Non-schedule Awards

NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Evaluation of non-schedule permanent partial disability (PPD-NSL) involves both medical and non- medical issues. For claims with a date of injury on or after March 13, 2007 (post-reform), the duration of PPD-NSL benefits is limited based on the claimant’s loss of wage earning capacity. Loss of wage earning capacity is based on three types of input:

1. Medical impairment
2. Functional ability/loss
3. Non-medical/vocational factors (e.g. education, skills, age, literacy, etc.) . The first two inputs are medical evidence that is provided by the treating provider and the carrier consultant, when appropriate. Section 9.2 provides further guidance for medical professionals on how to evaluate and document impairment and functional loss. The third input is non-medical evidence that is presented by the parties as part of the evaluation of loss of wage earning capacity.

Section 9.3 provides direction on how to determine loss of wage earning capacity for those with PPD- NSL. Medical professionals should not express opinions on the ultimate issue of loss of wage earning capacity, but rather should provide information on the claimant’s medical impairment, functional and exertional limitations, and other medical issues relevant to the judge’s determination of loss of wage earning capacity. The ultimate determination of loss of wage earning capacity is a legal issue for the Board to decide based on the evidence in the record as developed.

NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

To be eligible for a PPD-NSL award, an injured worker must have a permanent medical impairment that is eligible for a non-schedule award (see Chapter 1.6) and have reached maximum medical improvement (See Chapter 1.2). The treating physician should perform an impairment and functional assessment when the claimant has reached MMI and has a permanent impairment or when directed by the Board to provide such an assessment. The results of the impairment and functional assessments should be recorded on the Doctor’s Report of MMI/Permanent Impairment (Form C-4.3).

Impairment Evaluation To evaluate and rate medical impairment, a medical professional should follow the steps set forth in Chapter 1.4 and apply the evaluation criteria contained in the appropriate tables. The physician should document the injured worker’s diagnosis(es) and impairment ranking, including the body part(s) or system(s), the primary impairment table(s) used to rank the severity of the impairment, and the severity ranking(s). The severity rankings provided in chapters 11 to 16 are alphabetical (A-Z). For schedule injuries that are subject to classification and body parts that are not covered by impairment guidelines, the physician should follow chapter 17.

The physician should also state the medical basis for the impairment classification, including the relevant history, physical findings and diagnostic test results. The non-schedule impairment tables provide the relevant criteria that need to be documented to satisfy a particular classification of impairment. For body parts that would otherwise be subject to a schedule, the physician should document why classification is appropriate.

Functional Evaluation For non-schedule permanent partial disability claims, the medical assessment of the injured worker’s residual functional abilities and losses is a key component in a judge’s determination of loss of wage

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 9: Non-schedule Awards

earning capacity. An individual’s ability to perform physical activities in the workplace is an important determinant of what type of work he or she can do and the level of earnings he or she may achieve.

The physician’s functional evaluation should include the following considerations and be recorded on the Doctor’s Report of MMI/Permanent Impairment (Form C-4.3).

1. At-injury job: The physician should first document whether or not the injured worker is capable of performing the work activities of the at-injury job. To understand the major work requirements of the at-injury job, the physician should request a job description or other similar documentation from the employer and speak with the claimant about the job requirements. If the employer maintains that the injured worker is capable of performing the at-injury job, the employer must provide appropriate detail about the physical job requirements. The physician should document whether the claimant can perform the at-injury job requirements based on the best information available to the physician about the job requirements at the time of evaluation.

2. Functional ability/restrictions: On examination, the physician should measure the injured worker’s performance and restrictions across a range of functional abilities, including dynamic abilities(lifting, carrying, pushing, pulling and grasping), general tolerances (walking, sitting and standing) and specific tolerances (climbing, bending/stooping, kneeling, and reaching). These abilities and restrictions, including specific weight and time limitations, should be recorded on the Form C-4.3. Alternatively, the physician may refer the injured worker to a physical or occupational therapist for completion of the functional measurements and, after the physician’s review, incorporate them into the Form C-4.3.

3. Exertional ability: Finally, the physician should rate the injured worker’s residual exertional capacity according to the standard classification system of Sedentary to Very Heavy. Theexertional capacities relate to those activities that require lifting and/or pushing or pulling objects. The definitions of each category, which are derived from the Dictionary of Occupational Titles and used in the Social Security system, are as follows:1

Sedentary: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Light: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or negligible amount of force constantly to move objects. Physical requirements are in excess of those for sedentary work. Even though the weight lifted may only be a negligible amount, a job should be rated light work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Medium: Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for light work.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 9: Non-schedule Awards

Heavy: Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for medium work.

Very Heavy: Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in excess of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for heavy work.

4. Psychiatric limitations: For claims involving an established, permanent psychiatric impairment, the treating provider should document the impact of the psychiatric impairment on the claimant’s ability to function in the workplace, including activities that are relevant to obtaining, performing and maintaining employment (e.g. personal hygiene and grooming, interpersonal relations, etc.)

5. Other limitations: The physician should also document other limitations caused by thepermanent impairment(s) that impact the claimant’s ability to function in the workplace. This includes any limitations caused by the medical condition or treatment, including prescription medication, that impact the claimant’s ability to work.

6. Payment: A physician who fully completes an evaluation of permanent impairment, including a full evaluation of functional limitations, on a Form C-4.3 shall be entitled to payment for a Level 5 E&M consultation code (CPT 99245).

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 9: Non-schedule Awards

NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Loss of wage-earning capacity (LWEC) is the reduction in an injured worker’s earning capacity due to a work-related injury or disease. The determination of LWEC establishes the maximum number of benefit weeks available in post-reform claims pursuant to WCL §15(3)(w) (Table 9.1).

Table 9.1. LWEC and Maximum PPD Benefit LWEC Max. weeks of PPD benefits

0-15% 225 weeks 15-30% 250 weeks 30-40% 275 weeks 40-50% 300 weeks 50-60% 350 weeks 60-70% 375 weeks 70-75% 400 weeks 75-80% 425 weeks 80-85% 450 weeks 85-90% 475 weeks 90-95% 500 weeks 95-99% 525 weeks

The benefit rate is calculated under WCL § 15(5), and is based on wage earning capacity (WEC) per WCL § 15(5-a). For a working claimant, the earnings represent the claimant’s wage earning capacity, and the compensation rate is two-thirds of the difference between the claimant’s average weekly wage and earnings. For a non-working claimant with a non-scheduled permanent partial disability, WEC is based on the Board’s assessment of impairment plus vocational factors. In such cases, the rate is reflective of the diminished WEC. For example, if the Board finds a 60% WEC, the non-working claimant would receive benefits at 40% * 2/3 of the Average Weekly Wage, subject to statutory maximums per WCL § 15(6).

Legal Determination of Loss of Wage Earning Capacity: The Board must establish LWEC and WEC based on the facts in the case. The LWEC is determined based on medical evidence and vocational factors. Medical evidence includes the nature and degree of the work-related permanent physical and/or mental impairment and its impact on the claimant’s functional abilities. The inquiry seeks to quantify how much earning power an injured worker has lost in light of his or her medical impairment, functional limitations, prior work history, education, skills, and aptitudes. There is no simple formula to determine loss of wage earning capacity. See Matter of Longley Jones Management Corp., 2012 NY Wrk Comp 60704882. Once there is credible medical evidence that a clamant has reached maximum medical improvement, the parties will be given the opportunity to produce medical evidence of the nature and degree of claimant’s permanent impairment and functional ability/loss, and evidence of non-medical vocational factors. After the parties are afforded the opportunity to develop the record, the Board will determine claimant’s LWEC based on the evidence before it. If the parties fail to produce medical evidence of claimant’s functional ability/loss or non-medical vocational factors, the Board will determine the claimant’s LWEC despite the absence of such evidence. The only evidence that is in all instances required to determine LWEC is a medical opinion that claimant has reached maximum medical improvement and has a permanent physical or mental impairment.

As to WEC, in Matter of Rosales v Eugene J. Felice Landscaping, 144 AD3d 1206 [2016] the Appellate Division, Third Department, affirmed the Board’s “determination to fix claimant's wage-earning capacity based on the undisputed evidence of his physical disability and loss of wage-earning capacity resulting from his functional limitations and vocational impediments”.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 9: Non-schedule Awards

Medical Issues Medical Impairment The analysis of loss of wage earning capacity begins with an evaluation as to whether an injured worker has a permanent medical impairment and, if so, the severity of that medical impairment. To qualify for benefits under WCL § 15(3)(w), an injured worker must have a permanent medical impairment that is not subject to a schedule award, as defined by these medical impairment guidelines. These guidelines enable a physician to assess and quantify the severity of the permanent medical impairment(s) in a manner that is objective and consistent.

Each category of impairment is assigned a severity ranking from A to Z. Impairment severity is based on the estimated impact of the condition on overall health and bodily function. The physician’s role is to objectively assign the category of impairment that best fits the claimant at the time of MMI.

Chapter 18 translates each impairment’s letter ranking into a severity category from the least severe (category 1) to the most severe (category 6). This allows for relative comparison of the likely impact on function and wage-earning capacity of different categories of impairment across body parts.

Although it is not uncommon for an injured worker to have a permanent impairment of more than one body part or system, the guidelines do not provide for a mathematical combination of medical impairments. Rather, one must consider the impact of each impairment on function and wage earning capacity to determine their cumulative effect.

Medical impairment cannot be directly translated into loss of wage-earning capacity. The impact of impairment on one’s ability to perform specific job functions or maintain employment in a particular occupation varies depending on the type of impairment, the impacted work functions, and the job’s functional requirements. In general, however, more severe impairments lead to greater losses of work opportunity and reduced earning capacities.

Functional Loss In general, permanent medical impairment reduces earning capacity by restricting the worker’s ability to perform certain work related activities or tasks or limits work environments. If the impairment does not prevent the worker from performing the essential functions of the pre-injury job, the worker may be able to return to his/her former employment and, therefore, have no or very limited loss of wage earning capacity, despite having a permanent impairment. In contrast, an injury that prevents an injured worker from returning to the former occupation or any similar type of work may result in a significant loss of earning capacity. This is especially true when the worker had high earnings at the pre-injury job but is now unable, by virtue of lack of education, transferable skills, literacy or other reasons, to qualify for employment with similar wages.

In accordance with the functional guidelines, the treating physician should measure and document the injured workers’ ability to perform various work-related functions such as sitting, standing, walking, and overhead reaching, and whether there are restrictions as to how long and/or frequently such activities may be performed. The physician should also evaluate the individual’s residual exertional capacity such as the ability to lift or carry weights. The exertional limitations are described according to a standard classification of physical demand requirements on a scale from Sedentary to Very Heavy.2

Generally, one who can only perform sedentary work has fewer job options than the same person who can perform light, medium or heavy work. Yet, the impact of one’s exertional loss may vary considerably depending on the type of work that one previously performed and other factors such as education and transferable skills.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 9: Non-schedule Awards

In addition to physical and exertional limitations, an injured worker may have other limitations, such as environmental restrictions that preclude work in particular occupations. The impact of such restrictions will be greater if the injured worker’s previous employment requires such ability.

Vocational Issues Education and Training Education plays a significant role in a worker’s ability to qualify for different occupations and level of income. The relationship between education and loss of wage earning capacity is complicated by the fact that the impact of education is also generally reflected in workers’ pre-injury wages. Those with more education generally earn more than those with less education, both pre-injury and post-injury. Thus, in determining loss of wage earning capacity, it is important to evaluate the degree that educational achievement buffers or intensifies the impact of a medical impairment on a worker’s earning capacity.

For example, an injured worker whose education and training qualifies him to perform work that, despite his disability, he is physically capable of doing, and that pays similarly to his pre-injury work, will have a smaller LWEC. In contrast, an injured worker whose injury prevents him from doing his former occupation and does not have the education or training to perform any comparably paid work will have a higher LWEC.

Skills Prior work skills are often as important as formal education in an individual’s qualification for employment. Someone who has only performed unskilled or semi-skilled work in the past is unlikely to qualify for skilled work post-injury. A worker who has performed skilled work may be able to find other skilled work within his functional limitations, though this depends on the nature of the worker’s job skills.

A key consideration is whether the worker’s skills are readily transferable to alternative employment. The transferability of skills from a prior occupation generally depends on the similarity of occupationally significant work activities among different jobs. The similarity can be measured by the level of similarity in the degree of skill involved, the tools and machines used, and the materials, products, processes or services involved.3

Age The impact of age on wage earning capacity is complex. Age should be considered in the context of residual function, education, and work experience. Generally, advancing age may adversely impact a person’s ability to obtain employment that involves work that is different from one’s prior work experience or requires developing new skills.

Literacy and English Proficiency The ability to read, write, and speak English fluently is a requirement for many occupations in New York. Those who have limited or no ability to read, write or speak English fluently may still qualify to perform manual labor and other work that does not require interaction with the public or involvement with written documents. Workers who are illiterate or have limited or no English proficiency and, by virtue of their impairment, are rendered unable to perform manual work may have a significant loss of earning capacity.

Other Considerations Other factors may be considered in determining an injured worker’s loss of earning capacity. The key consideration is whether the factor impacts the injured worker’s ability to perform paid employment.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 10: Medical Impairment General Principles – Non-schedule

NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Table 11.1: Soft Tissue Spine Conditions - Non Surgically Treated

1. Table 11.1 requires a minimum duration of six months of symptoms from the time of the injuryto the impairment rating and no surgical intervention.

2. The appropriate spine injury table (Table 11.1: Soft Tissue Spine Conditions - Non-Surgically Treated, or Table 11.2: Surgically Treated Spine Conditions, or Table 11.3: Vertebral Fractures) should be chosen for determining impairment to a given spinal region.

3. All references to symptoms and findings must be related to and consistent with the specific documented workplace injury. A history of workplace injury encompasses acute, repetitiveor episodic events.

4. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

5. The severity ranking is generally predictive of the functional outcome for each Class relative tothe other Classes within a Table.

6. Please state diagnosis(es) at time of impairment rating:

7. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.1: Soft Tissue Spine Conditions - Non Surgically Treated Medical Impairment Class Severity Ranking Cervical Thoracic Lumbar Class 1. Medically documented injury with: None None None no symptoms; no clinical findings. Class 2. Medically documented injury with all of A A A the following: recurrence/persistence of symptoms; no objective clinical findings consistent with spinal pathology; no correlative imaging findings. Class 3. Medically documented injury with all of B B B the following: recurrence/persistence of symptoms; no objective clinical findings consistent with spinal pathology; correlative imaging findings.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Class 4. Medically documented injury with: C-H C-G D-J recurrence/persistence of symptoms; and See Tables See Tables See Tables (a) weakness in myotomal distribution S11.4, S11.5, S11.4 and S11.4, S11.6 and/or sensory changes in dermatomal and S11.7 for S11.7 for and S11.7 for distribution; determining determining determining or placement placement placement (b) tension/compression signs; within within within range.** or range.** range.** (This excludes (This (This adjustments for (c) objective clinical findings*. excludes excludes multiple roots The symptoms and findings must be consistent adjustments adjustments and root with: for multiple for multiple avulsion.) spinal pathology roots and root roots and root and avulsion.) avulsion.) correlative imaging findings or correlative electro-diagnostic findings as described in the radiculopathy chart (Table 11.4)

• Objective clinical findings mean atrophy or reflex changes. ** Use Tables S11.4, S11.5 and S11.6 as appropriate to determine the number of points associated with the identified radiculopathy. Then use Table S11.7 to determine the letter that corresponds to the number of points. This letter is the Severity Ranking within the radiculopathy range.

Non-category: Medically documented injury event with subjective symptoms, with objective clinical findings consistent with spinal pathology and no correlative findings on imaging (such as x-rays, non- contrast MRI). Further objective testing is indicated to identify the underlying pathology. Pending such testing, a finding of MMI should be deferred.

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Table 11.2: Surgically Treated Spine Conditions

1. The appropriate spine injury schedule (Table 11.1: Soft Tissue Spine Conditions – Non Surgically Treated, or Table 11.2: Surgically Treated Spine Conditions, or Table 11.3: Vertebral Fractures) should be chosen for determining impairment to a given spinal region.

2. All references to symptoms and findings must be related to and consistent with the specific documented workplace injury. A history of workplace injury encompasses acute, repetitiveor episodic events.

3. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

4. The severity ranking is generally predictive of the functional outcome for each Class relative to the other Classes within a Table.

5. Please state diagnosis(es) at time of impairment rating.

6. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.2: Surgically Treated Spine Conditions Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 1. Medically documented injury with all of the following: None None None related surgical intervention(s); no residual symptoms*; no post-surgical clinical findings. Class 2. Medically documented injury with all of the following: A A A related surgical intervention(s); residual symptoms*; no objective residual clinical findings**; no post-surgical imaging findings that can account for the symptoms. Class 3. Medically documented injury with all of the following: B B B related surgical intervention(s); residual symptoms*; no objective residual clinical findings**; post-surgical imaging findings that can account for the symptoms.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Table 11.2: Surgically Treated Spine Conditions Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 4. Medically documented injury with all of the following: C-H C-G D-J related surgical intervention(s); residual symptoms; See Tables See Tables See Tables one or more residual findings of: S11.4, S11.5 S11.4 and S11.4, S11.6 (a) weakness in myotomal distribution and S11.7 S11.7 to and S11.7 to and/or sensory changes in dermatomal for determine determine distribution; determining placement placement or placement within within (b) tension/compression signs; within range*** range.*** or range.*** (This (This (c) objective clinical findings.** (This excludes excludes excludes adjustments adjustments Symptoms and findings must be consistent adjustments for multiple for multiple with: for multiple roots and roots and post-surgical imaging findings that roots and root root can account for the symptoms; root avulsion) avulsion) or avulsion) post-surgical correlative electro- diagnostic findings as described in the radiculopathy chart (Table 11.4) Class 5. Complications relatedto surgery: symptoms consistent with the Ranking may be adjusted according to clinical complications and with either: circumstances. clinical findings; or imaging findings and/or lab work consistent with post-surgical consequences; does not include commonly seen post-surgical changes.

• Residual symptoms refers to symptoms from the original condition and not from post-operative complications covered in Table 11.2, Class 5, Complications Related to Surgery. **Objective clinical findings mean atrophy or reflex changes. ***Use Tables S11.4, S11.5 and S11.6 as appropriate to determine the number of points associated with the identified radiculopathy. Then use Table S11.7 to determine the letter that corresponds to the number of points. This letter is the Severity Ranking within the radiculopathy range.

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NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Table 11.3: Vertebral Fractures

The impairments listed below are the same with or without surgery, unless otherwise indicated.

1. In the event of multiple fracture patterns to the same spinal region, the rater is to useonly the highest rating from Table 11.3(a), 11.3(b) or 11.3(c). For spinal cord injury, the rater should use Table 11.8.

2. Non-adjacent fractures at distinctly different areas may be rated separately. Accompanying impairments to other organ systems are calculated separately.

3. The appropriate spine injury schedule (Table 11.1: Soft Tissue Spine Conditions – Non Surgically Treated, Table 11.2: Surgically Treated Spine Conditions, or Table 11.3: Vertebral Fractures) should be chosen for determining impairment to a given spinal region.*

4. All references to symptoms and findings must be related to and consistent with the specific documented workplace injury.

5. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

6. The severity ranking is generally predictive of the functional outcome for each Class relative to the other Classes within a Table.

7. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity.

• FRACTURE PATTERNS: 11.3(a) Stable Compression/Burst Fracture Pattern; 11.3(b) Translation/Rotation Fracture Pattern (including PLC integrity); and 11.3 (c) Distraction Fracture Pattern (including PLC integrity)4 5

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Table 11.3(a): Stable Compression/Burst Fracture Pattern

The impairments listed below are the same with or without surgery.

1. Pre-existing compression fracture should be rated only when there is objective evidence of an aggravation (i.e. permanent worsening of a prior condition) by the new injury or accident. Such objective evidence will usually require supportive imagingstudies.

2. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

3. The severity ranking is generally predictive of the functional outcome for each Class relativeto the other Classes within a Table.

4. Please state diagnosis(es) at time of impairment rating.

5. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.3(a): Stable Compression/Burst Fracture Pattern Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 1. Medically documented injury with all of the following: None None None imaging finding(s) of healed compression fracture(s); no residual symptoms; no clinical findings. Class 2(a). Medically documented injury with all of the following: A A A imaging finding(s) of healed compression fracture(s); residual symptoms consistent with the healed compression fracture(s); no residual clinical findings of spinal deformity), ROM limitation, or weakness. Class 2(b). For compression fractures of two or more consecutive vertebrae, the severity ranking is increased by one letter for each additional vertebrae with >20 % compression.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Table 11.3(a): Stable Compression/Burst Fracture Pattern Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 3(a). Medically documented injury with all of the following: B B B imaging finding(s) of healed compression fracture(s) with compression percentage less than or equal to 50%; residual symptoms consistent with the healed fracture(s); residual clinical findings consistent with the healed fracture(s).

Clinical findings are one or more of the following: spinal deformity; ROM limitation; sensory changes; weakness. Class 3(b). Medically documented injury with all of the following: C C C imaging finding(s) of healed compression fracture(s) with compression fracture percentage greater than 50%; residual symptoms consistent with the healed fracture(s); residual clinical findings consistent with the healed fractures.

Clinical findings are one or more of the following: spinal deformity; ROM limitation; sensory changes; weakness.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Table 11.3(a): Stable Compression/Burst Fracture Pattern Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 4. Medically documented injury with all of the following: C-H C-G D-J imaging finding(s) of healed compression fracture(s) with compression percentage See Tables See Tables See Tables

50%; S11.4, S11.5 S11.4 and S11.4, S11.6 residual symptoms consistent with the healed and S11.7** S11.7** to and S11.7** to fracture(s); to determine determine determine clinical neurologic findings consistent with placement placement placement radiculopathy. within range. within range. within range. (This (This (This excludes Clinical neurologic findings consistent with excludes excludes adjustments for radiculopathy are one or more of the following: adjustments adjustments multiple roots for multiple for multiple and root weakness in myotomal distribution and/or roots and roots and avulsion.) sensory changes in dermatomal distribution; root root or avulsion.) avulsion.) tension/compression signs; or objective clinical findings.*

Symptoms and findings must be consistent with: post-fracture imaging findings that can account for the symptoms; or post-fracture correlative electro-diagnostic findings of fibrillation potentials and/ or positive sharp waves seen in at least 2 muscles in the distribution of a nerve root. (Table S11.4) Class 5. Medically documented injury with all the following: *** See Spinal Cord Injury Table 11.8 imaging finding(s) of healed compression fracture(s); residual symptoms consistent with the healed fracture(s); clinical neurologic findings consistent with spinal cord or cauda equina injury.*** *Objective clinical findings mean atrophy or reflex changes. **Use Tables S11.4, S11.5 and S11.6 as appropriate to determine the number of points associated with the identified radiculopathy. Then use Table S11.7 to determine the letter that corresponds to the number of points. This letter is the Severity Ranking within the radiculopathy range.

Note: For discordant pain intensity, see Chapter 16, Pain.

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Table 11.3(b):Translation/Rotation Fracture Pattern (including PLC integrity) Typified by unilateral and bilateral dislocations, facet fracture dislocations, pars fractures with vertebral subluxation (traumatic spondylolisthesis).6

The impairments listed below are the same with or without surgery.

1. For compression/burst fractures, refer to Table 11.3(a).

2. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

3. The severity ranking is generally predictive of the functional outcome for each Class relative to the other Classes within a Table.

4. Please state diagnosis(es) at time of impairment rating.

5. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.3(b):Translation/Rotation Fracture Pattern (including PLC integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 1. Medically documented injury with all of the following: None None None imaging finding(s) of healed fracture(s); no residual symptoms; no clinical findings. Class 2. Medically documented injury with all of the following: A A A imaging finding(s) of healed displaced or non-displaced fracture(s); residual symptoms consistent with the healed fracture(s); no residual clinical findings of spinal deformity (kyphosis, scoliosis), tenderness, ROM limitation, sensory changes, or weakness.

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NYS Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity Ch. 11: Spine and Pelvis

Table 11.3(b):Translation/Rotation Fracture Pattern (including PLC integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 3. Medically documented injury with all of the following: C C C imaging finding(s) of healed displaced or non-displaced fracture(s) with residual symptoms consistent with the healed fracture(s); residual clinical findings consistent with the healed fracture(s).

Clinical findings are one or more of the following: spinal deformity; ROM limitation; sensory changes; weakness. Class 4(a). Medically documented injury with all of the following: C-H C-G D-J imaging finding(s) of healed displaced or non-displaced fracture(s); See Tables See Tables See Tables residual symptoms consistent with the healed S11.4, S11.5 S11.4 and S11.4, S11.6 fracture(s); and S11.7** S11.7** for and S11.7** clinical neurologic findings consistent with to determine determining for determining radiculopathy. placement placement placement within range. within range. within range. Clinical neurologic findings consistent with (This (This (This excludes radiculopathy are one or more of the following: excludes excludes adjustments for weakness in myotomal distribution and/or adjustments adjustments multiple roots sensory changes in dermatomal distribution; for multiple for multiple and root or roots and roots and avulsion.) tension/compression signs; root root or avulsion.) avulsion.) objective clinical findings.* Symptoms and findings must be consistent with: post-fracture imaging findings that can account for the symptoms; or post-fracture correlative electro-diagnostic findings of fibrillation potentials and/ or positive sharp waves seen in at least 2 muscles in the distribution of a nerve root. Class 4(b). Displaced spinal fractures/dislocations at two or more levels, add the following to the C C C severity rating for radiculopathy.

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Table 11.3(b):Translation/Rotation Fracture Pattern (including PLC integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR

Class 5. Medically documented injury with all of the following: See Table 11.8: Spinal Cord Injury imaging finding(s) of healed displaced or non-displaced fracture(s); residual symptoms consistent with the healed fracture(s); clinical neurologic findings consistent with spinal cord or cauda equina injury. *Objective clinical findings mean atrophy or reflex changes. **Use Tables S11.4, S11.5 and S11.6 as appropriate to determine the number of points associated with the identified radiculopathy. Then use Table S11.7 to determine the letter that corresponds to the number of points. This letter is the Severity Ranking within the radiculopathy range.

Note: For discordant pain intensity, see Chapter 16: Pain

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Table 11.3(c): Distraction Fracture Pattern (including PLC integrity)

Rostral spinal column becomes separated from posterior element. Fractures may be present. Kyphotic deformities. Often very unstable fractures. Angulation frequent at time of injury.7 8

The impairments listed below are the same with or without surgery.

1. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

2. The severity ranking is generally predictive of the functional outcome for each Class relative to the other Classes within a Table.

3. Please state diagnosis(es) at time of impairment rating.

4. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.3(c): Distraction Fracture Pattern (including PLC Integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR Class 1. Medically documented injury with all of the following: None None None imaging finding(s) of healed fracture(s); no residual symptoms; no clinical findings. Class 2. Medically documented injury with all of the following: A A A imaging finding(s) of healed displaced or non-displaced fracture(s); residual symptoms consistent with the healed fracture(s); no residual clinical findings of spinal deformity, ROM limitation, sensory changes, or weakness.

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Table 11.3(c): Distraction Fracture Pattern (including PLC Integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR Class 3. Medically documented injury with all of the following: C C C imaging finding(s) of healed displaced or non-displaced fracture(s) with residual symptoms consistent with the healed fracture(s); residual clinical findings consistent with the healed fracture(s). Clinical findings are one or more of the following: spinal deformity; ROM limitation; sensory changes; weakness. Class 4(a). Medically documented injury with all of the following: C-H C-G D-J imaging finding(s) of healed displaced or non-displaced fracture(s); See Tables See Tables See Tables S11.4, residual symptoms consistent with the S11.4, S11.5 S11.4 and S11.6 and S11.7** healed fracture(s); and S11.7** S11.7** for for determining to determine determining placement within clinical neurologic findings consistent with placement placement range. (This radiculopathy. within range. within range. excludes Clinical neurologic findings consistent with (This (This adjustments for radiculopathy are one or more of the following: excludes excludes multiple roots and weakness in myotomal distribution and/or adjustments adjustments root avulsion.) sensory changes in dermatomal for multiple for multiple distribution; roots and roots and or root root tension/compression signs; avulsion.) avulsion.) or objective clinical findings.*

Symptoms and findings must be consistent with: post-fracture imaging findings that can account for the symptoms; or post-fracture correlative electro-diagnostic findings of fibrillation potentials and/or positive sharp waves seen in at least 2 muscles in the distribution of a nerve root.

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Table 11.3(c): Distraction Fracture Pattern (including PLC Integrity) Medical Impairment Class Severity Ranking

CERVICAL THORACIC LUMBAR Class 4(b). Displaced spinal fractures/dislocations at two or more levels, C C C add the following to the severity rating for radiculopathy. Class 5. Medically documented injury with all See Table 11.8: Spinal Cord Injury of the following: imaging finding(s) of healed displaced or non-displaced fracture(s); residual symptoms consistent with the healed fracture(s); clinical neurologic findings consistent with spinal cord or cauda equina injury. *Objective clinical findings mean atrophy or reflex changes. **Use Tables S11.4, S11.5 and S11.6 as appropriate to determine the number of points associated with the identified radiculopathy. Then use Table S11.7 to determine the letter that corresponds to the number of points. This letter is the Severity Ranking within the radiculopathy range.

Note: For discordant pain intensity, see Chapter 16: Pain.

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Table S11.4: Radiculopathy Criteria

Residual radicular pain >6 months after surgery is usually investigated with post-operative imaging. Table S11.4: Radiculopathy Criteria Objective Documented Objective Findings at the Score Testing Time of Rating Imaging Findings of: significant disc abnormalities that displace nerve tissue Yes/No and/or Yes = 16 bony/mechanical nerve root encroachment evident on No=0 imaging.

These imaging findings must correlate with the clinical picture. EMG Findings of: Abnormalities fibrillation potentials Yes/No and/or Yes = 6 positive sharp waves No=0 seen in at least 2 muscles in the distribution of the involved nerve root(s).*

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Table S11.4: Radiculopathy Criteria Objective Documented Objective Findings at the Score Testing Time of Rating Muscle Findings of: Yes/No Involvement objective muscle weakness Yes = 6-20. See Table 11.4(a) and/or to determine value within range. No=0

muscle atrophy. For muscle atrophy, Yes/No. Yes = 6. Unilateral muscle atrophy shown: No=0. by obtaining bilateral circumferential measurements of the calf, thigh, arm or forearm or by inspection of the hand or foot muscles; with a recording at a specified distance from bony landmarks (such as medial malleolus, anterior superior iliac spine, medial or lateral epicondyle).

differences of less than 2 centimeters in measurement of the two limbs at the same level can be a normal variation, especially if the lesser measurement is on the non-dominant side.

symmetric muscle bulk and strength are expected unless the patient has a relatively long-standing neurologic impairment or disorder of the extremity muscle or joint.

An alternative method for detecting atrophy can be sequential measurements over time, providing measurements are taken at the same distance from bony landmarks as above. Sensory Findings, as determined by the clinical examination, imaging Yes/No Involvement studies and/or electrodiagnostic testing, of: reproducible alteration of sensation (sharp/dull, light Yes = 4-6 touch) consistent with specific dermatomal See Table 11.4(b) distribution; to determine value and within range) dermatomal distribution of sensory disturbances consistent with the location of the spinal lesion. No=0

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Table S11.4: Radiculopathy Criteria Objective Documented Objective Findings at the Score Testing Time of Rating Reflex Requires: Reflexes Changes loss of/or significantly diminished deep tendon (0 to +++) reflexes (biceps-tricepsbrachioradialis-patellar-or ankle jerk) as compared to the reactive non-affected Absent = 6 side. a difference of one or more grades in the reflex Present but response between the two sides is significant. diminished = 4 Reflexes: 0 Absent Normal = 0

• Present but diminished (++, +++) ++ Normal +++ Increased but not necessarily pathological Tension- Spurling's Sign** Yes/No Compression Straight Leg Raise*** Signs Femoral Stretch**** Yes = 4

*Electrodiagnostic Verification of Radiculopathy: Unequivocal electrodiagnostic evidence of acute nerve root pathology includes the presence of multiple sharp waves or fibrillation potentials in muscles innervated by one nerve root. However, the skills of the person performing and interpreting the study are critical. Electromyography (EMG) should be performed only by a licensed MD/DO qualified by reason of education, training and experience in these procedures who is in attendance while the procedure is being performed. EMG does not detect all compressive radiculopathies and cannot determine the cause of the nerve root pathology. On the other hand, EMG can detect non- compressive radiculopathies, which are not identified by imaging studies. Interpretation must be in accordance with the published guidelines of the American Association of Electrodiagnostic Medicine.10

** Spurling’s Sign is defined as pain in the distribution of a cervical nerve root that is produced by simultaneous neck extension, ipsilateral rotation, and axial compression.

***Straight Leg Raise is defined as pain in the distribution of the L5 or S1 lumbar nerve root that is produced when the ipsilateral hip is flexed from 30 degrees to 70 degrees, while the knee remains in full extension.

****Femoral stretch is defined as a pain in the distribution of the L2-L3-L4 nerve root that is produced when the patient is prone, the involved knee is flexed and the hip extended.

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Table S11.4(a). Motor Deficits: Categories for Determining Impairment Due To Loss of Function Resulting From Nerve Disorders (Upper or Lower Extremity Value)11 12

Grade Description of Motor Deficit Muscle Function 0 No contractions 20 1 Slight contraction and no 20 movement 2 Active movement (range of 18 motion as determined by passive measurement) with gravity eliminated 3 Active movement (range of 6 motion as determined by passive measurement) against gravity (without resistance) 4 Active movement (range of 0 motion as determined by passive measurement) against gravity with some resistance 5 Active movement (range of 0 motion as determined by passive measurement) against gravity with full resistance (no deficit)

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Table S11.4(b): Sensory Deficits: Categories For Determining Impairment Due To Nerve Root Disorders (Severity Multiplier)13

The dermatomal distribution of sensory disturbances should be consistent with the location of the spinal lesion as determined by clinical examination, imaging studies and/or electrodiagnostic testing. Description of Sensory Deficit Sensory Loss

Anesthesia Total sensory loss 6

Compromised Diminished or altered 4 sensation

Normal No loss of sensation 0

Note: For each additional root in the same spinal region (cervical or thoracic or lumbar), the Severity Ranking shall be increased by one letter per level, up to a maximum of 3 letters.

For root avulsion established by history, physical exam and proper imaging, the Severity Class shall be L for the non-dominant side and M for the dominant side; and for a flail limb (complete lower motor neuron paralysis of a limb), P for the non-dominant side and Q for the dominant side.

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Table S11.5: Spinal Nerve Root Impairment Affecting the Upper Extremity

Nerve Root Impaired Sensory Deficit Weakness C5 0 10 C6 6 10 C7 6 10 C8 4 12 T1 0 12

Table S11.6: Spinal Nerve Root Impairment Affecting the Lower Extremity

Nerve Root Impaired Sensory Deficit Weakness L3 0 12 L4 4 24 L5 4 16 S1 6 18

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Table S11.7: Radiculopathy Severity Rankings

To determine placement within the range of severity rankings for radiculopathy, follow these steps:

1. Determine the number of points from Tables S11.4(a), S11.4(b), S11.5 and S11.6, as applicable. a. Cervical: Tables S11.4(a), S11.4(b) and S11.5 b. Thoracic: Tables S11.4(a) and S11.4(b) c. Lumbar: Tables S11.4(a), S11.4(b) and S11.6

2. From either Table S11.7(a) (for cervical or thoracic injury) or Table S11.7(b) (for lumbar injury) below, determine the letter that corresponds to the number of points. This letter is the severity ranking.

Table S11.7(a): Points for Cervical and Thoracic Radiculopathy

Severity Ranking Cervical Thoracic C 0 0 D 4-16 4-16 E 17-32 17-32 F 33-48 33-48 G 49-64 49-64 H 65-80 -

Table S11.7(b): Points for Lumbar Radiculopathy

Severity Ranking Lumbar D 0 E 4-16 F 17-32 G 33-48 H 49-64 I 65-80 J 81-92

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Table 11.8: Spinal Cord Injury

The impairments listed below are the same with or without surgery.

1. This table refers to functional, not anatomic, levels of spinal cord injury.

2. Motor and sensory levels should be documented per ASIA Worksheet, Table S11.9.

3. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

4. The severity ranking is generally predictive of the functional outcome for each Class relativeto the other Classes within a Table.

5. Please state diagnosis(es) at time of impairment rating.

6. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity.

Table 11.8: Spinal Cord Injury Medical Impairment Class Severity Ranking Class 1(a). Medically documented injury with all of the following: Lumbar clinical neurologic findings consistent Incomplete with lumbar level spinal cord injury. L1 K Clinical neurologic findings consistent with a L2 lumbar level injury include one or more of the L3 following (incomplete injury*): paraparesis (may include cauda equina); motor weakness consistent with lumbar L4 E cord segmental level; sensory deficit consistent with lumbar cord segmental level; sensory testing is L5 D required to establish the lumbar cord sensory injury level; lower motor neuron findings including hypotonicity, areflexia, or atrophy.

Complete the ASIA Worksheet (Table S11.9).

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Table 11.8: Spinal Cord Injury Medical Impairment Class Severity Ranking Class 1(b). Medically documented injury with all of the following: Lumbar clinical neurologic findings consistent Complete with lumbar level spinal cord injury. L1 N Clinical neurologic findings consistent with a L2 lumbar level injury include one or more of the L3 following (complete injury**): paraplegia (may include cauda equina) motor weakness consistent with lumbar L4 F cord segmental level; sensory deficit consistent with lumbar cord segmental level; sensory testing is L5 E required to establish the lumbar cord sensory injury level; lower motor neuron findings including hypotonicity, areflexia or atrophy.

Complete the ASIA Worksheet (Table S11.9) Class 2(a). Medically documented injury with all of the following: Thoracic clinical neurologic findings consistent Incomplete with thoracic level spinal cord injury. T1 W Clinical neurologic findings consistent with a T2 thoracic level injury include one or more of the T3 following (incomplete injury*): paraparesis; motor weakness consistent with thoracic T4 Q cord segmental level; T5 sensory deficit consistent with thoracic T6 cord segmental level; sensory testing is required to establish the thoracic cord sensory injury level; T7 T8 N upper motor neuron findings including: T9 spasticity, hyperreflexia, Babinski sign, or clonus. lower motor neuron findings including hypotonicity, areflexia or atrophy; autonomic hyperreflexia. T10 T11 K Complete the ASIA Worksheet (Table S11.9) T12

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Table 11.8: Spinal Cord Injury Medical Impairment Class Severity Ranking Class 2(b). Medically documented injury with all of the following: Thoracic clinical neurologic findings consistent with Complete thoracic level spinal cord injury. T1 X Clinical neurologic findings consistent with a thoracic level injury include one or more of the following (complete injury**): T2 paraplegia; T3 T motor weakness consistent with thoracic T4 cord segmental level; T5 sensory deficit consistent with thoracic cord segmental level; sensory testing is required to establish the thoracic cord sensory injury T6 level; T7 Q T8 upper motor neuron findings including: T9 spasticity, hyperreflexia, Babinski sign, or clonus. lower motor neuron findings including T10 hypotonicity, areflexia or atrophy; T11 N autonomic hyperreflexia. T12 Complete ASIA Worksheet (Table S11.9). Class 3(a). Medically documented injury with all of the following: Cervical clinical neurologic findings consistent with Incomplete cervical level spinal cord injury. C1 Clinical neurologic findings consistent with a C2 Z cervical level injury include one or more of the C3 following (incomplete injury*): C4 quadriparesis; motor weakness consistent with cervical cord segmental level C5 Z sensory deficit consistent with cervical cord segmental level; sensory testing is required to establish the cervical cord sensory injury C6 Y level; upper motor neuron findings including: spasticity, hyperreflexia, Hoffman sign, C7 W Babinski sign, or clonus. lower motor neuron findings including C8-T1 W hypotonicity, areflexia or atrophy; autonomic hyperreflexia.

Complete ASIA Worksheet (Table S11.9).

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Table 11.8: Spinal Cord Injury Medical Impairment Class Severity Ranking Class 3(b). Medically documented injury with all of the following: Cervical clinical neurologic findings consistent Complete with cervical level spinal cord injury. C1 Clinical neurologic findings consistent with a C2 Z cervical level injury include one or more of the C3 following (complete injury**): C4 quadriplegia; motor deficit consistent with cervical cord segmental level; C5 Z sensory deficit consistent with cervical cord segmental level; sensory testing is required to establish the cervical cord C6 Y sensory injury level; upper motor neuron findings including: C7 Y spasticity, hyperreflexia, Hoffman sign, Babinski sign, or clonus. lower motor neuron findings including C8-T1 X hypotonicity, areflexia or atrophy; autonomic hyperreflexia.

Complete the ASIA Worksheet (Table S11.9). *Incomplete cord injury means the preservation of motor or sensory function below the level of injury, including the lowest sacral segments. (Preservation of voluntary anal sphincter contraction or peri-anal sensation). **Complete spinal cord injury means that there is no sensory or motor function preserved in the lowest sacral segment (S4-S5).

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Table S11.9: Standard Neurological Classification of Spinal Cord Injury Worksheet (ASIA Worksheet)14

1. The ASIA Worksheet should be used to document the neurologic findings associated with aspinal cord injury. The total point scores for Motor and Sensory on the ASIA Worksheet are not used in the Spinal Cord Injury Table and need not be calculated.

2. The following steps should be used to document the neurological findings, using theappropriate Worksheet sections: determine the sensory levels for right and left sides determine motor levels for right and left sides (see Number 3 below) determine the neurological level determine whether the injury is complete or incomplete

3. To document motor levels/findings, use the muscle grading system below. Grade Description 0 No contractions 1 Slight contraction and no movement 2 Active movement (range of motion as determined by passive measurement) with gravity eliminated 3 Active movement (range of motion as determined by passive measurement) against gravity (without resistance) 4 Active movement (range of motion as determined by passive measurement) against gravity with some resistance 5 Active movement (range of motion as determined by passive measurement) against gravity with full resistance (No deficit)

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Table 11.10: The Pelvis

1. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

2. The severity ranking is generally predictive of the functional outcome for each Class relative tothe other Classes within a Table.

3. Please state diagnosis(es) at time of impairment rating.

4. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity. Table 11.10: The Pelvis Medical Impairment Class Severity Ranking Class 1. Medically documented injury with: imaging finding(s) of healed non-displaced or None displaced fracture(s) or dislocation(s) with or without surgery no residual symptoms no clinical findings Class 2(a). Sacrum Medically documented injury with all of the following: C imaging finding(s) of healed, non-displaced or displaced sacral fracture(s) residual symptoms clinical findings consistent with the healed fracture(s)

Clinical findings are gait dysfunction and One or more of the following neurologic findings: reflex abnormalities in the bulbocavernosus, or anal wink reflexes sensory loss in a dermatomal distribution urinary or anal sphincter dysfunction* (decreased anal sphincter tone on rectal exam) bowel and/or bladder** dysfunction without incontinence

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Table 11.10: The Pelvis Medical Impairment Class Severity Ranking Class 2(b). Sacrum Medically documented injury with all of the following: I imaging finding(s) of healed, non-displaced or displaced sacral fracture(s) residual symptoms clinical findings consistent with the healed fracture(s)

Clinical findings are gait dysfunction and One or more of the following neurologic findings: saddle anesthesia urinary and/or fecal incontinence secondary to sacral nerve injury Class 3. Symphysis Pubis Medically documented injury with all of the following: A imaging finding(s) of pubic symphysis separation or displacement residual symptoms clinical findings consistent with the separation or displacement

Clinical findings are one or more of the following: asymmetry or deformity tenderness pain over symphysis pubis on provocative testing gait dysfunction Class 4. Coccyx Medically documented injury with all of the following: A imaging finding(s) of healed, non-displaced or displaced coccyx fracture(s) residual symptoms clinical findings consistent with the healed fracture(s)

Clinical findings are one or both of the following: tenderness elicited upon provocative exam reproduction of pain by mobilization of coccyx on rectal exam

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Table 11.10: The Pelvis Medical Impairment Class Severity Ranking Class 5. Sacroiliac Joint Dysfunction Medically documented injury with all of the following: A-C imaging finding(s) of healed displaced sacroiliac fracture(s) involving the sacroiliac joint or dislocation of the sacroiliac joint residual symptoms clinical findings consistent with the healed fracture(s) or dislocation

Clinical findings are one or more of the following: deformity tenderness pain elicited upon provocative testing -positive Patrick’s sign *** -positive Gaenslen’s sign**** gait dysfunction Class 6. Ramus/Rami Medically documented injury with all of the following: A-B imaging finding(s) of healed, non-displaced or displaced single ramus, or bilateral and/or superior and inferior rami fracture(s) residual symptoms clinical findings consistent with the fracture(s)

Clinical findings are one or more of the following: deformity leg-length discrepancy of > one inch identified by measurement and a positive Galeazzi test***** gait dysfunction positive Patrick sign*** Class 7. Ilium Medically documented injury with the following: B-C imaging finding(s) of healed, non-displaced or displaced iliac fracture(s) residual symptoms may have clinical findings consistent with the fracture(s) and correlated with residual symptoms

Clinical findings may be one or more of the following: deformity leg-length discrepancy of > one inch identified by measurement and a positive Galeazzi test***** gait dysfunction range of motion limitation disuse atrophy

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Table 11.10: The Pelvis Medical Impairment Class Severity Ranking Class 8. Ischium Medically documented injury with all of the following: B-C imaging finding(s) of healed, non-displaced or displaced ischium fracture(s) residual symptoms clinical findings consistent with the fracture(s)

Clinical findings are one or more of the following: tenderness gait dysfunction straight leg raise limited by pain in area of injury positive Patrick sign*** MRI-partial or complete avulsion hamstring tendon

Class 9. Acetabulum Medically documented injury with all of the following: Evaluate based on restricted range of imaging finding(s) of acetabular fracture(s) motion (ROM) of hip joint (LE) residual symptoms Schedule Loss clinical findings consistent with the fracture(s)

Clinical findings are one or more of the following: limited range of motion gait dysfunction positive Patrick sign***

• Sphincter EMG will demonstrate the presence of denervation.

** Bladder dysfunction should be corroborated with bladder function studies, including ultrasound or catheterization to measure residual volumes and/or cystometry.

*** Patrick sign: Knee on affected side is flexed to 90 degrees and the foot on the affected side rests on the opposite knee. While the examiner holds the pelvis firm against the exam table, the affected hip is externally rotated by pushing the knee on the affected side laterally toward the exam table. Pain during this maneuver is considered a positive test.

**** Gaenslen’s sign: The patient is supine with the painful side as close as possible to the edge of the examining table or projecting beyond it. To stabilize this position and immobilize the lumbar spine, the patient flexes the knee and hip of the contralateral leg and draws the leg as close to the torso as possible. The examiner then passively hyperextends the other leg (the one not in contact with the table). If there is dysfunction in the sacroiliac (SI) joint, hyperextension of the leg will lead to motion in the SI joint causing pain or exacerbation of existing pain.

***** Galeazzi test: The patient is supine with the knees flexed 90 degrees and the soles of the feet flat on the examining table. The examiner evaluates the position of both knees from the end of the table and from the side. Normally both knees are at the same level. Where one knee is higher than the other, either the tibia on that side is longer or the contralateral side is shorter. Where one knee projects farther forward than the other, either that femur is longer or the contralateral femur is shorter.

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than Asthma)

Table 12.1: Pneumoconioses and other Occupational Respiratory Diseases (other than Asthma)

1. Radiographic or pathology findings are required to establish the diagnosis of pneumoconiosis.

2. The severity of radiographic changes does not influence the degree of impairment.

3. For rating objective pulmonary test results, see Table S12.7, entitled Severity of Pulmonary Function Test Abnormality. To identify the predicted and lower limits of normal (LLN) values for FEV1 and FVC, see Tables S12.8(a), S12.8(b), S12.9(a) and S12.9(b) and for predicted DLco values see Table S12.10(a) and S12.10(b).

4. For evaluating degree of dyspnea, see Table S12.13: Dyspnea Evaluation Questionnaire.

5. In the event that objective tests (spirometry or diffusing capacity [DLco]) indicate different impairment categories, use the more severe category. If the degree of dyspnea indicates a less severe impairment category than the objective test results, then the objective test results control the selection of the impairment category. If the degree of dyspnea indicates a more severe impairment category than the objective test results, then a cardiopulmonary exercise test is indicated. If the cardiopulmonary exercise test yields a VO2 max less than 84% of predicted, then the severity class is increased by one level from what the result would have been if determined by the original objective test results. See Table S12.11 and Table S12.12 and the related example of the impact of the cardiopulmonary exercise test on category placement.

6. Findings on physical examination of the lung have not been included as criteria in the impairment categories since they have not been demonstrated to predict function.

7. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

8. The severity ranking is generally predictive of the functional result for each Class relative to the other Classes within a Table.

9. Please state diagnosis(es) at time of impairment rating.

The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity.

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Table 12.1: Pneumoconioses and other Occupational Respiratory Diseases (other than Asthma) Medical Impairment Class Severity Ranking Class 1. Medically documented workplace exposure with all of the following: None no symptoms abnormal x-ray findings that can be medically attributed to (correlated with) the exposure and normal pulmonary function tests or no prior PFT data available or no loss of function in excess of age effect. Class 2. Medically documented workplace exposure with all of the following: None no symptoms normal pulmonary function tests loss of pulmonary function: FEV1 in excess of age effect (Table S12.6). Class 3. Medically documented workplace exposure with all of the following: A mild dyspnea normal pulmonary function tests, including spirometry, DLco and exercise testing. Class 4. Medically documented workplace exposure with: D mild dyspnea and abnormal pulmonary function tests as follows: (a) normal spirometry and lung volumes

with one of the following

(b) DLco >60% predicted but <80% predicted or (c) oxygen desaturation with exercise

20 mmHg decrease in PaO2 and/or 4% decrease in SaO2 or (d) abnormal cardiopulmonary stress test (exercise test) showing impairment of pulmonary function.

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Table 12.1: Pneumoconioses and other Occupational Respiratory Diseases (other than Asthma) Medical Impairment Class Severity Ranking Class 5. Medically documented workplace exposure with: E mild dyspnea and abnormal pulmonary function tests (a) FEV1 >70% but less than LLN or (b) DLco >40% predicted but <80% predicted. Class 6. Medically documented workplace exposure with: G moderate dyspnea and abnormal pulmonary function tests (a) FEV1 >70% predicted but less than LLN or (b) DLco >40% predicted but <80% predicted. Class 7. Medically documented workplace exposure with: I moderate dyspnea and abnormal pulmonary function tests (a) FEV1 60-69% predicted or (b) DLco >40% predicted but <80% predicted. Class 8. Medically documented workplace exposure with: L moderate dyspnea, and abnormal pulmonary function tests (a) FEV1 50-59% predicted or (b) DLco >40% predicted but <80% predicted. Class 9. Medically documented workplace exposure with: M moderately severe dyspnea and abnormal pulmonary function tests (a) FEV1 60-69% predicted or (b) DLco >40% predicted but <80% predicted.

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Table 12.1: Pneumoconioses and other Occupational Respiratory Diseases (other than Asthma) Medical Impairment Class Severity Ranking Class 10. Medically documented workplace exposure with: O moderately severe dyspnea and abnormal pulmonary function tests (a) FEV1 50-59% predicted or (b) DLco >40% predicted but <80% predicted. Class 11. Medically documented workplace exposure with: R severe dyspnea and abnormal pulmonary function tests (a) FEV1 50-59% predicted or (b) DLco >40% predicted but <80% predicted. Class 12. Medically documented workplace exposure with T severe dyspnea and abnormal pulmonary function tests (a) FEV1 50-59% predicted or (b) DLco <40% predicted.

Class 13. Medically documented workplace exposure with: V severe dyspnea and abnormal pulmonary function tests (a) FEV1 35-49% predicted or (b) DLco <40% predicted. Class 14. Medically documented workplace exposure with: X severe dyspnea and abnormal pulmonary function tests (a) FEV1 <35% predicted or (b) DLco <40 % predicted.

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Table 12.1: Pneumoconioses and other Occupational Respiratory Diseases (other than Asthma) Medical Impairment Class Severity Ranking Class 15. Medically documented workplace exposure with: Y very severe dyspnea and abnormal pulmonary function tests (a) FEV1 35-49% predicted or (b) DLco <40 % predicted.

Class 16. Medically documented workplace exposure with: Z very severe dyspnea and abnormal pulmonary function tests (a) FEV1<35% predicted or (b) DLCO <40 % predicted.

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NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Table 12.2: Asthma15

1. For rating objective pulmonary test results, see Table S12.7 entitled Severity of Pulmonary Function Abnormality. To identify the predicted and lower limits of normal (LLN) valuesfor FEV1 and FVC, see Tables S12.8(a), S12.8(b), S12.9(a), and S12.9(b).

2. In order to be rated for asthma, there should be a diagnostic workup that confirms the diagnosis of asthma. To establish a diagnosis of asthma, the clinician should determine that all of the following are present: i. There is a compatible history of episodic symptoms. Asthma symptoms include cough, sputum, wheeze, chest tightness, or breathlessness and are usually worse at night. ii. Airflow obstruction that is at least partially reversible, either spontaneously or after treatment OR the presence of airway hyper responsiveness to methacholine orhistamine in the absence of airflow limitation a. Spirometry is used to demonstrate airflow obstruction. Significant reversibility is defined as an increase in FEV1 or FVC of > 12% AND of > 200 ml from baseline measure after inhalation of a short acting B-agonist and/or a trial of corticosteroids.16 b. Airway hyper responsiveness is considered present when the PC20 is less than 16 mg/ml of methacholine17 (PC20 is the provocative concentration of methacholine that causes a 20% fall in FEV1 values from baseline.) and iii. Alternative diagnoses are excluded.

3. Work-related asthma is the broad term that refers to asthma that is induced (occupational asthma) or exacerbated (work aggravated/exacerbated) by inhalation exposures at work.

4. Occupational asthma (OA) can be (1) de novo asthma or (2) recurrence of previously quiescent asthma, induced either by sensitization to a specific substance or a chemical at work (sensitizer-induced OA) or by exposure to an inhaled irritant at work (irritant-induced asthma).

5. Work aggravated/exacerbated asthma refers to pre-existing asthma that is made worse by inhalation exposure to airborne irritants or allergens at the workplace.18

6. If an injured worker does not meet all the necessary requirements for any one Medical Impairment Class, then in determining the appropriate Class, objective tests should be given greater weight than other criteria.

7. Severity rankings are from “A” (the least severe medical impairment) to “Z” (the most severe medical impairment) for the Medical Impairment Classes within a Table.

8. The severity ranking is generally predictive of the functional result for each Class relativeto the other Classes within a Table.

9. Please state diagnosis(es) at time of impairment rating.

10. The medical impairment ranking is not to be used as a direct translation to loss of wage earning capacity.

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Table 12.2: Asthma Medical Impairment Class Severity Ranking Class 1(a). Intermittent Asthma Symptoms: <2 days/week A or nighttime awakening because of asthma symptoms <2x /month,

and all of the following:

Degree of interference with normal activity due toasthma symptoms: no interference

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm) <2 days/week.

Lung Function: normal FEV1 between exacerbations, FEV1 >80% predicted, normal FEV1/FVC between exacerbations.

Exacerbations: 0-1 x /year exacerbations requiring systemic oral corticosteroids. Class 1(b). Intermittent Asthma Symptoms: <2 days/week, B or nighttime awakening because of asthma symptoms <2x /month,

and all of the following:

Interference with normal activity because of asthma symptoms: No interference

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm) <2 days/week

Lung Function: Normal FEV1 between exacerbations, FEV1 >80% predicted, Normal FEV1/FVC between exacerbations.

Exacerbations :

2x /year requiring systemic oral corticosteroids.

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Table 12.2: Asthma Medical Impairment Class Severity Ranking Class 2(a). Persistent Mild Asthma Symptoms:

2 days/week but not daily, D or nighttime awakening because of asthma symptoms 3 – 4x /month,

and all of the following:

Degree of interference with normal activity because ofasthma symptoms: Minor limitation of normal activity.

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm):

2 days/week but not daily and not more than 1x on any day.

Lung Function: FEV1 >80% predicted and FEV1/FVC normal between exacerbations.

Exacerbations : 0-1x /year requiring systemic oral corticosteroids.

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Table 12.2: Asthma Medical Impairment Class Severity Ranking Class 2(b). Persistent Mild Asthma Symptoms:

2 days/week but not daily, F or nighttime awakening because of asthma symptoms 3 – 4x /month,

and all of the following:

Degree of interference with normal activity because ofasthma symptoms: Minor limitation of normal activity.

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm)

2 days/week but not daily, and not more than 1x on any day.

Lung Function: FEV1 >80% predicted and FEV1/FVC normal between exacerbations.

Exacerbations :

2 x/year requiring systemic oral corticosteroids. Class 3. Persistent Moderate Asthma Symptoms: daily symptoms L or nighttime awakening because of asthma symptoms > 1 x/week, but not nightly

and of the following

Degree of interference with normal activity because ofasthma symptoms: some limitation of normal activity.

Rescue medication need: Short-acting beta-2 agonist for symptom control (but not for prevention of exercise induced bronchospasm) not more than 1x /day.

Lung Function: FEV1 between exacerbations >60% but <80% predicted, or FEV1/FVC reduced by <5% of predicted.

Exacerbations :

1x/year requiring systemic oral corticosteroids.

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Table 12.2: Asthma Medical Impairment Class Severity Ranking Class 4. Severe Persistent Symptoms: symptoms throughout the day R or nightly awakening because of asthma symptoms

and all of the following:

Degree of interference with normal activity because ofasthma symptoms: extremely limited normal activity.

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm) several times per day.

Lung Function: FEV1 between exacerbations <60% predicted, or FEV1/FVC reduced by >5% predicted between exacerbations.

Exacerbations :

1x/year requiring systemic oral corticosteroids. Class 5. Severe Persistent Symptoms: symptoms throughout the day or nightly awakening because of asthma symptoms Z and all of the following:

Degree of interference with normal activity because of asthma symptoms: extremely limited normal activity.

Rescue medication need: Short-acting beta-2 agonist for symptom control (but NOT for prevention of exercise induced bronchospasm) several times per day.

Lung Function: FEV1 between exacerbations <35% predicted,

Exacerbations:

1x/year requiring systemic oral corticosteroids

Note: Current treatment recommendations state that patients with Occupational Sensitizer-Induced Asthma should not return to work in jobs that may result in exposure to the identified causing agent, even if patients are asymptomatic.

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Table S12.3: Examples of Potential Causes of Asthma from Sensitizers19 This list is illustrative of substances which can cause asthma and is not complete.

1. Animals and birds (including their parts, bedding, and waste)
2. Seafood (e.g., crab, shrimp) and fish
3. Insects (e.g., cockroaches) and insect parts
4. Plant parts, including wood and grain dusts, vegetable gums, and baking flour
5. Pharmaceuticals and enzyme powders (e.g., detergents and dough additives)
6. Diisocyanates (e.g., in glues, coatings, paints)
7. Anhydrides (in epoxy, resins, plastics)
8. Amines (in shellac, lacquer, hairdressing, paint, plastics, resins)
9. Solder fluxes, colophony
10. Metal dusts and salts (e.g., platinum, nickel, cobalt, chromium)

Table S12.4: Examples of Potential Causes of Asthma from Irritants This list is illustrative of substances which can cause asthma and is not complete.

1. Chlorine
2. Ammonia
3. Sulfur dioxide
4. Nitrogen oxides
5. Phosgene
6. Smoke
7. High level irritant dust

NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Table 12.5: Lung Cancer

All persons with lung cancer are severely impaired at diagnosis in the anticipation that treatment of cancer will result in temporary significant impairment. At re-evaluation one year after diagnosis is established, if the patient is found to be free of all evidence of tumor, that person is evaluated according to criteria listed in Table 12.1.

If there is still evidence of tumor, the patient is considered severely or totally impaired.

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NY WCB Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity, December 2012, effective 2012-12-01.

Table S12.6: Fifth Percentile Values of % FEV1 Loss by Test Interval (years) and Gender20 Test Interval, Years % FEV1 loss/year Men Women 1 - 10.4 - 10.6 2 - 6.1 - 6.4 3 - 4.6 - 4.8 4 - 3.8 - 4.0 5 - 3.2 - 3.6

To determine loss of pulmonary function in excess of aging process:

1. For comparisons between tests performed within 1-to-5 years-time-span a. Subtract the most recent measured FEV1 value in milliliters available for comparison from theinitial FEV1 value in milliliters.

b. Divide the value obtained in “a” by the initial FEV1 value in milliliters and multiply the result by 100. This provides loss of % FEV1 over the time interval considered for comparison.

c. Divide the value obtained in “b” by the number of years between the two tests consideredfor comparison. This provides loss of % FEV1 per year.

d. Compare the loss of %FEV1/yr obtained with the %FEV1/yr in Table 12.6, above. If the value obtained in “c” is in excess of the value noted in the table for the corresponding time-interval, the loss of pulmonary function is in excess of the aging process.

Examples: (i). 47-year-old male worker with a history of exposure to silica-containing dust while working for a company since the age of 25. Initial pulmonary function test done in 2004 revealed an FEV1 of 2,580 ml. A follow up test done in 2009 revealed an FEV1 of 2,140 ml. Is the loss in pulmonary function due to the aging process only?

a. Most recent FEV1 – initial FEV1: (2,140) – (2,580) = - 440 ml b. -440/2,580 = - 0.1705 x 100 = - 17.05%, loss of pulmonary function over 5 years c. -17.05/5 = -3.41%/year d. As per comparison with the reference Table 12.2, a loss of 3.41%/year is in excess of 3.2%/year; therefore, this is considered a loss of pulmonary function in excess of that due to the aging process.

(ii). 35-year-old male worker followed up for exposure to dust at work. Initial pulmonary function tests at age 30 revealed an FEV1 of 4,390 ml. Follow up tests done at age 33 revealed an FEV1 of 4,220. Is the loss in pulmonary function due to the aging process only?

a. Most recent FEV1 – initial FEV1: (4,220) – (4,390) = –170 ml b. – 170/4,390 = –0.0387 x 100 = –3.87%, loss of pulmonary function over 3 years. c. –3.87/3 = –1.29%/year d. As per comparison with the reference Table 12.2, a loss of 1.29% over a three-year interval is less than 4.6%; therefore, this is considered aging-related loss of pulmonary function.

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2. For comparisons of PFTs over time intervals longer than 5 years21 22 a. Subtract the most recent FEV1 value in milliliters from the initial FEV1 value in milliliters and divide by the number of years. This reflects loss of FEV1 in ml/yr. b. A loss of FEV1 in excess of 50 ml/yr is considered a loss of pulmonary function in excess of theaging effect.

3. For comparisons of PFTs for time intervals of less than 1 year23 For tests performed in intervals of less than one year, a change in FEV1 of greater than 7.1% is considered a loss of pulmonary function in excess of age.

4. General rules, comparability of pulmonary function tests24 25 Specific recommendations developed by the American Thoracic Society and other professional organizations to ensure accurate and reproducible measurements when using spirometers and spirometry testing have been developed and should be followed when performing PFTs and evaluating changes over time.

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Table S12.7: Severity of Pulmonary Function Test Abnormality26

Table S12.7(a) Degree of Severity of Any Spirometric Abnormality Based on Decrease in FEV127

Degree of severity FEV1 % predicted Mild >70% Moderate 60-69% Moderately severe 50-59% Severe 35-49% Very Severe <35%

Table S12.7(b) Degree of Severity of Decrease in Diffusing Capacity28

Degree of severity DLco % predicted Mild > 60% and < 80% Moderate 40-60% Severe < 40% Diffusing capacity should be altitude-adjusted and hemoglobin-adjusted.

Diffusing Capacity:29 Altitude adjusted DLco = measured DLco x [1 x 0.0035 (PAO2 –120)], or Altitude adjusted DLco = measured DLco x [1 x 0.0031 (PiO2 –150)], Estimated PiO2 = 0.21(PB – 47) Hemoglobin-adjusted DLco = observed DLco (10.22 + Hb)/1.7 Hb for adolescent and adult male Hemoglobin-adjusted DLco = observed DLco (9.38 + Hb)/1.7 Hb for children under 15 and women30

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Table S12.8(a): Prediction and Lower Limits of Normal Equations for Spirometric Parameters for Male Subjects31 Subjects Intercept Age Age2 Ht PRD Ht LLN R2 (cm)2* (cm)2* Caucasian <20 yr of age

FEV1 -0.7453 -0.04106 0.004477 0.00014098 0.00011607 0.8510 FEV6 -0.3119 -0.18612 0.009717 0.00018188 0.00015323 0.8692 FVC -0.2584 -0.20415 0.010133 0.00018642 0.00015695 0.8668 PEF -0.5962 -0.12357 0.013135 0.00024962 0.00017635 0.7808 FEF 25-75 -1.0863 0.13939 0.00010345 0.00005294 0.5601

Caucasian ≥20 yr of age

FEV1 0.5536 -0.01303 -0.000172 0.00014098 0.00011607 0.8510 FEV6 0.1102 -0.00842 -0.000223 0.00018188 0.00015323 0.8692 FVC -0.1933 0.00064 -0.000269 0.00018642 0.00015695 0.8668 PEF 1.0523 0.08272 -0.001301 0.00024962 0.00017635 0.7808 FEF 25-75 2.7006 -0.04995 0.00010345 0.00005294 0.5601.

African- American <20 yr of age

FEV1 -0.7048 -0.05711 0.004316 0.00013194 0.00010561 0.8080 FEV6 -0.5525 -0.14107 0.007241 0.00016429 0.00013499 0.8297 FVC -0.4971 -0.15497 0.007701 0.00016643 0.00013670 0.8303 PEF -0.2684 -0.28016 0.018202 0.00027333 0.00018938 0.7299 FEF 25-75 -1.1627 0.12314 0.00010461 0.00004819 0.4724

African- American ≥20 yr of age

FEV1 0.3411 -0.02309 0.00013194 0.00010561 0.8080 FEV6 -0.0547 -0.02114 0.00016429 0.00013499 0.8297 FVC -0.1517 -0.01821 0.00016643 0.00013670 0.8303 PEF 2.2257 -0.04082 0.00027333 0.00018938 0.7299 FEF 25-75 2.1477 -0.04238 0.00010461 0.00004819 0.4724

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Table S12.8(a): Prediction and Lower Limits of Normal Equations for Spirometric Parameters for Male Subjects31 Subjects Intercept Age Age2 Ht PRD Ht LLN R2 (cm)2* (cm)2* Mexican- American <20 yr of age

FEV1 -0.8218 -0.04248 0.004291 0.00015104 0.00012670 0.8536 FEV6 -0.6646 -0.11270 0.007306 0.00017840 0.00015029 0.8657 FVC -0.7571 -0.09520 0.006619 0.00017823 0.00014947 0.8641 PEF -0.9537 -0.19602 0.014497 0.00030243 0.00021833 0.7530 FEF 25-75 -1.3592 0.10529 0.00014473 0.00009020 0.5482

Mexican- American ≥20 yr of age

FEV1 0.6306 -0.02928 0.00015104 0.00012670 0.8536 FEV6 0.5757 -0.02860 0.00017840 0.00015029 0.8657 FVC 0.2376 -0.00891 -0.000182 0.00017823 0.00014947 0.8641 PEF 0.0870 0.06580 -0.001195 0.00030243 0.00021833 0.7530 FEF 25-75 1.7503 -0.05018 0.00014473 0.00009020 0.5482

*Ht PRD coefficient is used for prediction equation and Ht LLN is used (replaces Ht PRD) for the lower limit of normal equation. Lung function parameter = b0 +b1 + * age + b2 * age 2 = b3 * height2

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Table S12.8(b): Prediction and Lower Limits of Normal Equations for Spirometric Parameters for Female Subjects32

Subjects Intercept Age Age 2 Ht PRD Ht LLN R2 (cm)2* (cm)2* Caucasian <18 yr of age

FEV1 -0.8710 0.06537 0.00011496 0.00009283 0.7494 FEV6 -1.1925 0.06544 0.00014395 0.00011827 0.7457 FVC -1.2082 0.05916 0.00014815 0.00012198 0.7344 PEF -3.6181 0.60644 -0.016846 0.00018623 0.00012148 0.5559 FEF 25-75 -2.5284 0.52490 -0.015309 0.00006982 0.00002302 0.5005

Caucasian ≥18 yr of age

FEV1 0.4333 -0.00361 -0.000194 0.00011496 0.00009283 0.7494 FEV6 -0.1373 0.01317 -0.000352 0.00014395 0.00011827 0.7457 FVC -0.3560 0.01870 -0.000382 0.00014815 0.00012198 0.7344 PEF 0.9267 0.06929 -0.001031 0.00018623 0.00012148 0.5559 FEF 25-75 2.3670 -0.01904 -0.000200 0.00006982 0.00002302 0.5005

African- American <18 yr of age

FEV1 -0.9630 0.05799 0.00010846 0.00008546 0.6687 FEV6 -0.6370 -0.04243 0.003508 0.00013497 0.00010848 0.6615 FVC -0.6166 -0.04687 0.003602 0.00013606 0.00010916 0.6536 PEF -1.2398 0.16375 0.00019746 0.00012160 0.4736 FEF 25-75 -2.5379 0.43755 -0.012154 0.00008572 0.00003380 0.3787

African- American ≥18 yr of age

FEV1 0.3433 -0.01283 -0.000097 0.00010846 0.00008546 0.6687 FEV6 -0.1981 0.00047 -0.000230 0.00013497 0.00010848 0.6615 FVC -0.3039 0.00536 -0.000265 0.00013606 0.00010916 0.6536 PEF 1.3597 0.03458 -0.000847 0.00019746 0.00012160 0.4736 FEF 25-75 2.0828 -0.03793 0.00008572 0.00003380 0.3787

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Table S12.8(b): Prediction and Lower Limits of Normal Equations for Spirometric Parameters for Female Subjects32

Subjects Intercept Age Age 2 Ht PRD Ht LLN R2 (cm)2* (cm)2* Mexican- American <18 yr of age

FEV1 -0.9641 0.06490 0.00012154 0.00009890 0.7268 FEV6 -1.2410 0.07625 0.00014106 0.00011480 0.7208 FVC -1.2507 0.07501 0.00014246 0.00011570 0.7103 PEF -3.2549 0.47495 -0.013193 0.00022203 0.00014611 0.4669 FEF 25-75 -2.1825 0.42451 -0.012415 0.00009610 0.00004594 0.4305

Mexican- American ≥18 yr of age

FEV1 0.4529 -0.01178 -0.000113 0.00012154 0.00009890 0.7268 FEV6 0.2033 0.00020 -0.000232 0.00014106 0.00011480 0.7208 FVC 0.1210 0.00307 -0.000237 0.00014246 0.00011570 0.7103 PEF 0.2401 0.06174 -0.001023 0.00022203 0.00014611 0.4669 FEF 25-75 1.7456 -0.01195 -0.000291 0.00009610 0.00004594 0.4305

*Ht PRD coefficient is used for prediction equation and Ht LLN is used (replaces Ht PRD) for the lower limit of normal equation. Lung function parameter = b0 +b1 + * age + b2 * age 2 = b3 * height2

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Table S12.9(a): Prediction and Lower Limits of Normal Equations for FEV1/FEV6 % and FEV1/FVC % for Male Subjects33 Subjects Intercept PRD* Age Intercept LLN* R2 Caucasian

FEV1/FEV6 % 87.340 -0.1382 78.372 0.2151 FEV1/FVC % 88.066 -0.2066 78.388 0.3448

African- American

FEV1/FEV6 % 88.841 -0.1305 78.979 0.0937 FEV1/FVC % 89.239 -0.1828 78.822 0.1538

Mexican- American

FEV1/FEV6 % 89.388 -0.1534 80.810 0.1711 FEV1/FVC % 90.024 -0.2186 80.925 0.2713

*Intercept PRD is used for prediction equation and Intercept LLN is used (replaces Intercept PRD) for the lower limit of normal equation. Lung function parameter = b0 + b1 * age.

Table S12.9(b): Prediction and Lower Limits of Normal Equations for FEV1/FEV6 % and FEV1/FVC % for Female Subjects34

Subjects Intercept PRD* Age Intercept LLN* R2 Caucasian

FEV1/FEV6 % 90.107 -0.1563 81.307 0.3048 FEV1/FVC % 90.809 -0.2125 81.015 0.3955

African- American

FEV1/FEV6 % 91.229 -0.1558 81.396 0.1693 FEV1/FVC % 91.655 -0.2039 80.978 0.2284

Mexican- American

FEV1/FEV6 % 91.664 -0.1670 83.034 0.2449 FEV1/FVC % 92.360 -0.2248 83.044 0.3352

*Intercept PRD is used for prediction equation and Intercept LLN is used (replaces Intercept PRD) for the lower limit of normal equation. Lung function parameter = b0 + b1 * age.

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Table S12.10(a): DLCO Reference Equations for Men35

Reference No. N Equation r2 SEE Smoking Status 96 84 6.8-0.238A+15.5 * 5.04 * BSA 45 227 0.325H-0.200A- * 5.10 * 17.6 102 * 3.75VA- * * * 0.153A+19.93 98† 123 0.410H-0.210A- 0.60 4.82 NS 26.31 83 74 0.1646H- 0.46 4.84 NS 0.229A+12.9113 101 80 0.441H- 0.32 5.79 NS 0.1936A-31.3822 99 71 0.3551H- 0.67 4.57 NS 0.2741A-11.3527 4 ‡ 0.3319H- 0.79 4.21 * 0.1971A-18.006 119 194 0.3674H- 0.45 4.40 NS 0.1961A-21.8982 Definitions: VA = alveolar volume in L STPD; H = height in cm; A = age in years; W = weight in kg; BSA = body surface area; ECCS = European Community for Coal and Steel; NS = nonsmokers; ES = ex- smokers; r2 = coefficient of determination; SEE= standard of error of the estimate. Estimates of regression variability are listed under SEE regardless of how the author labeled the variability. *Information not available in reference. † Adjusted to a standard hemoglobin concentration of 14.6 g/dl. ‡ Summary equations from several studies.

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Table S12.10(b): DLCO Reference Equations for Women36

Reference No. N Equation r2 SEE Smoking Status 96 51 0.5- * 5.04 * 0.117A+15.5BSA 120 41 0.212H-0.156A- * 3.69 * 2.66 102 * 5.38VA- * * * 0.083A+7.72 98§ 122 0.256H-0.144A- 0.56 3.57 NS 8.36 83 159 0.1602H- 0.54 3.95 NS+ES 0.1111A+2.2382 101 291 0.1569H- 0.09 4.31 NS 0.0677A+5.0767 99 99 0.1872H- 0.38 4.50 NS 0.1460A+3.8821 4 ‡ 0.2441H-0.1463A- 0.44 3.49 * 8.20 119 167 0.1369H- 0.37 2.91 NS 0.1233A+0.0917W +1.8879 Definitions: VA = alveolar volume in L STPD; H = height in cm; A = age in years; W = weight in kg; BSA = body surface area; ECCS = European Community for Coal and Steel; NS = nonsmokers; ES = ex- smokers; r2 = coefficient of determination; SEE= standard of error of the estimate. Estimates of regression variability are listed under SEE regardless of how the author labeled the variability. *Information not available in reference. ‡ Summary equations from several studies. § No adjustment for hemoglobin (Hb) concentration; average Hb for the study population was 13.3g/dl.

Table S12.11: Selected Reference Values for Maximal Incremental Cycle Exercise Test37

Variables Equations* VO2 ml/min, male W x [50.75 – 0.372 (A)] VO2 ml/min, female (W + 43) x [22.78 – 0.17 (A)] HR, beats/min 210 x 0.65 (A) † O2 pulse, ml/beat Predicted VO2 max/predicted HR max VE/MVV, % ~72 + 15 AT, L/min (VO2) > 40% V pred

Definitions: AT = Anaerobic threshold; HR = heart rate; VE = minute ventilation; VO2 = oxygen uptake. *Age (A): years; height (H): centimeters; weight (W): kilograms. Predicted weight men: 0.79 x H – 60.7. Predicted weight women: 0.65 x H – 42.8. When actual weight > predicted, the predicted weight should be used in the equations. Wasserman and colleagues introduced new corrections factors which have not yet been published in peer reviewed journals. † See Lange-Andersen and coworkers

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Table S12.12: Suggested Normal Guidelines for Interpretation of Cardiopulmonary Exercise Testing Results

Maximum or peak cardiopulmonary responses except for anaerobic threshold and VE/VCO2 at AT38 Variables Criteria of Normality VO2 max or VO2 peak >84% predicted Anaerobic threshold >40% VO2 max predicted; wide range of normal (40-80%) Heart rate (HR) HR max >90% age predicted Heart Rate Reserve (HRR) HRR<15 beats/min Blood Pressure <220/90 O2 pulse (VO2/HR) >80% Ventilatory reserve (VR) MW – VE max: >11 L or VE max/MVV x 100: <85%. Wide normal range: 72 + 15% Respiratory frequency (fR) <60 breaths/min VE/VCO2 (at AT) <34 VD/VT <0.28; <0.30 for age > 40 years PaO2 >80 mm Hg P (A – a) O2 <35 mm Hg

To determine the impact of Cardiopulmonary Exercise Test on category placement in Pneumoconioses Schedule:

Example: Patient complains of moderate dyspnea. Spirometry test results are normal, with FVC, FEV1 and FEV1/FVC values above Lower Limits of Normal (LLN). Diffusing capacity is normal, measured at 85% of predicted. Post-exercise oxygen saturation decreased by 2% as compared to baseline values, a non-significant decrease. Cardiopulmonary exercise test yielded a VO2 max of 70% predicted. All of the studies conformed to technical standards of quality as per recommendations.

Category Placement This patient reports a degree of dyspnea that indicates a more severe impairment category than his spirometry and diffusing capacity test results. Therefore, this patient fulfills the criteria for cardiopulmonary exercise test evaluation. Result of this test showed an abnormally low VO2 max.

By “objective tests,” this patient would be classified in category 4. However, since the degree of dyspnea is worse than that category and the exercise test result is abnormal, patient would be finally classified within category 5, i.e., one level above from what the result would have been if determined by the original “objective” test results.

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Table S12.13: Dyspnea Evaluation Questionnaire39

Mild Do you have to stop for breath when hurrying on level ground or up a slight hill? Moderate Do you have to walk more slowly on level ground than people of your age because of breathlessness? Moderately Do you have to stop for breath when walking more than 100 yards (length of Severe football field) at your own pace on level ground? Severe Do you ever have to stop for breath after walking less than 100 yards or a few minutes on level ground? Very Severe Are you too breathless to leave the house or breathless after dressing or undressing?

Table S12.14: Normal FEV1/FVC (%)40

Age in Years % 8-19 85 20-39 80 40-50 75 60-80 70

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