as visible scars (not hypertrophic or atrophic) or abnormal pigmentation (refer toAMA5 Chapter 8 for skin disorders)

mild, unilateral, facial paralysis affecting most branches

nasal distortion that affects physical appearance

partial loss or deformity of the outer ear.

Facial abnormality involves loss of supporting structure of part of the face, with or without cutaneous disorder (eg depressed cheek, nasal, or frontal bones)

near complete loss of definition of the outer ear.

Facial abnormality involves absence of normal anatomic part or area of face, such as loss of eye or loss of part of nose, with resulting cosmetic deformity, combine with any functional loss, eg vision (AMA4 Chapter 8)

severe unilateral facial paralysis affecting most branches

mild, bilateral, facial paralysis affecting most branches.

Massive or total distortion of normal facial anatomy with disfigurement so severe that it precludes social acceptance

severe, bilateral, facial paralysis affecting most branches

loss of a major portion of or entire nose.

Note: Tables used to classify the examples in AMA5 Section 11.3 (pp 256-59) should also be ignored and assessors should refer to the modified table above for classification.

6.5 In AMA5 example 11-11 (p 257), add the words ‘visual impairment related to enophthalmos must be assessed by an Ophthalmologist’.

The nose, throat and related structures

6.6 - 6.9 Respiration (AMA5 Section 11.4a, pp 259-61)

6.6 In regard to sleep apnoea (third paragraph of AMA5 Section 11.4a, p 259), a sleep study and an examination by an ear, nose and throat specialist is mandatory before assessment by an approved assessor.

6.7 The assessment of sleep apnoea is addressed in AMA5 Section 5.6 (p 105) and assessors should refer to this chapter, as well as paragraphs 8.8 - 8.10 in Chapter 8 of the Guidelines.

6.8 AMA5 Table 11-6, ‘Criteria for rating impairment due to air passage defects’ (p 260), should be replaced with Table 6.2, below, when assessing permanent impairment due to air passage defects.

Table 6.2: Criteria for rating permanent impairment due to air passage defects

Percentage impairment of the whole person
Class 1a 0-5%	There are symptoms of significant difficulty in breathing through the nose. Examination reveals significant partial obstruction of the right and/ or left nasal cavity or nasopharynx or significant septal perforation.
Class 1 0-10%	Dyspnea does not occur at rest and dyspnea is not produced by walking freely on a level surface, climbing stairs freely or performance of other usual activities of daily living and dyspnea is not produced by stress, prolonged exertion, hurrying, hill climbing, or recreational or similar activities requiring intensive effort* and examination reveals partial obstruction of the oropharynx, laryngopharynx, larynx, upper trachea (to the fourth cartilaginous ring), lower trachea, bronchi or complete (bilateral) obstruction of the nose or nasopharynx.
Class 2 11-29%	Dyspnea does not occur at rest and dyspnea is not produced by walking freely on a level surface, climbing one flight of stairs or performance of other usual activities of daily living but dyspnea is produced by stress, prolonged exertion, hurrying, hill climbing, or recreational or similar activities (except sedentary forms) and examination reveals partial obstruction of the oropharynx, laryngopharynx, larynx, upper trachea (to the fourth cartilaginous ring), lower trachea, bronchi or complete (bilateral) obstruction of the nose or nasopharynx.
Class 3 11-29%	Dyspnea does not occur at rest and dyspnea is produced by walking freely more than one or two level blocks, climbing one flight of stairs, even with periods of rest, or performance of other usual activities of daily living and dyspnea is produced by stress, prolonged exertion, hurrying, hill climbing, or recreational or similar activities and examination reveals partial obstruction of the oropharynx, laryngopharynx, larynx, upper trachea (to the fourth cartilaginous ring), lower trachea or bronchi.
Class 4 50-89%	Dyspnea occurs at rest, although individual is not necessarily bedridden and dyspnea is aggravated by the performance of any of the usual activities of daily living (beyond personal cleansing, dressing or grooming) and examination reveals partial obstruction of the oropharynx, laryngopharyx, larynx, upper trachea (to the fourth cartilaginous ring), lower trachea, and/or bronchi.
Class 5 90%+	Severe dyspnea occurs at rest and spontaneous respiration is inadequate and respiratory ventilation is required and examination reveals partial obstruction of the oropharynx, laryngopharynx, larynx, upper trachea (to the fourth cartilaginous ring), lower trachea or bronchi.

* Prophylactic restriction of activity, such as strenuous competitive sport, does not exclude subject from class 1.

Note: Individuals with successful permanent tracheostomy or stoma should be rated at 25% WPI. AMA5 example 11-16 (p 261), ‘Partial obstruction of the larynx affecting only one vocal cord’, is better linked to voice (AMA5 Section 11.4e).

6.9 When using AMA5 Table 11-7 ‘Relationship of dietary restrictions to permanent impairment’ (p 262), the first WPI category is to be 0–19%, not 5–19%.

6.10 - 6.12 Speech (AMA5, pp 262-64)

6.10 Regarding the first sentence of the ‘Examining procedure’ subsection of AMA5 (pp 263–64): the examiner should have sufficient hearing for the purpose- disregard ‘normal hearing as defined in the earlier section of this chapter on hearing’.

6.11 ‘Examining procedure’ (AMA5, pp 263-64), second paragraph: ‘The examiner should base judgements of impairment on two kinds of evidence: (1) attention to and observation of the individual’s speech in the office – for example, during conversation, during the interview, and while reading and counting aloud – and (2) reports pertaining to the individual’s performance in everyday living situations’. Disregard the next sentence: ‘The reports or the evidence should be supplied by reliable observers who know the person well.’

6.12 ‘Examining procedure’ (AMA5, pp 263-64): where the word ‘American’ appears as a reference, substitute ‘Australian’, and change measurements to the metric system (eg 8.5 inches = 22 centimetres).

6.13 - 6.14 The voice (AMA5 Section 11.4e, pp 264-67)

6.13 Substitute the word ‘laryngopharyngeal’ for ‘gastroesophageal’ in all examples where it appears.

6.14 Example 11.25 (AMA5, p 269) ‘Impairment rating’, second sentence: add the words “including respiratory impairment” into the sentence to read ‘Combine with appropriate ratings due to other impairments including respiratory impairment to determine whole person impairment’.

6.15 Ear, nose, throat and related structures impairment evaluation summary

6.15 Disregard AMA5 Table 11-10 (pp 272–75), except for impairment of olfaction and/or taste, and hearing impairment as determined in the Guidelines.